[Age of patient, gender. 52-year-old male.
Social history I.e. lives with, include number of children and their ages, desire for children, if they have had vasectomy or want more children, occupation, exercise regime. Include smoking/alcohol/drugs, performance enhancing drugs/exogenous testosterone use] Lives with wife. Two children, ages 18 and 21. No desire for more children. Works as a software engineer. Exercises three times a week. Smokes 10 cigarettes a day. Drinks alcohol socially, approximately 2-3 units twice a week. Denies illicit drug use.
Medical Background:
-Hypertension, diagnosed 5 years ago. Hyperlipidemia, diagnosed 3 years ago.
Medications:
-Lisinopril 20mg daily. Atorvastatin 40mg daily.
Family History:
-Father had a myocardial infarction at age 62. Mother has type 2 diabetes.
Symptoms:
-Patient presents with fatigue, decreased libido, and difficulty with erectile function for the past six months. No weight changes. No night sweats. No headaches.
-No red flag symptoms.
-Risk factors include smoking, family history of cardiovascular disease, and age.
Investigations:
-Height: 178 cm, Weight: 95 kg, Blood Pressure: 145/90 mmHg.
-Blood work pending.
Impression:
-52-year-old male with symptoms suggestive of testosterone deficiency.
-Issue, problem or request 1 (issue, request or condition name only). Testosterone Deficiency. [Assessment, likely diagnosis for Issue 1 (condition name only)] Likely diagnosis of hypogonadism secondary to age and lifestyle factors. Discussed risks of testosterone therapy, including potential effects on fertility, need for long-term monitoring, methods of administration (e.g., injections, gels), and potential side effects (e.g., acne, increased red blood cell count). Patient understands and is keen to proceed with treatment.
-Differential diagnosis for Issue 1. Secondary hypogonadism due to obesity, medication side effects (e.g., lisinopril), or other underlying medical conditions.
-Issue, problem or request 2 (issue, request or condition name only). Hypertension. [Assessment, likely diagnosis for Issue 2 (condition name only)] Hypertension, not well controlled.
-Differential diagnosis for Issue 2. Primary hypertension, secondary hypertension due to underlying renal or endocrine disorders.
Plan:
1. Investigations planned for Issue 1. Complete blood count, comprehensive metabolic panel, lipid panel, morning testosterone level, LH, FSH, and prolactin levels.
2. Treatment planned for Issue 1. Initiate testosterone replacement therapy (TRT) with intramuscular injections. Review in 3 months.
3. Relevant referrals for Issue 1. Referral to urologist for further evaluation if symptoms persist or worsen.
4. Investigations planned for Issue 2. Repeat blood pressure monitoring at home. Consider 24-hour ambulatory blood pressure monitoring.
5. Treatment planned for Issue 2. Increase lisinopril to 40mg daily. Lifestyle modifications: smoking cessation, weight loss, and increased exercise.
6. Relevant referrals for Issue 2. Referral to a cardiologist if blood pressure remains uncontrolled.
7. Follow up plan (noting timeframe if stated). Follow up in 3 months to review blood test results and response to treatment. Next appointment 1 November 2024.
[Age of patient, gender.
Social history I.e. lives with, include number of children and their ages, desire for children, if they have had vasectomy or want more children, occupation, exercise regime. Include smoking/alcohol/drugs, performance enhancing drugs/exogenous testosterone use] (Only include if explicitly mentioned in transcript, context or clinical note; else omit completely)
Medical Background:
-[include the past medical history or surgical history](Only include if explicitly mentioned in transcript, context or clinical note; else omit completely)
Medications:
-|Drug history/medications] (Only include if explicitly mentioned in transcript, context or clinical note; else omit completely)
Family History:
[Relevant family history(if applicable) particular if they Do or DO NOT have family history of early cardiovascular disease] (Only include if explicitly mentioned in transcript, context or clinical note; else omit completely)
Symptoms:
[History of presenting complaints](Only include if explicitly mentioned in transcript, context or clinical note; else omit completely)
[Presence or absence of red flag symptoms relevant to the presenting complaint](Only include if explicitly mentioned in transcript, context or clinical note; else omit completely)
[Relevant risk factors] (Only include if explicitly mentioned in transcript, context or clinical note; else omit completely)
Investigations:
[Vital signs, mainly height, weight and blood pressure if mention] (Only include if explicitly mentioned in transcript, context or clinical note; else omit completely)
[Investigations which is mainly blood work and blood tests. with results] (Only include if explicitly mentioned in transcript, context or clinical note; else omit completely)
Impression:
[Age and gender of patient, with summary of workup, usually will be worked up for , or treated for, testosterone deficiency.
Issue, problem or request 1 (issue, request or condition name only)]. [Assessment, likely diagnosis for Issue 1 (condition name only)] (Include details about discussions of the risks of testosterone therapy, effect on fertility, need for long term monitorring, methods of administration and potential risks and side effects) (Only include if explicitly mentioned in transcript, context or clinical note; else omit completely)
- [Differential diagnosis for Issue 1] (Only include if explicitly mentioned in transcript, context or clinical note; else omit completely)
[ Issue, problem or request 2 (issue, request or condition name only)]. [Assessment, likely diagnosis for Issue 2 (condition name only)] (Only include if explicitly mentioned in transcript, context or clinical note; else omit completely)
- [Differential diagnosis for Issue 2] (Only include if explicitly mentioned in transcript, context or clinical note; else omit completely)
[Issue, problem or request 3, 4, 5 etc (issue, request or condition name only)]. (Only include if explicitly mentioned in transcript, context or clinical note; else omit completely)[Assessment, likely diagnosis for Issue 3, 4, 5 etc (condition name only) (include only if mentioned)] (Only include if explicitly mentioned in transcript, context or clinical note; else omit completely)
- [Differential diagnosis for Issue 3, 4, 5 etc (include only if applicable and if mentioned)](Only include if explicitly mentioned in transcript, context or clinical note; else omit completely)
Plan:
(Create a numbered list.)
1. [Investigations planned for Issue 1](Only include if explicitly mentioned in transcript, context or clinical note; else omit completely)
2. [Treatment planned for Issue 1](Only include if explicitly mentioned in transcript, context or clinical note; else omit completely)
3. [Relevant referrals for Issue 1](Only include if explicitly mentioned in transcript, context or clinical note; else omit completely)
4. [Investigations planned for Issue 2](Only include if explicitly mentioned in transcript, context or clinical note; else omit completely)
[Treatment planned for Issue 2](Only include if explicitly mentioned in transcript, context or clinical note; else omit completely)
[Relevant referrals for Issue 2](Only include if explicitly mentioned in transcript, context or clinical note; else omit completely)
[Investigations planned for Issue 3, 4, 5 etc](Only include if explicitly mentioned in transcript, context or clinical note; else omit completely)
[Treatment planned for Issue 3, 4, 5 etc](Only include if explicitly mentioned in transcript, context or clinical note; else omit completely)
[Relevant referrals for Issue 3, 4, 5 etc](Only include if explicitly mentioned in transcript, context or clinical note; else omit completely)
[Follow up plan (noting timeframe if stated)] (Only include if explicitly mentioned in transcript, context or clinical note; else omit completely)
(Never come up with your own patient details, assessment, diagnosis, differential diagnosis, plan, interventions, evaluation, plan for continuing care, safety netting advice, etc - use only the transcript, contextual notes or clinical note as a reference for the information you include in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript or contextual notes, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or section blank.)(Use as many sentences as needed to capture all the relevant information from the transcript and contextual notes.)