Specialty: General Practitioner
Summary:
Patient is a 45-year-old male who underwent excision of a sebaceous cyst from his left forearm two weeks prior. No significant past medical history. The previous procedure was uncomplicated.
Follow-up: Session 1
Consultation Date:
1 November 2024
Wound Assessment:
- Wound appearance: 3 cm linear incision, clean with well-approximated edges. No surrounding erythema or swelling. Staples are intact. No discharge present. Granulation tissue noted, indicating good healing progress.
- Wound management performed: Wound cleaned with saline solution. Staples removed. Steri-strips applied.
Management Plan Updates:
- Management plan updates: Advised patient to keep the area clean and dry. Avoid heavy lifting for the next 48 hours. No further dressing required. Monitor for any signs of infection (redness, pus, increased pain).
- Medications administered: None.
Follow-up: Session 2
Consultation Date:
8 November 2024
Wound Assessment:
- Wound appearance: Incision site is fully closed and well-healed. No signs of infection, discolouration, or tenderness. Steri-strips have fallen off naturally. Minimal scarring visible.
- Wound management performed: Briefly cleaned the site with antiseptic wipes. No further intervention required.
Management Plan Updates:
- Management plan updates: Advised patient that the wound is fully healed. Normal activities can be resumed. No specific restrictions.
- Medications administered: None.
Final Note:
- Concise summary of the patient’s treatment progress: The patient's wound from the sebaceous cyst excision has healed completely without complications over two follow-up sessions. Initial assessment showed good healing with staple removal, followed by complete closure and resolution in the subsequent visit.
- Outline final instructions given to the patient: Patient discharged from wound care. Advised to moisturise the area to help with scar maturation. No further follow-up appointments are necessary regarding this wound. Patient was advised to contact the surgery if any new concerns arise.
Summary:
[Summarize the patient's condition, relevant medical history, and details of the previously performed procedure as extracted from the prior procedure note] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Follow-up: Session [Insert session number starting from 1 and increment sequentially] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Consultation Date:
[Insert date of the follow-up consultation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Wound Assessment:
- [Describe wound appearance including size, colour, discharge, sutures, and signs of infection or healing progress] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Describe wound management performed during this consultation such as cleaning, dressing changes, suture removal, or debridement] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Management Plan Updates:
- [Document any changes or modifications to the original post-procedure management plan, including reasons and updated instructions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [List any medications administered during this consultation, including name, dose, route, and indication] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Follow-up: Session [Insert next session number] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Consultation Date:
[Insert date of the follow-up consultation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Wound Assessment:
- [Describe wound appearance including size, colour, discharge, sutures, and signs of infection or healing progress] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Describe wound management performed during this consultation such as cleaning, dressing changes, suture removal, or debridement] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Management Plan Updates:
- [Document any changes or modifications to the original post-procedure management plan, including reasons and updated instructions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [List any medications administered during this consultation, including name, dose, route, and indication] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Final Note:
- [Provide a concise summary of the patient’s treatment progress across all follow-up sessions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Outline final instructions given to the patient, including future follow-up appointments, referrals, or additional investigations requested] (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, wound findings, assessments, management plans, medications, instructions, 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. If multiple follow-up sessions are documented, include each session as a separate section in numerical order, and include the Final Note only once after all sessions.)