Plantilla URGPED Cast

MOTIVO DE CONSULTA [Menciona el motivo de consulta] (Utilizar máximo 3 o 4 palabras. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) ANTECEDENTES [Menciona si tiene alguna alergia medicamentosa o de otro tipo] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Menciona el estado vacunal] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Menciona los antecedentes médicos o personales del paciente] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) ENFERMEDAD ACTUAL [Menciona el tipo de paciente entre neonato, lactante, niño o adolescente] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Menciona la edad del paciente en días, meses o años] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Menciona quién le acompaña] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Menciona los detalles de la enfermedad actual] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) EXPLORACIÓN FÍSICA [Describir la exploración física. Utilizar la plantilla base estándar de exploración física pediátrica y modificar únicamente los hallazgos que hayan sido mencionados explícitamente en la transcripción. No añadir hallazgos no mencionados. Tener en cuenta que los menores de 18 meses no presentan signos meníngeos.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) EVOLUCIÓN [Menciona el razonamiento clínico verbalizado por el médico] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) EXPLORACIONES COMPLEMENTARIAS [Menciona las exploraciones complementarias realizadas y sus resultados] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) DIAGNÓSTICOS [Menciona el diagnóstico] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) TRATAMIENTOS Y RECOMENDACIONES AL ALTA Observación domiciliaria. [Menciona el tratamiento indicado por el médico] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Se explican signos de alarma por los que debiera reacudir a urgencias. [Menciona los signos de alarma indicados por el médico] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Control por pediatra de zona. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (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 that the information has not been mentioned in your output; simply omit the relevant placeholder completely.)