Diagnosis:
* Atopic dermatitis
* Contact dermatitis
Management:
* Prescribed topical corticosteroids.
* Advised on emollients and moisturising routine.
* Referral to allergy testing.
* Follow-up appointment in 4 weeks.
I am writing to you regarding Mrs. Eleanor Vance, who presented to our clinic on 1 November 2024.
Mrs. Vance was referred to our clinic by her GP due to a persistent rash and concerns about potential allergies.
Mrs. Vance reported a history of recurrent itchy rashes, particularly on her elbows, knees, and neck. She stated that the rash had been present for several months and was exacerbated by certain soaps and detergents. She also reported a family history of eczema.
Mrs. Vance has no significant past medical history. She takes no regular medications, but uses over-the-counter antihistamines as needed. She has no known drug allergies. She is a non-smoker and drinks alcohol occasionally. She works as a teacher.
Examination revealed erythematous, scaly patches on her elbows, knees, and neck. There was evidence of excoriation due to scratching.
No investigations were performed during this consultation.
Clinical impression: Atopic dermatitis and contact dermatitis.
Mrs. Vance was prescribed a topical corticosteroid to be applied twice daily to the affected areas. She was advised to use emollients regularly to moisturise her skin. She was also referred for allergy testing to identify potential triggers. A follow-up appointment was scheduled in four weeks to assess her response to treatment and discuss the results of the allergy testing.
Thank you for your referral once again. Please do not hesitate to contact me if you require any further information.
Diagnosis:
[Diagnoses or problems identified during consultation, listed as dot points] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write each diagnosis or clinical issue as a brief dot point.)
Management:
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I am writing to you regarding [Patient's Full Name] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely), who presented to our clinic on [Date of Visit] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely).
[Describe reason for referral] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in full sentences.)
[Describe current issues, reasons for visit, discussion topics, history of presenting complaints etc] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in full sentences.)
[Describe past medical history, previous surgeries] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in full sentences.) [Mention medications and herbal supplements] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in full sentences.) [Mention allergies] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in full sentences.) [Describe social history] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in full sentences.)
[Describe examination findings] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in full sentences.)
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Thank you for your referral once again. Please do not hesitate to contact me if you require any further information.
(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.)