HPI:
1 November 2024
Mr. John Smith, 68-year-old male, presents today for a follow-up on his peripheral artery disease (PAD) and assessment of leg pain. He reports worsening claudication in his left leg.
Mr. Smith describes the onset of his leg pain as gradual, starting approximately 6 months ago. The pain is located in his left calf and is described as a cramping sensation. The duration of the pain is typically 10-15 minutes and is brought on by walking. The pain is relieved by rest. He rates the severity of the pain as 6/10.
Mr. Smith is retired and walks for exercise 30 minutes daily. His diet is balanced, and he denies any limitations in his usual activities.
Mr. Smith is a former smoker, having quit 10 years ago. He smoked one pack of cigarettes per day for 30 years. He is not currently interested in smoking cessation.
Medications include: Aspirin 81mg daily, Atorvastatin 20mg daily, and Lisinopril 10mg daily.
Imaging:
Duplex Ultrasound of the lower extremities was performed.
Performed at the local vascular lab.
Date of imaging: 20 October 2024.
Results showed significant stenosis in the left superficial femoral artery.
ABI Results:
R ABI result: 0.85
L ABI result: 0.60
R TBI result: 0.90
L TBI result: 0.65
Vascular History:
* 2018 – Left Femoral-Popliteal Bypass – Dr. Emily Carter – City Hospital
Assessment and Plan:
68-year-old male with peripheral artery disease (I73.9).
Peripheral Artery Disease (I73.9)
- Assessment: Worsening claudication in the left leg, consistent with progression of PAD. Reduced ABI in the left leg.
- Plan: Continue Aspirin and Atorvastatin. Increase walking exercise to 45 minutes daily. Schedule follow-up duplex ultrasound in 6 months. Refer to vascular surgery for possible intervention.
- Counseling: Discussed the importance of smoking cessation and lifestyle modifications.
Short Summary:
Mr. Smith presented for a follow-up on his PAD and reported worsening claudication. The plan includes continued medical management, lifestyle modifications, and referral to vascular surgery.
HPI:
[Date of encounter] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Patient's full name, age, and gender along with reason for visit including symptoms, follow-up for prior procedures, or known diagnosis] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraphs of full sentences.)
[Detailed description of symptoms using OLDCARTS: onset, location, duration, characteristics, aggravating and relieving factors, severity] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraphs of full sentences.)
[Lifestyle and functional impact: include activity level, nutrition, occupation, and limitations in usual activities] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraphs of full sentences.)
[Smoking history including status (current/former/never), quantity, and interest in cessation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraphs of full sentences.)
[All medications mentioned, including prescriptions and over-the-counter] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as list.)
Imaging:
[Type of imaging (e.g., Ultrasound, CTA, MRI, Angiogram)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraphs of full sentences.)
[Location where imaging was performed] (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 results] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraphs of full sentences.)
ABI Results:
[R ABI result] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[L ABI result] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[R TBI result] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[L TBI result] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Vascular History:
[List of previous vascular procedures in format: Date – Procedure – Physician – Location] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as bullet points.)
Assessment and Plan:
[Patient age] year-old [gender: M/F] with [primary vascular diagnosis] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. If venous insufficiency is diagnosed, include CEAP score.)
[Medical issue (condition name and ICD-10 code if applicable)] (Repeat this section for each condition.)
- [Assessment: Current assessment of the condition] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Plan: Proposed plan for management or follow-up] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Counseling: Discussion of the condition or education provided] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Short Summary:
[Summarise today's visit in no more than 2 sentences] (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 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.)
