Specialty: Internal Medicine Specialist
Past Medical History:
- Relevant past medical history: Type 2 Diabetes Mellitus (diagnosed 5 years ago, well-controlled on metformin), Hypertension (diagnosed 10 years ago, managed with lisinopril).
- Smoking history: Quit 2 years ago, previously smoked 1 pack per day for 20 years.
- Medication adherence: Reports excellent adherence to all prescribed medications.
- Allergies: Penicillin (hives).
- Recent travel: No recent international travel; visited family in Cornwall last month.
Subjective:
- Presenting complaint and duration: Follow-up for routine diabetes and hypertension management. Patient reports feeling generally well with no acute concerns.
- Additional symptoms: Denies chest pain, shortness of breath, palpitations, dizziness, or peripheral oedema.
- Impact on daily activities: No impact on daily activities; maintains regular exercise routine.
- Pertinent negatives: No new symptoms of hyperglycaemia or hypoglycaemia. Blood pressure readings at home have been within target range.
- Appetite: Good, no significant changes in appetite or weight.
- Living situation and sick contacts: Lives with spouse, no sick contacts.
- Medications prescribed: Metformin 1000mg twice daily, Lisinopril 20mg once daily.
- Diagnostic tests ordered: Recent HbA1c and lipid panel results reviewed.
- Specialists referred to: No current referrals to specialists.
- Advice to start medications or see specialists: Advised to continue current medications. No new specialist referrals at this time.
- Advice regarding laboratory investigations: Advised to repeat routine blood tests (HbA1c, renal function, electrolytes, lipid panel) in 6 months.
- Follow-up instructions: Follow up in 6 months for routine review.
Social History:
- Occupation and hobbies: Retired teacher, enjoys gardening and reading.
- Alcohol use and sleep habits: Occasional social alcohol use (1-2 units per week). Reports 7-8 hours of good quality sleep per night.
Objective:
- Vitals: BP 128/78 mmHg, HR 72 bpm, RR 16 bpm, Temp 36.8°C, O2 Sat 98% on room air.
- Lung exam: Clear to auscultation bilaterally, no wheezes, crackles, or rhonchi.
- Cardiac exam: Regular rate and rhythm, S1 S2 present, no murmurs, rubs, or gallops.
- Abdominal exam: Soft, non-tender, non-distended, no organomegaly.
Assessment:
- Primary diagnosis: 1. Type 2 Diabetes Mellitus, well-controlled. 2. Essential Hypertension, well-controlled.
Plan:
- Diagnostic tests ordered: Repeat HbA1c, renal function, electrolytes, and lipid panel in 6 months.
- Medications prescribed: Continue Metformin 1000mg twice daily and Lisinopril 20mg once daily. No changes to current medication regimen.
- Inhaler optimisation and technique education: Not applicable.
- Follow-up instructions: Schedule follow-up appointment in 6 months for routine review of chronic conditions.
- Return precautions: Advised to return sooner if experiencing any acute symptoms such as chest pain, severe headache, vision changes, or signs of infection.
- Medication adherence counselling: Reinforced importance of continued adherence to medication for optimal blood glucose and blood pressure control.
- Preventative measures discussion: Discussed maintaining healthy diet and regular exercise. Recommended annual flu vaccination and pneumonia vaccination as per guidelines.
- Deferral of non-urgent issues: No non-urgent issues identified for deferral.
Notes for nursing staff:
- Advise patient to book blood tests for 6 months time and to schedule follow-up appointment with Dr. Thomas Kelly.
Past Medical History:
- [Relevant past medical history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Smoking history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Medication adherence] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Allergies] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Recent travel] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Subjective:
- [Presenting complaint and duration] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Additional symptoms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Impact on daily activities] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Pertinent negatives] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Appetite] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Living situation and sick contacts] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Medications prescribed] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Diagnostic tests ordered] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Specialists referred to] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Advice to start medications or see specialists] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Advice regarding laboratory investigations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Follow-up instructions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Social History:
- [Occupation and hobbies] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Alcohol use and sleep habits] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Objective:
- Vitals: [Vital signs] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Lung exam: [Lung examination findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Cardiac exam: [Cardiac examination findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Abdominal exam: [Abdominal examination findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Assessment:
- [Primary diagnosis] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Plan:
- [Diagnostic tests ordered] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Medications prescribed] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Inhaler optimisation and technique education] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Follow-up instructions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Return precautions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Medication adherence counselling] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Preventative measures discussion] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Deferral of non-urgent issues] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Notes for nursing staff:
- [Notes for nursing staff] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(For each section, only include if explicitly mentioned in the transcript or contextual notes; otherwise omit the section entirely. Never come up with your own patient details, diagnoses, assessment, plan, interventions, evaluation, counselling, or next steps—use only the transcript, contextual notes, or clinical note as the source of truth. If any information related to a placeholder has not been explicitly mentioned, do not state that it is missing; simply omit the placeholder or section entirely. Use as many lines, paragraphs, or dashed bullet points as needed to accurately reflect the documented information.)