Pre-Employment Exam

[Mention age and gender] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit. Use this to determine if patient is addressed as sir or ma'am.) [Mention any drug allergies or lack of drug allergies if available] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit.) [Mention code status of patient if available] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit.) [Mention smoking history if available] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit.) [Mention activities of daily living and independence if available] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit.) [Mention occupation if available] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit.) [Mention dominant hand of patient if available] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit.) [Mention accompanying family members or friends if available] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit.) (Do not include the patient's name.) Past Medical History: [Mention contributing factors including past medical and surgical history, investigations, treatments, relevant to the reasons for visit and chief complaints] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit. Number each condition.) -[Mention social history that may be relevant to the reasons for visit and chief complaints] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit.) -[Mention family history that may be relevant to the reasons for visit and chief complaints] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit.) -[Mention exposure history] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit.) - Other: [Mention any other relevant subjective information] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit.) (If no past medical history is mentioned, print "No known significant past medical history.") Vaccination History: -[Mention vaccination and immunization history and status] (Only include this entire section if explicitly mentioned in transcript, contextual notes or clinical note, else omit this entire section including the heading.) Family History: -[Mention family history in this section] (Only include if explicitly mentioned in transcript, contextual notes or clinical note. If no family history is mentioned, print "No known significant family history.") Presenting: "1) Pre-employment medical examination" -[Mention reasons for visit, chief complaints such as requests, symptoms etc] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit.) -[Mention duration, timing, location, quality, severity, context of complaint] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit.) -[Mention anything that worsens or alleviates the symptoms, including self-treatment attempts and their effectiveness] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit.) -[Progression: Describe how the symptoms have changed or evolved over time] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit.) -[Previous episodes: Detail any past occurrences of similar symptoms, including when they occurred, how they were managed, and the outcomes] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit.) -[Impact on daily activities: Explain how the symptoms affect the patient's daily life, work, and activities] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit.) -[Associated symptoms: Mention any other symptoms, focal and systemic, that accompany the reasons for visit and chief complaints] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit.) LMP: -[Mention day of last menstrual period/menses] (Only include this entire section if explicitly mentioned in transcript, contextual notes or clinical note, else omit this entire section including the heading.) Examination: (If "examination with chaperone" is mentioned in the transcript, print "With female Nurse Chaperone." at the start of this section.) -[Mention abnormal constitutional findings] (If normal or not explicitly mentioned as abnormal in transcript, contextual notes or clinical note, print "Afebrile Vitals unremarkable GCS 15") -[Mention abnormal eye findings] (If normal or not explicitly mentioned as abnormal in transcript, contextual notes or clinical note, print "PEARL. EOM full No subconjunctival pallor No scleral icterus Ophthalmoscopy: Normal bilaterally. No papilloedema") -[Mention abnormal ear findings] (If normal or not explicitly mentioned as abnormal in transcript, contextual notes or clinical note, print "Otoscopy: TM clear bilaterally") -[Mention abnormal mouth or throat findings] (If normal or not explicitly mentioned as abnormal in transcript, contextual notes or clinical note, print "Mucous membranes moist") -[Mention abnormal neurological findings] (If normal or not explicitly mentioned as abnormal in transcript, contextual notes or clinical note, print "CN II-XII grossly intact No focal upper limb or lower limb neuro deficits No cerebellar signs Steady gait") -[Mention abnormal spine findings] (If normal or not explicitly mentioned as abnormal in transcript, contextual notes or clinical note, print "No spinal tenderness or step deformity") -[Mention abnormal cardiovascular findings] (If normal or not explicitly mentioned as abnormal in transcript, contextual notes or clinical note, print "H S1S2. No murmur") -[Mention abnormal respiratory findings] (If normal or not explicitly mentioned as abnormal in transcript, contextual notes or clinical note, print "L Clear") -[Mention abnormal abdominal findings] (If normal or not explicitly mentioned as abnormal in transcript, contextual notes or clinical note, print "A Soft. Non-tender Murphy's negative No hepatosplenomegaly BS+ Hernia orifices clear") -[Mention abnormal extremity or vascular findings] (If normal or not explicitly mentioned as abnormal in transcript, contextual notes or clinical note, print "Calves supple No pedal oedema") -[Mention abnormal skin findings] (If normal or not explicitly mentioned as abnormal in transcript, contextual notes or clinical note, print "No rash") -[mental state examination findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit entirely.) Impression: "1) Pre-employment medical examination" Plan: -[Investigations planned] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit.) -[Treatment planned] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit.) -[Mention relevant other actions such as referrals etc] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit.) (Do not include counselling and advice in this section. Keep this section brief and to the point. No exposition required.)