Physician H&P

Chief Complaint: [Specific question or reason for the consult] (Only include if explicitly mentioned in transcript or context, otherwise omit completely.) History of Presenting Illness: [State the patient's age and relevant past medical history. Detailed history of the presenting illness in narrative form. This should include onset, provoking factors, quality, radiations, severity and time course.] (Only include if explicitly mentioned in transcript or context, otherwise omit completely.) [Detailed history of investigations and findings performed in the emergency department or referring facility, including treatment administered (e.g. IV fluids, oxygen, antibiotics). Also include reason for admission to the ward or referral for inpatient management.] (Only include if explicitly mentioned in transcript or context, otherwise omit completely.) Past Medical History: [Relevant past medical history such as HIV, TB, hypertension, diabetes, stroke, or known chronic illnesses] (Only include if explicitly mentioned in transcript or context, otherwise omit completely.) Home Medications: [List of current medications including dosages and chronic medication dispensed via clinic or private pharmacy] (Only include if explicitly mentioned in transcript or context, otherwise omit completely.) Allergies: [List of known allergies] (Only include if explicitly mentioned in transcript or context, otherwise omit completely.) Social History: [Relevant social history including smoking, alcohol, drug use, marital status, household setup, employment, or access to social grants] (Only include if explicitly mentioned in transcript or context, otherwise omit completely.) Family History: [Relevant family medical history including TB, diabetes, hypertension, cancer, or hereditary conditions] (Only include if explicitly mentioned in transcript or context, otherwise omit completely.) Review of Systems: Constitutional symptoms: [Weight change, Fever, Chills, Night sweats, Fatigue, Malaise] Eyes: [Eye pain, Redness, Discharge, Vision changes] Ears, Nose, Mouth, Throat: [Ear pain, Nasal congestion, Sore throat] Cardiovascular: [Chest pain, SOB, Orthopnoea, Palpitations] Respiratory: [Cough, Sputum, Dyspnoea, Wheezing] Gastrointestinal: [Nausea, Vomiting, Diarrhoea, Abdominal pain] Genitourinary: [Dysuria, Frequency, Flank pain, Vaginal symptoms] Musculoskeletal: [Joint pain, Back pain, Stiffness] Skin: [Rash, Skin lesions, Itching] Neurological: [Weakness, Numbness, Headache, Falls, Confusion] Psychiatric: [Anxiety, Mood symptoms, Hallucinations, Suicidal ideation] Endocrine: [Polyuria, Polydipsia, Heat or cold intolerance] Hematologic/Lymphatic: [Easy bruising, Bleeding, Swollen glands] Allergic/Immunologic: [History of allergic reactions, Autoimmune conditions] (Only include relevant systems if explicitly mentioned in transcript or context, otherwise omit each system not mentioned.) Physical Exam: [Findings from vitals: Temperature (°C), BP (mmHg), Pulse (bpm), RR (bpm), SpO₂ (%), Weight (kg)] (Only include if explicitly mentioned in transcript or context, otherwise omit completely.) [Findings from general and system-specific physical examination] (Only include if explicitly mentioned in transcript or context, otherwise omit completely.) Lab Results: [Results of relevant laboratory investigations including full blood count, urea/electrolytes, creatinine, liver function, HIV rapid or viral load/CD4, TB GeneXpert, sputum, malaria test, or any other relevant results] (Only include if explicitly mentioned in transcript or context, otherwise omit completely.) Imaging Results: [Relevant imaging results such as chest x-ray, abdominal ultrasound, CT/MRI, echocardiogram] (Only include if explicitly mentioned in transcript or context, otherwise omit completely.) Assessment/Plan: [1. Issue, problem or request 1] [Impression, likely diagnosis for Issue 1 (condition name only)] [Differential diagnosis for Issue 1 (only if applicable)] [Investigations planned for Issue 1 (only if applicable)] [Treatment planned for Issue 1 (only if applicable)] [Relevant referrals for Issue 1 (only if applicable)] (Only include if explicitly mentioned in transcript or context, otherwise omit completely.) [2. Issue, problem or request 2] [Impression, likely diagnosis for Issue 2 (condition name only)] [Differential diagnosis for Issue 2 (only if applicable)] [Investigations planned for Issue 2 (only if applicable)] [Treatment planned for Issue 2 (only if applicable)] [Relevant referrals for Issue 2 (only if applicable)] (Only include if explicitly mentioned in transcript or context, otherwise omit completely.) [3. Issue, problem or request 3, 4, 5 etc] [Impression, likely diagnosis for Issue 3, 4, 5 etc (condition name only)] [Differential diagnosis for Issue 3, 4, 5 etc (only if applicable)] [Investigations planned for Issue 3, 4, 5 etc (only if applicable)] [Treatment planned for Issue 3, 4, 5 etc (only if applicable)] [Relevant referrals for Issue 3, 4, 5 etc (only if applicable)] (Only include if explicitly mentioned in transcript or context, otherwise omit completely.) Two Midnight Documentation: The patient's stay will likely span more than 2 midnights in the hospital because of the severity of illness. (Include this standard wording only if relevant per context.) Time Spent: [Mention total time spent] (Only include if explicitly mentioned in transcript or context, otherwise omit completely.) (Never come up with your own patient details, assessment, plan, investigations, treatment or referrals – use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, omit the placeholder entirely. Use as many lines, paragraphs or bullet points as needed to capture all relevant information.)