Scribe BC - BG New Consult

Scribe BC - BG New Consult **REASON FOR CONSULTATION:** [document the primary reason the patient is seeking endocrinology consultation, including the onset, duration, and main symptoms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) **HISTORY OF PRESENT ILLNESS:** [detail the chronological development of the patient's current endocrine-related symptoms or condition, including any associated symptoms, exacerbating or relieving factors, and previous treatments or investigations related to this complaint] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) **REVIEW OF SYSTEMS:** [document a systematic review of symptoms across various body systems, including general, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, neurological, dermatological, and psychological, with specific attention to endocrine-related symptoms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) **PAST MEDICAL HISTORY:** [list all significant past medical conditions, including chronic diseases, previous hospitalizations, and any other relevant health issues. also include surgical procedures (including dates and complications) here, not in a separate Past Surgical History section] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) **MEDICATIONS:** [document a comprehensive list of all current medications, including prescription drugs, over-the-counter medications, supplements, and herbal remedies, along with dosages and frequencies] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) **ALLERGIES:** [list all known allergies to medications, food, or environmental substances, specifying the type of reaction] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) **FAMILY HISTORY:** [record relevant family medical history, focusing on endocrine disorders, autoimmune conditions, and other significant illnesses in first-degree relatives] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) **SOCIAL HISTORY:** [describe aspects of the patient's social life relevant to their health, including occupation, living situation, diet, exercise habits, smoking, alcohol consumption, and recreational drug use] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) **PHYSICAL EXAMINATION:** [detail the findings of the physical examination, including general appearance, vital signs, and focused examination of relevant systems (e.g., thyroid palpation, skin changes, signs of hormonal imbalance). do not include findings here that were mentioned by the patient in the history, only include findings that the physician mentions on their examination] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) **INVESTIGATIONS:** [list any relevant laboratory tests, imaging studies, or other diagnostic procedures that have been performed or are pending, along with their results if available, and include dates] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) **IMPRESSION:** [state the provisional or definitive diagnosis based on the clinical assessment and available data, include differential diagnoses that are mentioned in the transcript. do not include medical conditions that are irrelevant to the current endocrine condition] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) **PLAN:** [outline the proposed plan for treatment, including further investigations, pharmacological interventions, lifestyle modifications, referrals to other specialists, and patient education. include the rationale for each component of the plan. when discussing medications, make sure to include potential risks and side effects that were mentioned] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) **FOLLOW-UP:** [outline the proposed plan for follow-up with the current provider] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) "This document was created using AI Ambient Scribe and Front-End Speech Recognition software and may include incorrect spelling/words. Consent for usage of AI was obtained by patient/guardian." (Never come up with your own patient details, assessment, plan, interventions, evaluation, or 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.)