[Dr. Eleanor Vance, 123 Specialist Lane, London, SW1A 0AA, Fax: 020 7946 0000]
"Dear Dr. Anya Sharma"
"RE: John Smith"
"DOB: 12/03/1960"
"URN: 789456123"
**Primary Issue:**
1. Hypertension
- Blood pressure monitoring, lifestyle advice, and medication (Amlodipine 5mg) have been trialled.
**Background:**
(bg::Hypertension, diagnosed 2018, stable on current medication. No end-organ damage.)
(bg::Type 2 Diabetes Mellitus, diagnosed 2020, well-controlled with Metformin.)
**Medications:**
Amlodipine 5mg,
Metformin 1000mg twice daily,
Atorvastatin 20mg
**Investigations:**
Fasting blood glucose: 6.2 mmol/L (10/10/2024)
HbA1c: 6.8% (10/10/2024)
Lipid profile: within normal limits (10/10/2024)
**Review:**
Independent 64-year-old male.
Progressing well since last review 6 months ago.
Patient reports no new symptoms.
**Assessment and Management:**
Blood pressure remains slightly elevated despite current medication. Increase Amlodipine to 10mg daily. Continue lifestyle advice regarding diet and exercise. Review in 3 months.
**Medication Changes Today:**
Amlodipine dose increased to 10mg.
**Recommendations:**
Monitor blood pressure at home and record readings. Review in 3 months. Consider referral to cardiology if blood pressure remains uncontrolled.
"Cordial Regards,"
Dr. Eleanor Vance
Internal Medicine Specialist
Provider Number: 1234567
London General Hospital
[letter recipient name, practice address, fax number or email] (Only include if explicitly mentioned in transcript or context)
"Dear" [letter recipient] (Only include if explicitly mentioned in transcript or context)
"RE:" [patient full name]
"DOB:" [patient date of birth]
"URN:" [patient medical records or unique record identification number]
**Primary Issue:**
1. primary-issue::[A diagnosis or problem for which this patient is being reviewed] (Only include if explicitly mentioned. Use full diagnostic descriptor if possible.)
- [List pertinent investigations and treatment that has already been trialled or is currently being trialled] (Only include if explicitly mentioned)
**Background:**
(bg::[Background medical problem 1, year of diagnosis if known, relevant investigation results, complications])
(bg::[Background medical problem 2, year of diagnosis if known, relevant investigation results, complications])
(bg::[Continue as needed])
**Medications:**
[Medication 1 name and dose] (include "dose changed today" if changed),
[Medication 2 name and dose],
[Continue list as needed]
**Investigations:**
[List of most recent relevant investigations — bloods, imaging, special tests, etc. Include date if known and result summary.]
**Review:**
[Description of patient’s demographics and general functional status — e.g., "Elderly woman presenting with daughter", "Independent middle-aged man"]
[Statement on course of primary problem and when last seen — e.g., "Progressing well since last review 3 months ago"]
[Summary of developments since last review OR initial presentation details]
[Detailed symptom history of primary complaint, with pertinent negatives and positives.]
[Additional symptoms outside the primary complaint.]
[Brief summary of patient observations (if relevant)]
[Primary clinical findings]
[Systems review findings]
**Assessment and Management:**
[Diagnosis and management plan for the primary issue, including any recommended further investigations.]
[Additional recommendations for unrelated issues if identified — one paragraph per issue.]
**Medication Changes Today:**
[List of medication changes made during this review, if any]
**Recommendations:**
[Task requests for GP — e.g., monitor medication, organise outpatient investigations, initiate a referral.]
"Cordial Regards,"
[Clinician Full Name]
[Role/Designation]
[Provider Number]
[Practice or Hospital Name]
(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 include 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.)