NeuroMed 1st Consultation

[Patient demographics including age and gender, referring physician, and chief complaint] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write in full sentences.) [Primary diagnosis or clinical concern including relevant demographic context] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Do not invent or infer a diagnosis.) - [Duration of main symptom] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - [Key investigation and result] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - [Working diagnosis or differential diagnosis] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Do not invent or infer a diagnosis.) History of Presenting Illness [Detailed chronological account of symptom onset, progression, character, location, aggravating and relieving factors, associated symptoms, and relevant contextual information] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as detailed bullet points describing the full timeline and characteristics of the presenting complaint.) Past Medical History [Relevant previous medical conditions, hospitalisations, and surgical history] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as bullet points.) Medications [Current medications including name, dose, frequency, and any effects on the presenting complaint] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as bullet points.) Family History [Relevant family medical history] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else write "No relevant family history was discussed.") Physical Examination [Systematic physical examination findings organised by body system] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as bullet points with each point starting with the name of the body system or area examined followed by a colon.) Investigations: [Imaging studies, laboratory tests, and other diagnostic procedures with results] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write each investigation on a separate line.) Summary [Clinical synthesis including patient demographics, presenting complaint, diagnostic considerations, and rationale for the management plan including discussion of procedures, risks, and patient counselling] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as a comprehensive narrative paragraph.) Plan: [Diagnostic and therapeutic interventions with rationale] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write with a main bullet point for each intervention and an optional indented sub-bullet starting with an asterisk to provide the rationale.)