Cardiology Consult Note

I had the pleasure of seeing [document patient's full name] today. [He/She] is a pleasant [document patient's age] year old [document patient's gender] that was referred for cardiac assessment. CARDIAC RISK FACTORS [document presence or absence of increased BMI] (Only include if explicitly mentioned in transcript or context, else write "None known.") [document presence or absence of hypertension] (Only include if explicitly mentioned in transcript or context, else write "None known.") [document presence or absence of dyslipidemia] (Only include if explicitly mentioned in transcript or context, else write "None known.") [document presence or absence of diabetes mellitus] (Only include if explicitly mentioned in transcript or context, else write "None known.") [document smoking status, including pack-years, number of years smoked, and cigarettes or packs per day if available] (Only include if explicitly mentioned in transcript or context, else write "None known.") [if patient is an ex-smoker, document year they quit and whether they quit remotely] (Only include if patient is not currently smoking. Only include if explicitly mentioned in transcript or context, else write "None known.") [document family history of premature atherosclerotic disease in first-degree relatives, including specific events such as MI, PCI, CABG, stroke or peripheral interventions before age 55 in men or 65 in women] (Only include if explicitly mentioned in transcript or context, else write "None known.") CARDIAC HISTORY [document known cardiac diagnoses including heart failure (with HFpEF or HFrEF), cardiomyopathy, arrhythmias (e.g., atrial fibrillation, flutter, SVT, VT, AV block), pacemakers, ICDs, valvular disease, endocarditis, pericarditis, tamponade, myocarditis, coronary artery disease] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) [for heart failure, include subtype (HFpEF/HFrEF), ICD implantation status, date and model if known] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) [for arrhythmias, document history of cardioversions or ablations, including dates and type] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) [for AV block, syncope or bradyarrhythmias, include pacemaker implantation date, model and indication] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) [for valvular disease, include diagnosis, intervention type and year] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) [for coronary disease, list angiogram findings, coronary anatomy, PCI, stents, CABG with graft details and dates] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) OTHER MEDICAL HISTORY [document all relevant non-cardiac conditions and past surgeries with year if known] (Only include if explicitly mentioned in transcript or context, else write "None known.") CURRENT MEDICATIONS [document all current medications, categorised into antithrombotics, antihypertensives, heart failure medications, lipid-lowering agents, and other medications. For each, include drug name, dose, frequency, administration route, and typical tablet/capsule strength if different from patient’s dose] (Only include if explicitly mentioned in transcript or context, else write "None known.") ALLERGIES AND INTOLERANCES [list all allergies or medication intolerances, including type of reaction in parentheses if available, and present them as a sentence separated by commas] (Only include if explicitly mentioned in transcript or context, else write "None known.") SOCIAL HISTORY [describe patient’s living situation, marital or partner status, children, work or retirement status, smoking and alcohol use, recreational or illicit drug use, health or drug plan coverage, and level of independence with ADLs and IADLs. If patient smokes or is ex-smoker, write “Smoking history as above.” If patient is a non-smoker, write “Non-smoker.” If patient drinks alcohol, include frequency and quantity if known] (Only include if explicitly mentioned in transcript or context, else write "None known." Write in short-paragraph narrative form.) HISTORY [document the reason(s) for today’s visit with a detailed history of presenting illness, including symptom onset, frequency, duration, associated features, exacerbating/relieving factors, relevant physical activity patterns and exercise tolerance. Include any relevant negatives] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in narrative paragraphs.) "Review of systems is otherwise non-contributory." PHYSICAL EXAMINATION [document vital signs including blood pressure, heart rate, and oxygen saturation] (Only include if explicitly mentioned in transcript or context, else omit.) [document findings from cardiac examination] (Only include if explicitly mentioned in transcript or context. If not mentioned or if findings are normal, write: "Precordial examination was unremarkable with no significant heaves, thrills or pulsations. Heart sounds were normal with no significant murmurs, rubs, or gallops.") [document respiratory exam findings] (Only include if explicitly mentioned in transcript or context. If not mentioned or if findings are normal, write: "Chest was clear to auscultation.") [document presence or absence of peripheral edema] (Only include if explicitly mentioned in transcript or context. If not mentioned or if normal, write: "No peripheral edema.") [document any other physical exam findings] (Only include if explicitly mentioned in transcript or context. Omit otherwise.) (Write all exam findings together in one short-paragraph narrative.) INVESTIGATIONS [laboratory test results including CBC, electrolytes, creatinine and GFR, troponins, BNP/NT-proBNP, HbA1c, lipid panel and other relevant labs. Include dates in parentheses followed by a colon, formatted in one single line without line breaks] (Only include if explicitly mentioned in transcript or context, else write "None known.") [document ECG results and date in same format] (Only include if explicitly mentioned in transcript or context, else write "None known.") [document echocardiogram findings and date] (Only include if explicitly mentioned in transcript or context, else write "None known.") [document stress test results including stress echocardiograms or exercise challenges with dates] (Only include if explicitly mentioned in transcript or context, else write "None known.") [document Holter monitor findings and date] (Only include if explicitly mentioned in transcript or context, else write "None known.") [document device interrogation results and date] (Only include if explicitly mentioned in transcript or context, else write "None known.") [document cardiac perfusion imaging results and date] (Only include if explicitly mentioned in transcript or context, else write "None known.") [document cardiac CT findings and date] (Only include if explicitly mentioned in transcript or context, else write "None known.") [document cardiac MRI findings and date] (Only include if explicitly mentioned in transcript or context, else write "None known.") [document any other investigations including title and date] (Only include if explicitly mentioned in transcript or context, else write "None known.") SUMMARY [document patient name] is a pleasant [document age] year old [document gender] that was seen today for cardiac assessment. [document list of cardiac risk factors] (Only include if explicitly mentioned in transcript or context, else omit.) [summarise patient’s symptoms and relevant cardiac investigations based on information documented above] (Only include if explicitly mentioned in transcript or context, else omit.) ASSESSMENT/PLAN #1 [document medical issue or condition] Assessment: [document current clinical assessment of this condition] (Only include if explicitly mentioned in transcript or context, else omit.) Plan: [document proposed management plan, including investigations, medications, referrals, education and follow-up. Provide rationale for choices if given.] (Only include if explicitly mentioned in transcript or context, else omit.) (Repeat for additional conditions, continuing numerical listing.) FOLLOW-UP [document follow-up plan and time frame if specified] (Only include if explicitly mentioned in transcript or context. If time frame not mentioned, write: "Will follow-up in due course, pending investigations, or sooner should the need arise.") "Thank you for the privilege of allowing me to participate in [patient's name]’s care. Feel free to reach out directly if any questions or concerns." (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 section blank if not explicitly mentioned. Use as many lines, paragraphs or bullet points as needed to capture all relevant information.)