I had the pleasure of seeing Sarah in follow up today.
History:
Patient returns today for a follow up appointment regarding her chronic sinusitis. She reports persistent nasal congestion, facial pressure, and headaches, despite previous treatment with antibiotics and nasal corticosteroids. She denies any new symptoms or worsening of existing ones. She is employed as a teacher and enjoys gardening in her free time. Her husband was in attendance with her.
Examination:
Vital signs: Blood pressure 120/80 mmHg, pulse 78 bpm, respirations 16 breaths/min, temperature 37.0°C.
Physical examination: Anterior rhinoscopy revealed moderate swelling and inflammation of the nasal mucosa bilaterally, with purulent discharge present. No polyps were visualized. The oropharynx was clear. Ears and neck were unremarkable.
Management:
Investigations planned: A CT scan of the sinuses was ordered to assess for any structural abnormalities or complications.
Treatment planned: Continue nasal corticosteroid spray twice daily. Prescribed a course of oral antibiotics (amoxicillin-clavulanate) for 14 days. Advised on saline nasal rinses.
Relevant other actions: Provided patient education on sinus infection management and potential complications. Scheduled a follow-up appointment in 4 weeks.
Diagnosis:
Chronic sinusitis.
Plan:
Continue current treatment plan and follow up in 4 weeks. Review CT scan results and adjust treatment as needed.
Thank you again for including me in this patient's care.
I had the pleasure of seeing [Patient's first name] in follow up today.
History:
[Brief summary of presenting or history of complaint, reason for visit, current issues, who was in attendance with the patient, employment status, type of work, leisure interests and activities] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Any other associated symptoms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Examination:
[Vital signs] (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)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Management:
[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 counselling, referrals etc] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Causal Link: (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Causal Medical Link Between Proposed Treatment & Covered Injury] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[How is the current complaint and presentation thought to be linked to the injury stated] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Diagnosis:
[Concise diagnosis and how it relates to the injury mentioned] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Plan:
[Brief plan to manage condition or injury] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Thank you again for including me in this patient's care.
(For each section, only include if explicitly mentioned in transcript or context, else omit section 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 in the output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)