1 November 2024
Jane Smith
1234567890
01/01/1980 (Age: 44)
CRN12345
Reason for attendance:
Follow-up appointment
Diagnosis
Multiple Sclerosis
Symptom onset
01/06/2020
Date of diagnosis
01/08/2020
Current DMT
Ocrelizumab
Previous DMT(s)
Interferon beta-1a
Other diagnoses
Depression
Other medications
Sertraline 100mg daily
Vitamin D 2000 IU daily
Actions for GP/recommendations
Continue current medications
Assessment
I was pleased to meet Jane today.
Patient reports ongoing fatigue, some mild cognitive difficulties, and occasional tingling in her left leg. She reports that her mobility has been stable over the past year. She has had no new relapses.
Patient is able to walk approximately 500 meters before needing to stop.
Past medical history:
Hypertension, well-controlled with medication.
Smoking status:
Non-smoker
Alcohol intake:
2 units per week
History of vaccinations:
Up to date with all recommended vaccinations, including COVID-19 boosters.
Family planning, contraceptive methods, parity:
Patient is not planning any further pregnancies.
Medication allergies:
No known allergies.
MS-related symptoms
Fatigue: Managed with lifestyle adjustments and regular exercise.
Tingling in left leg: Mild, intermittent, managed with gabapentin as needed.
Cognitive difficulties: Mild, patient is using cognitive strategies.
On neurological examination
Normal cranial nerves. Mildly increased reflexes in lower extremities. No other focal neurological deficits.
Current EDSS 3.0
Last images
MRI brain and spine
Date of imaging
15/10/2024
Imaging findings
Stable disease, no new lesions.
Labs
Vitamin D level
Date of results
16/10/2024
Analysis
Patient's MS is currently stable on Ocrelizumab. Fatigue and cognitive difficulties are ongoing, but manageable. No new relapses or significant progression of symptoms.
Discussion of treatment options and patient's preferences: Patient is happy with current treatment. Discussed the importance of adherence to medication and lifestyle modifications.
Recommendations for additional management, such as mood symptoms: Continue current management of depression.
Plan:
Continue Ocrelizumab infusions every six months.
Pre-treatment tests and monitoring: Routine blood tests and physical examination prior to each infusion.
Multidisciplinary team involvement: Continue to see the MS nurse and physiotherapist.
Follow-up imaging: Repeat MRI brain and spine in one year.
Recommendations for GP: Continue to monitor blood pressure and general health.
Patient education and resources: Provided updated information on MS and support groups.
Follow-up plan: Review in six months.
Lifestyle recommendations: Encourage regular exercise, a healthy diet, and stress management.
Yours sincerely,
Dr. Emily Carter
Consultant Neurologist
MS Clinic
City Hospital
[Date] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Patient name] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[NHS number] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Date of birth] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Use dd/mm/yyyy format. If age is explicitly stated, include after this item.)
[CRN number] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Reason for attendance:
[Reason for attendance] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Diagnosis
[Diagnosis] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Symptom onset
[Symptom onset date] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Date of diagnosis
[Date of diagnosis] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Current DMT
[Current disease-modifying therapy] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Previous DMT(s)
[Previous disease-modifying therapy 1] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Previous disease-modifying therapy 2] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Other diagnoses
[Other diagnosis 1] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Other diagnosis 2] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Other medications
[Medication 1] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Medication 2] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Medication 3] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Medication 4] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Medication 5] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Medication 6] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Actions for GP/recommendations
[Recommendation for GP 1] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Recommendation for GP 2] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Assessment
I was pleased to meet [Patient's first name] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) today.
[Description of current symptoms and relevant medical history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Mention how long the patient is able to walk in terms of distance before needing to stop] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Past medical history: [Relevant past medical history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Smoking status: [Smoking status] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Alcohol intake: [units per week] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
History of vaccinations: [Covid vaccinations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Family planning, contraceptive methods, parity] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Medication allergies] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
MS-related symptoms
[Symptom 1 and management] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Symptom 2 and management] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Symptom 3 and management] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Symptom 4] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Symptom 5] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Symptom 6] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Symptom 7] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Symptom 8] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
On neurological examination
[Neurological examination findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Current EDSS [EDSS score value] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Last images
[Type of imaging] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Date of imaging] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Imaging findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Labs
[Relevant laboratory results] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Date of results] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Analysis
[Analysis of the patient's diagnosis, symptoms, and imaging/lab results] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Discussion of treatment options and patient's preferences] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Recommendations for additional management, such as mood symptoms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Plan:
[Treatment plan, including disease-modifying therapy and administration details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Pre-treatment tests and monitoring] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Multidisciplinary team involvement] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Follow-up imaging] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Recommendations for GP] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Patient education and resources] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Follow-up plan] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Notifications to relevant authorities and organizations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Lifestyle recommendations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Yours sincerely,
[Clinician full name] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Clinician professional title and specialty] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Department or practice name] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Practice or hospital name] (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 transcript or context; otherwise omit entirely. Never come up with your own patient details, assessment, plan, interventions, evaluation, or next steps—use only the transcript, contextual notes, or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that it is missing; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information.)
