PATIENT'S NAME: Sarah Jenkins
Date of Service: 01/11/2024
Date of Birth: 15/03/2022
Age: 2 years, 7 months, 17 days
Sex: Female
Accompanied By: Emily Jenkins (Mother)
Subjective:
- Reason for Visit: Persistent cough and low-grade fever for 3 days.
- History of Present Illness: Sarah developed a non-productive cough 3 days ago, which has since become productive with clear mucus. Her mother reports intermittent low-grade fever (max 38.2°C) managed with paracetamol. No difficulty breathing or wheezing noted by mother. Appetite slightly reduced, but remains hydrated. Attends nursery.
- Review of Systems:
- Respiratory: Productive cough, no shortness of breath, no stridor.
- Constitutional: Low-grade fever, mild fatigue.
- HEENT: No ear pain, no sore throat, no nasal discharge initially, now clear rhinorrhoea.
- Gastrointestinal: Normal bowel movements, no vomiting or diarrhoea.
- Skin: No rashes.
- Past Medical History: Full-term healthy baby. No significant past medical history. No hospitalisations.
- Medication History: Paracetamol 120mg as needed for fever (last dose 6 hours ago).
- Allergies: No known drug allergies (NKDA). No food or environmental allergies.
- Immunisations: Up-to-date according to EPI-SA schedule (all recommended doses for age received).
- Growth and Development: Meeting all developmental milestones. Walks independently, uses several words, feeds self with spoon. No recent concerns from mother.
- Diet and Nutrition: Breastfed until 12 months, now on solids and cow's milk. Eats a varied diet, no specific food preferences or aversions. Good hydration with water. No food security concerns.
- Family History: Mother has seasonal allergies. Maternal grandfather had hypertension. No family history of TB or diabetes.
Objective:
- Growth Parameters: Wt: 13.5 kg, Ht: 92 cm
- Vital Signs: Temp: 37.8°C, Pulse: 110 bpm, Respiratory Rate: 28 bpm, Blood Pressure: 90/55 mmHg, Oxygen Saturation: 98% on room air
Physical Examination:
- General Appearance: Alert, interactive and playful, in no acute distress. Mild nasal congestion.
- Eyes: Clear conjunctivae, pupils equal and reactive to light. No discharge.
- Nose: Clear rhinorrhoea, mild mucosal oedema.
- Ears: Tympanic membranes clear, intact, and pearly grey bilaterally. No discharge. Responds to soft voice.
- Throat: Oropharynx mildly erythematous. Tonsils 1+. No exudates.
- Chest/Lungs: Symmetrical chest expansion. Good air entry bilaterally. Occasional scattered coarse crepitations, no wheeze or rhonchi. No increased work of breathing.
- Cardiovascular: S1 S2 heard, regular rhythm. No murmurs. Peripheral pulses strong and equal. Capillary refill time <2 seconds.
- Abdomen: Soft, non-tender, non-distended. No organomegaly detected. Bowel sounds present and active.
- Skin: Warm and dry. No rashes, lesions, or petechiae. Good skin turgor.
- Musculoskeletal: Full range of motion in all extremities. No joint effusions or tenderness. Normal gait for age. No deformities.
- Central Nervous System: Alert and oriented to surroundings. Appropriate tone and reflexes for age. Good head control. Demonstrates age-appropriate social interaction and play.
Investigations:
- Rapid Strep Test: Negative
- Urinalysis: Negative
Assessment and Plan:
- Viral Upper Respiratory Tract Infection (URTI)
- Investigations planned for this issue: None at this time, symptoms are consistent with viral aetiology.
- Treatment planned for this issue: Supportive care including adequate hydration, nasal saline drops for congestion, and paracetamol for fever/discomfort as needed. Advised mother on signs of worsening condition (e.g., increased work of breathing, persistent high fever, lethargy) and to return if concerns arise.
- Relevant referrals for this issue: None.
Clinician Signature:
Dr. Aisha Khan
PATIENT'S NAME: [Patient's full name] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.)
Date of Service: [Current Date] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.)
Date of Birth: [DD/MM/YYYY] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.)
Age: [Age in years, months, days] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.)
Sex: [Sex of the patient] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.)
Accompanied By: [Person accompanying the patient] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.)
Subjective:
- Reason for Visit: [Specific complaint or reason for the visit] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.)
- History of Present Illness: [Detailed description including onset, duration, character, and associated symptoms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.)
- Review of Systems: [Pertinent positives and negatives] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.)
- Past Medical History: [Details on chronic conditions, previous illnesses, and surgeries] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.)
- Medication History: [List of current medications and dosages] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.)
- Allergies: [Specific allergies, especially to medications] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.)
- Immunisations: [Status of immunisations according to South African Expanded Programme on Immunisation (EPI-SA) schedule] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.)
- Growth and Development: [Milestones and concerns] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.)
- Diet and Nutrition: [Feeding patterns, dietary intake, breastfeeding status, food security considerations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.)
- Family History: [Hereditary conditions or relevant family diseases such as TB, hypertension, diabetes] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.)
Objective:
- Growth Parameters: Wt: [Weight in kg], Ht: [Height in cm] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.)
- Vital Signs: [Temperature (°C), Pulse (bpm), Respiratory Rate (bpm), Blood Pressure (mmHg), Oxygen Saturation (%)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.)
Physical Examination:
- General Appearance: [Overall health appearance and demeanour] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.)
- Eyes: [Ophthalmic findings, visual tracking or discharge] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.)
- Nose: [Nasal findings including congestion or discharge] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.)
- Ears: [Tympanic membrane status, discharge, hearing response] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.)
- Throat: [Oropharyngeal findings including tonsil size, inflammation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.)
- Chest/Lungs: [Respiratory findings such as wheeze, crepitations, respiratory effort] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.)
- Cardiovascular: [Heart sounds, murmurs, peripheral pulses, capillary refill] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.)
- Abdomen: [Findings such as distension, tenderness, hepatosplenomegaly] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.)
- Skin: [Rash, lesions, hydration, pigmentation changes] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.)
- Musculoskeletal: [Gait, tone, joint range of motion, deformities] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.)
- Central Nervous System: [Neurological status including alertness, tone, reflexes, developmental observations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.)
Investigations:
[List of any completed investigations and their results such as rapid diagnostic tests, bloodwork, radiology or point-of-care tests] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.)
Assessment and Plan:
[For each identified clinical issue, include the following if applicable:] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.)
- [Description of issue, problem, or clinical question]
- [Investigations planned for this issue]
- [Procedures done for this issue]
- [Treatment planned for this issue]
- [Relevant referrals for this issue, including appropriate public or private health services]
Clinician Signature:
[Name of clinician] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise 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.)
