Seen alone.
**History:**
- The patient presents today with a 2-week history of a worsening cough, productive of yellow sputum, and associated with shortness of breath, especially on exertion. She reports feeling generally unwell with fatigue and a low-grade fever.
- The patient is here today to discuss her cough, which started after a recent cold. She is concerned about the severity of her symptoms and wants to rule out pneumonia. She reports a worsening cough, productive of yellow sputum, and associated with shortness of breath, especially on exertion. She reports feeling generally unwell with fatigue and a low-grade fever.
- Pain is present in the chest, described as a sharp, stabbing pain that worsens with coughing. It is located in the right side of the chest. The pain is intermittent, occurring several times a day, and lasts for a few minutes each time. It is not relieved by rest or medication.
- Haemoptysis.
- Smoker.
- None.
**Relevant Investigations:**
- Chest X-ray performed today, results pending.
- Full blood count performed today, results pending.
B/G - Asthma, Hypertension.
Meds - Salbutamol inhaler, Amlodipine.
FH - Father with history of COPD, Mother with history of asthma.
SH - Lives with husband, non-smoker, drinks alcohol socially, works as a teacher, no recent travel, no carers.
**Examination:**
- The patient appears to be in mild respiratory distress, but is alert and oriented.
- Temp 37.8°C, Sats 96%, HR 88 bpm and regular, BP 130/80 mmHg, RR 20.
- No murmurs, rubs, or gallops.
- Reduced air entry in the right lower lobe, with scattered wheezes.
- Soft, non-tender abdomen.
- No abnormalities noted.
- No abnormalities noted.
- No abnormalities noted.
- No abnormalities noted.
**Diagnosis:**
1. Pneumonia.
2. Asthma exacerbation.
3. Bronchitis, COPD.
**Plan:**
- Prescribed antibiotics (Amoxicillin 500mg three times a day for 7 days). Continue Salbutamol inhaler as needed. Advised to rest and drink plenty of fluids. Review in 2 weeks.
- Follow-up appointment in 2 weeks. Advised to seek immediate medical attention if symptoms worsen, including increased shortness of breath, chest pain, or high fever.
- Provided education on the importance of completing the course of antibiotics and the signs and symptoms of pneumonia. Counseled on smoking cessation.
- Chest X-ray and full blood count ordered.
- Advised to return immediately if experiencing worsening symptoms, such as increased shortness of breath, chest pain, or high fever.
[Insert the following sentence: Using Heidi Health for note taking - consent gained] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[specify if telephone call and if reviewing the patient in person then specify whether anyone else is present i.e. "seen alone" or "seen with…"] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
**History:**
- [History of presenting complaints, including time frames of complaint] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [describe current issues, reasons for visit, discussion topics, history of presenting complaints] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [If pain history, describe in terms of SOCRATES structure for a pain history for those elements mentioned, although do not use SOCRATES headings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Presence or absence of red flag symptoms relevant to the presenting complaint] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Please write in bullet points on separate lines, do not mention the words 'red flags.')
- [Relevant risk factors] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. List them on one line and do not mention the words 'risk factors.')
- [previous consultations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
**Relevant Investigations:** (omit section entirely if no relevant investigations)
- [Investigations with results] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Document relevant blood results prior to consultation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Document imaging results (e.g. X-Rays, CT scans, MRI scans)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Document urine dipstick result in terms of blood, nitrites and leucocytes] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[B/G - ] [include the relevant past medical history or surgical history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Please format this on one line as a list.)
[Meds - ] [Include the medications trialed for this presenting complaint and relevant drug history/medications. Use generic names.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Please format this on one line as a list.)
[FH - ] [include relevant family history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Please format this on one line as a list.)
[SH - ] [include relevant social history i.e. lives with, occupation, smoking/alcohol/drugs, recent travel, carers/package of care] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Please format this on one line as a list.)
**Examination:** (omit section entirely if no examination performed)
- [describe general appearance] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [document vital signs on same line as: Temp, Sats %, HR (and regular/irregular if mentioned), BP mmHg, RR] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [describe findings from cardiovascular examination] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [describe findings from respiratory examination] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [describe findings from abdominal examination] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [describe findings from head and neck examination] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [describe findings from musculoskeletal examination] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [describe findings from neurological examination] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [describe findings from skin examination] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
**Diagnosis:**
1. [list primary diagnosis] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
2. [list secondary diagnoses] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
3. [list differential diagnoses] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
**Plan:**
- [describe treatment plan including medications, therapies, and lifestyle modifications] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [describe follow-up plans and referrals] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [mention patient education and counselling provided] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [mention any diagnostic tests or procedures ordered] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [describe safety netting advice] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(Always refer to the patient by their name if available; only use "the patient" if no name is provided in patient details.)
(Never come up with your own patient details, assessment, diagnosis, plan, interventions, evaluation, safety netting, or continuing care. Use only the transcript, contextual notes or clinical note as reference. If any placeholder has no explicitly mentioned information, omit it entirely.)
(For each section, only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the section entirely. Never hallucinate any patient details, symptoms, diagnoses, assessments, management plans, interventions, or next steps.)
