Pulmonary Clinic Note

Pulmonary Clinic Note [Specify visit type: Initial Consult/Follow-up] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in full sentences to clearly state the type of pulmonary visit.) Patient’s Name: [Insert patient name] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write full legal name.) Date of Service: [Insert date] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Use DD/MM/YYYY format in line with South African standards.) Consulting Physician: [Insert physician name] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Include full name and credentials.) Referring Provider: [Insert referring provider if applicable] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Include name and facility if stated, e.g. CHC, district hospital.) Chief Complaint: [Describe the patient’s chief complaint or reason for visit] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) History of Present Illness: [Introduce the patient with age, relevant history, and reason for evaluation] [Describe onset and progression of symptoms] [Summarise prior treatments or interventions, including public sector prescriptions or oxygen from district hospitals] [Summarise results of previous imaging and diagnostic testing (e.g. TB GeneXpert, sputum AFB, CXR findings)] [Describe exacerbations and hospitalisations (e.g. ER visits at tertiary centres, admissions to state hospitals)] [Describe current symptom status and associated complaints] [Document environmental and occupational exposures, including mining, factory work, paraffin use, woodfire cooking] [Describe relevant comorbidities impacting respiratory health] [Summarise previous specialist evaluations and record reviews (e.g. pulmonologist at regional hospital, infectious diseases clinic follow-up)] [Describe patient’s functional status and symptom impact on daily life] [Summarise patient’s or family’s concerns and expectations] (Only include if explicitly mentioned in transcript or context, else omit each line item entirely.) Interval History: [Summarise changes or events since last visit] (Use bullet points. Only include if explicitly mentioned.) Past Medical and Surgical History: [List relevant medical conditions and surgeries with dates] - [e.g. Pulmonary TB – diagnosed 08/2021, completed treatment 03/2022] - [e.g. HIV – on ART since 2016, latest VL undetectable 02/2023] (Only include if explicitly mentioned.) Current Medications: [List current medications including dose, frequency, and route] - [e.g. Salbutamol inhaler 2 puffs PRN] - [e.g. Isoniazid 300mg daily – prophylaxis] (Only include if explicitly mentioned.) Allergies: [List known allergies and reactions] - [e.g. No Known Drug Allergies (NKDA)] - [e.g. Penicillin – rash] (Only include if explicitly mentioned.) Active Ambulatory Problems: [List currently active diagnoses with dates] (Only include if explicitly mentioned.) Resolved Ambulatory Problems: [List resolved diagnoses with dates] (Only include if explicitly mentioned.) Family History: [Document family history of relevant conditions such as asthma, TB, COPD, lung cancer] (Only include if explicitly mentioned.) Social History: (Use bullet points. Only include if explicitly mentioned.) - Tobacco Use: [Include pack years and cessation attempts if applicable] - Marijuana Use: [Include route and frequency] - Vaping: [Include frequency and brand/device if known] - Alcohol Use: [Include quantity and type] - Illicit Drug Use: [Include type and route] - Employment History: [e.g. Mineworker for 12 years, exposed to silica dust] - Living History: [e.g. Lives in informal settlement with indoor cooking using paraffin] - Pets: [e.g. Keeps pigeons at home] - Home Exposures: [e.g. Damp, visible mould on walls, unventilated space] - Inhalant/Irritant Exposures: [e.g. Paint fumes, chemical factory] - Other Identifiable Toxic Exposures: [e.g. Worked with asbestos in past employment] Review of Systems: [Summarise patient-reported symptoms by system] (Use bullet points per system. Only include if explicitly mentioned.) OBJECTIVE Vitals: - Blood Pressure: [Document BP reading] - Pulse: [Document HR] - Oxygen Saturation: [Document on room air and/or exertion] - Weight: [Include kg and change from previous weight if known] - Height: [Document in cm or metres] (Only include if explicitly mentioned.) Physical Exam: - General Appearance: [e.g. Cachectic, in mild respiratory distress, alert] - Head: [e.g. Normocephalic, no facial swelling] - Eyes: [e.g. Conjunctiva pale] - Cardiovascular Exam: [e.g. Regular rate and rhythm, no murmurs] - Chest/Lungs: [e.g. Decreased air entry bilateral bases, coarse crackles RLL] - Abdomen: [e.g. Soft, non-tender, no hepatosplenomegaly] - Extremities: [e.g. No pedal oedema, no digital clubbing] - Neurological Exam: [e.g. Alert, oriented x3, grossly intact motor and sensation] (Only include items above if explicitly mentioned.) Review of Laboratory Data: (Only include if explicitly mentioned. Use bullet points under each relevant heading.) - Electrolytes/Renal Function: - Hematology: - Liver Function Tests: - Coagulation Studies: - Inflammatory Markers/Infection: - Metabolic Panel: - Arterial Blood Gas: - Additional Tests: Review of Imaging and Studies: - [Date, Type of Study:] - Findings: - Impression: (Only include if explicitly mentioned.) Pulmonary Function Test Results: - [Summarise FEV1, FVC, DLCO etc and interpret pattern if available] (Only include if explicitly mentioned.) Assessment and Plan: [Summarise each active issue and plan, using bullet or numbered list] - [e.g. Chronic asthma: continue ICS/LABA, reinforce spacer use, repeat PFTs in 3 months] - [e.g. History of PTB with fibrosis: monitor symptom progression, consider HRCT] - [e.g. Suspected COPD: initiate tiotropium, arrange smoking cessation referral] Follow-up: [Specify next clinic appointment, pending results, and referrals to e.g. state cardiology, CT scan at district hospital, DOTS programme, TB clinic] (Only include if explicitly mentioned.) Pulmonary Health Maintenance: [List vaccination and screening plans, e.g.:] - Influenza vaccine - Pneumococcal vaccine - COVID-19 booster - Smoking cessation support (Only include if explicitly mentioned.) Immunization History: [Summarise vaccinations administered, e.g.:] - Influenza: [DD/MM/YYYY] - Pneumococcal: [DD/MM/YYYY] - COVID-19: [DD/MM/YYYY] (Only include if explicitly mentioned.) (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 that 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 as needed to capture all the relevant information from the transcript.)