**Update to Patient and Family**
On 1 November 2024, I, Dr. Thomas Kelly, discussed the current clinical findings with the patient, Mr. John Smith, and his wife, Mrs. Jane Smith. The patient presented with post-operative complications following a laparoscopic cholecystectomy performed on 20 October 2024. During the physical examination, the patient exhibited mild abdominal distension and tenderness in the right upper quadrant. His overall status was stable, but he reported persistent nausea and a poor appetite.
Relevant blood test results revealed an elevated WBC count of 14.5 and CRP of 35. These findings suggest an ongoing inflammatory process, possibly related to a bile leak or intra-abdominal infection. LFTs were within normal limits, indicating no significant liver dysfunction.
An abdominal CT scan showed a small amount of free fluid in the peritoneal cavity, but no evidence of abscess formation or bile duct injury. The gallbladder bed appeared normal.
The current management plan includes IV fluids and antiemetics to manage nausea. The patient is being kept nil by mouth and is on IV antibiotics (Cefuroxime) to cover for potential infection. Regular monitoring of vital signs and abdominal examination is ongoing. The patient is also receiving regular pain relief.
The proposed future management plan includes:
- Continued IV antibiotics for 5 days.
- Repeat CT scan in 3 days to assess for any changes.
- If the patient's condition improves, a gradual reintroduction of oral intake will be attempted.
- Consultation with a dietician to address nutritional needs.
- Follow-up appointment in 2 weeks.
Questions raised by the patient and family included:
- "What caused the pain?" Answer: "The pain is likely due to inflammation or infection related to the surgery."
- "When can I eat again?" Answer: "We will start reintroducing food when your nausea subsides and your abdomen settles."
The patient and his wife expressed concerns about the prolonged recovery and the need for further investigations. These concerns were acknowledged, and the patient was reassured that all necessary steps were being taken to ensure his recovery. The potential risks and benefits of each intervention were discussed.
A shared decision-making process took place. The patient and his wife actively participated in the discussion, asking questions and expressing their concerns. They understood and agreed with the proposed management plan, including the need for further investigations and the potential for a longer recovery period.
**Update to Patient and Family**
[Summarize the current clinical findings, including observations from physical examination, reported symptoms, and overall patient status, and indicate who was present during the discussion with the patient and family.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.)
[Provide a clear explanation of relevant blood test results, highlighting any significant findings, normal values, or trends, and explain their implications for the patient's condition.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraph format using medical abbreviations and acronyms where appropriate. Do not include units.)
[Describe the radiological findings from any imaging studies, detailing what was observed and its relevance to the patient's diagnosis or condition.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraph format using abbreviations where possible.)
[Detail the current management plan, including all ongoing treatments, medications, procedures, and supportive care measures, explaining the rationale behind each component.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraph format using clinical terminology and acronyms.)
[Outline the proposed future management plan, including any planned investigations, consultations with specialists, changes in treatment, follow-up appointments, or long-term care strategies, and indicate that this plan was discussed and agreed upon with a senior clinician.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraph format or bullet points using "-" as needed.)
[Document all questions raised by the patient and/or their family during the discussion, along with the comprehensive answers or explanations provided to address each query.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as bulleted list using "-".)
[Describe any concerns expressed by the patient and/or their family, and detail how these concerns were acknowledged, addressed, and mitigated during the discussion.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraph or bullet format as appropriate.)
[Confirm that a shared decision-making process took place, detailing how the patient and/or family participated in the decision-making regarding their care, and indicating their agreement or understanding of the proposed plans.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraph format.)
(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. Use medical and investigations acronym where possible through out consultation. Avoid writing investigations and vitals units, write only numbers. Compile for documentation with points and paragraphs as needed.)