History of Present Illness:
Mr. John Smith is a 67-year-old male with a history of hypertension and type 2 diabetes presenting for a routine check-up.
Mr. Smith has been a patient of "Dr. Thomas Kelly" for the past 5 years. He has been compliant with his medications and has been attending his appointments regularly. His last HbA1c was 7.2% three months ago.
Hypertension:
Mr. Smith was diagnosed with hypertension 10 years ago. He has a family history of hypertension. He takes Lisinopril 20mg once daily. His blood pressure readings at home have been consistently around 130/80 mmHg. His most recent blood pressure reading in the clinic was 132/82 mmHg on 1 November 2024.
Type 2 Diabetes:
Mr. Smith was diagnosed with type 2 diabetes 5 years ago. He takes Metformin 1000mg twice daily. His last HbA1c was 7.2% three months ago. He monitors his blood sugar levels at home and reports readings within the target range.
Other Medications and Supplements:
* Aspirin 81mg daily
* Vitamin D 1000 IU daily
Allergies:
* No known drug allergies
Social History:
Mr. Smith is a retired accountant. He is married and lives with his wife. He does not smoke or drink alcohol. He exercises regularly and maintains a healthy diet.
Objective:
Vital Signs:
* BP: 132/82 mmHg
* HR: 72 bpm
* Temp: 37°C
* RR: 16 breaths/min
* SpO2: 98% on room air
* Weight: 80 kg
* Height: 178 cm
* BMI: 25.2 kg/m²
Physical Examination:
* General: Alert and oriented, appears well.
* Cardiovascular: Regular rate and rhythm, no murmurs, rubs, or gallops.
* Respiratory: Clear to auscultation bilaterally.
* Abdomen: Soft, non-tender.
* Extremities: No edema.
Assessment and Plan:
Hypertension
* Assessment: Controlled hypertension.
* Plan: Continue Lisinopril 20mg daily. Monitor blood pressure at home. Follow up in 3 months.
Type 2 Diabetes
* Assessment: Controlled type 2 diabetes.
* Plan: Continue Metformin 1000mg twice daily. Monitor blood sugar levels at home. Follow up in 3 months. Review HbA1c in 3 months.
Additional Recommendations:
Encourage Mr. Smith to continue with his healthy lifestyle. Provide education on the importance of regular exercise and a balanced diet. Schedule a flu shot for the upcoming flu season.
History of Present Illness:
[Patient name] is a [age] [male/female] with a history of [relevant past medical history] presenting for [presenting complaint or reason for visit]. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraphs of full sentences.)
[Summarise contextual notes from prior clinical encounters relevant to today’s visit] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraphs of full sentences.)
[Concern 1 or group of related concerns]
(Write a paragraph including relevant past medical history, social history, surgical history, family history. Include medications and supplements (with dosages and frequency) taken for this concern. Organise chronologically. Include relevant laboratory and imaging results with dates. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Concern 2 or group of related concerns]
(Write a paragraph including relevant past medical history, social history, surgical history, family history. Include medications and supplements (with dosages and frequency) taken for this concern. Organise chronologically. Include relevant laboratory and imaging results with dates. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Concern 3 or group of related concerns]
(Write a paragraph including relevant past medical history, social history, surgical history, family history. Include medications and supplements (with dosages and frequency) taken for this concern. Organise chronologically. Include relevant laboratory and imaging results with dates. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Other Medications and Supplements:
[List any other current medications and herbal supplements not associated with specific concerns] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as list.)
Allergies:
[Document drug, food, or environmental allergies] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as list.)
Social History:
[Describe relevant social history including tobacco/alcohol/substance use, occupation, living situation, relationship status, etc.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraph format.)
Objective:
Vital Signs:
[Include vital signs if available: BP, HR, Temp, RR, SpO2, weight, height, BMI] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Physical Examination:
[Include physical exam findings if explicitly mentioned. If general template is used, adapt based on specific findings or omit completely.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraph or bullet format.)
Assessment and Plan:
[Concern 1 or related concern group]
- Assessment: [Diagnosis or clinical impression] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Plan: [Treatment plan, medications, investigations, referrals, follow-up instructions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Concern 2 or related concern group]
- Assessment: [Diagnosis or clinical impression] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Plan: [Treatment plan, medications, investigations, referrals, follow-up instructions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Concern 3 or related concern group]
- Assessment: [Diagnosis or clinical impression] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Plan: [Treatment plan, medications, investigations, referrals, follow-up instructions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Additional Recommendations:
[Include additional instructions or recommendations based on the patient's conditions. Where appropriate, include guideline names and key points.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraphs of full sentences.)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - 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, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)
