Verbally consented to the use of Heidi for note-taking.
Referral source:
- Google search
- Dr. Emily Carter, GP
History:
Patient is a 35-year-old male presenting with lower back pain. He reports no smoking history and drinks alcohol socially. He works as a software engineer.
Primary Complaint
Lower back pain that started approximately 2 weeks ago.
Secondary Complaints
Neck stiffness.
OPQRST:
Onset
- Symptoms began approximately 2 weeks ago after lifting a heavy box.
Duration/Frequency
- Pain is constant, rated 6/10, and worsens with prolonged sitting.
Traumas or accidents:
- Lifting a heavy box 2 weeks ago at work.
Previous treatment:
- Over-the-counter pain relievers, which provided minimal relief.
Subjective Quality:
- "It feels like a constant ache with sharp, shooting pains down my leg." Pain is rated as a 6/10 on a visual analogue scale.
- Pain is worse when sitting for long periods and alleviated by walking around.
- Associated symptoms: Tingling in the left leg.
Goals and expectations:
- Life Effect: The pain is affecting his ability to work and enjoy his hobbies.
- The patient wants to return to his normal activities without pain.
- Long term effect of this condition: The patient is concerned about the pain becoming chronic.
- Goals and Expectations: Patient desires pain relief, improved mobility, and a return to normal activities.
Subjective progression:
- The condition has been worsening over the past week.
Types of care:
- Patient is seeking short-term acute management.
Medical History:
- No significant past medical or surgical history.
- Family history of back pain in his father.
- Social history: Non-smoker, social alcohol use.
- Allergies: No known allergies.
- Medications: Ibuprofen as needed.
- Immunization history & status: Up to date.
- Other relevant history or contributing factors: Sedentary lifestyle.
Physical Examination:
- Vital signs: Blood pressure 120/80, pulse 72 bpm, temperature 37°C.
- Physical or mental state examination findings, including system specific examination(s):
- Musculoskeletal: Lumbar paraspinal muscle spasm, decreased range of motion in lumbar spine, positive straight leg raise test on the left.
- Neurological: Normal reflexes, sensation intact.
- Orthopedic: Positive Kemp's test.
- Chiropractic: Palpable tenderness at L4-L5.
Investigations:
- None completed at this time.
Clinical Impression:
- Likely diagnosis: Lumbar sprain/strain.
- Differential diagnosis: Disc herniation.
Management Plan:
- Investigations planned: X-rays of the lumbar spine.
- Treatment planned: Chiropractic adjustments, soft tissue therapy, and home exercises.
- Relevant other actions, such as counseling, referrals, lifestyle recommendations, etc.: Advised on proper lifting techniques and ergonomics. Recommended a follow-up appointment in one week.
Verbally consented to the use of Heidi for note-taking.
Referral source:
- [How the patient found the practice, Specific referral source, whether that be a person, digital media, or doctor] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely)
- [Current General practitioner and any other specialists that the patient is seeking care from currently] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely)
(do not include occupation in this part of the note)
History:
[General history: the general story of what has brought the patient in today; in this section you can add things such as systems review, smoking history, alcohol consumption, occupation, children, spouse, etc. This is also the section to place red flags, such as history of infection, changes to bowel or bladder control, radicular symptoms, etc]
Primary Complaint
[Primary complaint: note the main reason for the patient attending the practice, history of presenting complaints etc] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely) (present this as a paragraph or sentence rather than dot points)
Secondary Complaints
[Secondary complaint: when more than one reason for the patient presenting is raised, briefly list the secondary complaints] (when multiple other complaints are listed, list them as secondary complaints) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely)
OPQRST:
Onset
- [Mention how long the symptoms have been present for, when the very first episode occured and what caused the symptoms]
Duration/Frequency]
- [How often do the symptoms occur and how long do they last]
Traumas or accidents:
- [include reasons for the onset of their condition as well as any occuptational stressors, traumas and accidents, sports injuries, etc] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely)
Previous treatment:
- [list what types of treatment have been trialed and the outcome of the treatments sought] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely)
- [if they have sought prior treatment from a chiropractor, list what the chiropractor did] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely)
Subjective Quality:
- [Detail exactly what the patients symptoms feel like at their absolute worst] (please include their exact description of what the pain or symptoms feel like in their own words, use their exact quote as to how their symptoms feel)
- [Mention the subjective rating of pain on a visual analogue scale from 0-10] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely)
(these prior 2 placeholders should be written in prose)
- [List anything that worsens or alleviates the symptoms] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely)
- [Associated symptoms: any other symptoms (focal and systemic) that accompany the reasons for visit & chief complaints] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely)
Goals and expectations:
- [Life Effect: the effect these symptoms and disability is having on the patient's life and their quality of life, interupting activities that they enjoy or want to be able to do, impact on their work or occupation, impact on their family life] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely)
- [Mention how the symptoms affect the patient's daily life, work, and activities] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely)
- [Long term effect of this condition: what effect does this have on the patient in 12 months from now} (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely)
- [Goals and Expectations: list the patients desired outcomes to care, list the individual outcomes the patient wants to achieve, list their expectations of their care and the results they desire] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely)
Subjective progression:
- [Note if their conditioning has been getting better, worsening, or staying the same. Mention if this change has been regarding their frequency or intensity of symptoms] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely)
Types of care:
- [Mention whether they are looking for a short term acute management, or if they are desiring a long term outcome to completely resolve the problem they presented with] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely)
Medical History:
- [Medical history: including past medical and surgical history relevant to the current complaints] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely)
- [Family history that may be relevant to the reasons for visit and chief complaints] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely)
- [Social history: any relevant social factors, including smoking, alcohol, drug use, or occupational exposures] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely)
- [Allergies, including details on reactions] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely)
- [Medications, including current prescribed medications, over-the-counter drugs, and supplements] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely)
- [Immunization history & status] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely)
- [Other relevant history or contributing factors] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely)
Physical Examination:
- [Vital signs] (e.g. pulse, blood pressure, temperature etc, but only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely)
- [Physical or mental state examination findings, including system specific examination(s)] (make sure each systems examination findings are separated line by line, and only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely)
- [List all completed tests, include orthopaedic, neurological and chiropractic tests] (ensure all tests are included regardless of whether they are positive or negative)
Investigations:
- [Completed investigations with results] (Planned or ordered investigations should be documented under the Management Plan section.) (Only include completed investigations with results if they have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely
Clinical Impression:
- [Likely diagnosis] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely)
- [Differential diagnosis] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely)
Management Plan:
- [Investigations planned] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely)
- [Treatment planned] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely)
- [Relevant other actions, such as counseling, referrals, lifestyle recommendations, etc.] (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 the information has not been explicitly mentioned in your output, just leave the relevant placeholder or section blank.)
