Chief Complaint:
Patient presents to the Emergency Department with acute onset of severe left flank pain, radiating to the groin, accompanied by nausea and vomiting. The patient reports feeling a sharp, stabbing pain that began approximately 4 hours prior to arrival. There is no fever or chills reported.
Past Medical History:
* Hypertension
* Benign Prostatic Hyperplasia (BPH)
* Previous kidney stone (right kidney, 2021)
* Appendectomy (2010)
* Medications: Amlodipine 5mg daily, Tamsulosin 0.4mg daily
* Allergies: NKDA
Investigations:
* Urinalysis: Positive for hematuria, few WBCs
* CT KUB: 6mm stone in the proximal left ureter, mild hydronephrosis.
Assessment:
Acute left ureteral colic secondary to nephrolithiasis.
Plan/Treatment:
* Administered IV fluids (1L Normal Saline).
* Administered IV Ketorolac 30mg for pain control.
* Administered IV Ondansetron 4mg for nausea.
* Patient to be admitted for pain management and further evaluation.
* Urology consult requested.
* Repeat CT KUB in 24 hours.
* Discharge instructions: Patient to follow up with urology in 2 weeks for stone management plan.
Chief Complaint:
[brief description of the presenting issue or reason for ED visit, including current issues, relevant signs, and associated symptoms] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraph format.)
Past Medical History:
[any known chronic medical conditions] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as list.)
[details of previous surgeries or hospitalisations] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as list.)
[current medications and dosages] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as list.)
[any known allergies, particularly to medications] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as list.)
Investigations:
[results of pathology including blood tests, urine tests, etc.] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as list.)
[results of imaging including X-rays, CT scans, MRIs, etc.] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as list.)
[results of other investigations such as ECG, ultrasound, etc.] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as list.)
Assessment:
[presumed diagnosis based on current consult summary] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as paragraph.)
[differential diagnoses if considered] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as list.)
Plan/Treatment:
[details of treatment administered in the ED] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
[plans for further investigations or monitoring] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
[referrals to specialists or other departments] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
[discharge instructions and follow-up plan] (Only include if explicitly mentioned in transcript or context, else omit section entirely. 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 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.)