Respiratory OPD - New

GP: [Referring doctor surname] Thank you for referring [Patient name] who was reviewed in the Respiratory Clinic on [date of review]. Reason for referral: [Reason for referral] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) "Issues:" - [problem 1 condition name] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) • [Brief summary of problem 1] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) - [problem 2 condition name] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) • [Brief summary of problem 2] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) (Repeat until all problems noted.) "Recent investigations:" - [Investigation 1] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) - [Investigation 2] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) (Repeat until all investigations noted. Name investigation, date and results. Only include information mentioned in the transcript, contextual notes, or clinical note, otherwise omit the line/section completely. List relevant tests performed, including imaging such as chest X-ray, CT scan, or ultrasound. Include pulmonary function tests (spirometry, DLCO, plethysmography), arterial blood gases, bronchoscopy findings, sputum cultures, or any blood tests. Mention any pending investigations and their expected results.) Current medications: [Current medications] (Only include information mentioned in the transcript, contextual notes, or clinical note, otherwise omit the line/section completely. Detail all prescribed medications, including inhalers, nebulizers, antibiotics, steroids, biologics, or supplemental oxygen. Provide names, dosages, frequencies, and adherence details. Include any recent medication changes. Mention if inhaler technique was checked.) Allergies: [Allergies] (Specify drug allergies and reactions, particularly to respiratory medications such as antibiotics, steroids, or bronchodilators. Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) History: Presenting complaint: [Presenting complaint] (Describe the primary reason for consultation, including onset, duration, and progression of symptoms. Capture relevant details such as breathlessness, cough, wheeze, sputum production, hemoptysis, chest pain, fever, hoarseness, or systemic symptoms. Note exacerbating and relieving factors. Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Review of systems: [Review of systems] (Document any additional symptoms related to respiratory, cardiovascular, systemic, or other relevant systems. Include constitutional symptoms such as weight loss, night sweats, fatigue, or fever if present. Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Previous medical history: [Previous medical history] (Include past respiratory conditions such as asthma, COPD, bronchiectasis, tuberculosis, pneumonia, lung cancer, or interstitial lung disease. Document other significant co-morbidities like cardiovascular disease, diabetes, or immunosuppression. Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Smoking history: [Smoking history] (Document smoking status, including pack years, age of starting, when stopped, and quit attempts. Include vaping and other tobacco-related products. Include cannabis use. Note any passive smoking. Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Occupational history: [Occupational history] (Describe entire work history and any occupational exposures to dust, fumes, asbestos, or allergens that may contribute to respiratory disease. Include reduction or worsening of symptoms when away from work. Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Environmental exposure: [Environmental exposure] (Note exposure to pollutants, household allergens, mold, pet dander, or secondhand smoke. Note any pets and bird. Note birds inside or in an aviary. Note who cleans bird cages. Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Family history: [Family history] (Include any family history of respiratory diseases such as asthma, cystic fibrosis, lung cancer, or genetic conditions. Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Travel history: [Travel history] (Document recent travel, particularly to areas endemic with tuberculosis or respiratory infections. Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Vaccination history: [Vaccination history] (Note history of influenza, pneumococcal, and COVID-19 vaccinations. Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Examination: [General appearance] (Describe the patient's overall condition, including signs of respiratory distress, use of accessory muscles, and cyanosis. Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) [Vital signs] (Document respiratory rate, oxygen saturation, temperature, pulse rate, and blood pressure. Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) (Record physical examination findings, organised by body system. Use paragraph form. Start each sentence with a capital letter. Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Summary: [Summary] (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 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.) (Summarize the key points discussed with the patient, including advice given, referrals made, and plans for follow-up. Use dot points. Start each sentence with a capital letter. Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Plan: [Plan] (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 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.) (Provide a numbered plan and recommendations, including medications, referrals, or tests ordered. Keep it short. Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) - [Management strategy] (Outline treatment plan, including inhaler therapy, antibiotics, steroids, or oxygen therapy. Specify if hospital admission is required. Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) - [Further investigations] (Document any pending tests, referrals, or follow-ups needed. Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) - [Patient education] (Include information given about inhaler technique, smoking cessation, trigger avoidance, and disease management. Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) - [Safety netting] (Advise the patient on symptoms that require urgent medical attention. Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Follow up: [Follow up] (State time frame for follow up, and reason for follow up. Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Issue for GP to action: [Issue for GP to action] (Add management and follow up of investigations required from the GP. Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) (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 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.)