Thrombosis Consult

Identification: [Include patient's name, age, place of residence, relevant past medical history, and referral reason e.g. "referred to thrombosis clinic for management of" type of VTE or clinical question] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraph form.) Reason for Referral: [Summarise the reason for referral to hematology/thrombosis clinic] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in full sentences.) Thrombosis History: [Include how the patient presented (e.g. "They presented with ... on ..."), date of presentation, summary of imaging findings, and treatment of thrombosis to date] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraph form.) Anticoagulation History: [Document prior and current anticoagulation use, medication names, dosages, duration, complications (e.g. bleeding), and INR control if relevant] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as list or paragraph depending on detail.) Other Past Medical History: [Document significant past medical history excluding thrombosis] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as list.) Medications: [List current medications including dose and frequency] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as list.) Allergies: [Document drug or other allergies and reactions] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as list.) History of Presenting Illness: [Include a detailed narrative of presentation including relevant imaging, review of systems (infection, immobility, surgery, trauma, HRT, malignancy), constitutional symptoms, personal/family history of malignancy] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in full sentences.) Family History: [Include relevant family history including VTE, clotting disorders, malignancy] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as list or paragraph.) Social History: [Include smoking status, alcohol intake, occupation, recent travel, immobility, physical activity] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraph form.) Physical Examination: [Include vitals and system-based findings: general appearance, cardiac, respiratory, lymph node, abdominal, extremities (edema, calf size, tenderness, erythema)] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraph form.) Laboratory Results: [Summarise relevant labs including CBC, D-dimer, coagulation profile, renal/liver function, thrombophilia screen if available] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as list.) Imaging: [Include relevant imaging findings such as Doppler, CT-PE, CTPA, V/Q scans, ultrasound, etc.] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as list or paragraph.) Impression and Plan: [Summarise impression including diagnosis and clinical considerations. Restate identifying info if necessary, then provide plan with action items] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in complete sentences. Highlight action items in **bold**.) (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.)