Our Ref: CLN/2024/1101
NHS No: 1234567890
Date of Clinic: 1 November 2024
Dear Doctor,
This patient has been followed up as part of our Pneumonia Follow-up Pathway following their hospital admission or attendance.
This involves a chest X-ray 6 weeks following discharge and an 8-week follow-up with one of our Advanced Nurse Practitioners via telephone.
Past Medical History:
* Hypertension
* Type 2 Diabetes Mellitus
* COPD
Initial CXR Report:
* Right lower lobe consolidation, suggestive of pneumonia.
CURB65:
* CURB65 score of 2 (Confusion, Urea >7mmol/L, Respiratory rate >30, Blood pressure <90/60, Age >65)
Treatment:
* Intravenous antibiotics (co-amoxiclav)
* Oxygen therapy via nasal cannula (2L/min)
* Nebulised salbutamol for bronchospasm
Follow-up CXR Report:
* Resolution of consolidation in the right lower lobe.
Plan:
* Patient discharged with advice to continue with usual medications.
* Follow-up with GP in 2 weeks.
* Advised to seek immediate medical attention if any worsening of symptoms.
Our Ref: [Insert clinic or hospital reference number] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
NHS No: [Insert NHS number] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
Date of Clinic: [Insert date of clinic] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
Dear Doctor,
This patient has been followed up as part of our Pneumonia Follow-up Pathway following their hospital admission or attendance.
This involves a chest X-ray 6 weeks following discharge and an 8-week follow-up with one of our Advanced Nurse Practitioners via telephone.
Past Medical History:
[Summarise relevant past medical history] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely. Write as list.)
Initial CXR Report:
[Summarise findings from the initial chest X-ray at admission] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
CURB65:
[State the CURB-65 score and relevant parameters used to assess pneumonia severity] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
Treatment:
[Summarise treatment given during the initial admission or following discharge, including any antibiotics, oxygen support, or other interventions] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
Follow-up CXR Report:
[Summarise findings from the 6-week follow-up chest X-ray] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
Plan:
[Summarise clinical management and follow-up plan, including any further referrals, investigations, discharge, or safety netting advice] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely. Write as bullet points.)
(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.)