Admission Note

Clinical Note: Patient: [Insert patient’s full name] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in a continuous line of text.) Age: [Insert patient’s age] (DOB: [Insert patient’s date of birth]) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in a continuous line of text.) cc: [Insert person(s) accompanying the patient] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in a continuous line of text.) Date seen: [Insert admission date] – [Insert discharge date] (inpatient admission) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in a continuous line of text.) Clinician: [Insert clinician’s name and profession] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in a continuous line of text.) Chief Complaint: - [Insert description of chief complaint(s), including symptoms and onset] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) History of Presenting Complaint: [Insert detailed history of the presenting complaint, including onset, progression, associated symptoms, and relevant events or observations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in full sentences.) Physical Examination: General appearance on admission: - [Insert description of general appearance, demeanour, alertness, and notable observations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Throat examination: - [Insert throat examination findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Neck examination: - [Insert neck examination findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Special Investigations: - [Insert full blood count results with relevant abnormalities] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Insert C-reactive protein (CRP) level] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Insert EEG investigation status or results] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Diagnosis: - [Insert primary diagnosis, including qualifiers such as “possible” if stated] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Insert secondary or co-occurring diagnosis] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Management Plan: - [Insert details of medical interventions performed, such as IV access or drips and their purpose] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Insert results of blood tests during admission, including specific values] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Insert medications initiated with dosage and indication] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Insert symptomatic treatments provided] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Insert details of further investigations planned or performed] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Insert date of subsequent examination] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Examination: - General appearance: [Insert description of general appearance on this date] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - HEENT: [Insert head, eyes, ears, nose, and throat findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Other systems: [Insert statement regarding normality or abnormalities of other systems] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Management: - [Insert discharge instructions, medications, dosages, and duration] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Insert instructions for managing future symptoms such as fever] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Follow-up: - [Insert follow-up plans, rescheduled appointments, or further investigations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (For each section, only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the section entirely. Never come up with your own patient details, diagnoses, examination findings, assessments, management plans, treatments, or follow-up arrangements. Use only the transcript, contextual notes, or clinical note as the source of truth. If any information related to a placeholder has not been explicitly mentioned, do not state that it is missing—simply omit the placeholder or section entirely.)