PATIENT
John Smith
DATE OF CONSULTATION
1 November 2024
PLACE OF CONSULTATION
Rooms, 123 Vascular Clinic, London
PROBLEM LIST
68-year-old male
* Chronic limb ischaemia, right leg
* Rutherford class 3
* Peripheral arterial disease, multilevel
* Previous right femoropopliteal bypass (2022)
* Right common iliac artery 80% stenosis
* Type 2 Diabetes Mellitus
* Insulin dependent, suboptimal control (HbA1c 8.5%)
* Diabetic neuropathy, mild
* No evidence of retinopathy or nephropathy
* Hypertension
* Controlled on 2 antihypertensive agents (ramipril, amlodipine)
* Left ventricular hypertrophy, mild
* Hyperlipidaemia
* On statin therapy
NEW CONCERNS/COMPLAINTS
Patient reports increased claudication distance to 50 meters, previously 100 meters, right calf pain.
CLINICAL EXAMINATION
Right leg: Cool to touch below knee. Absent popliteal, dorsalis pedis, and posterior tibial pulses. Capillary refill time >3 seconds. No trophic changes. No ulceration. Left leg: WNL.
SPECIAL INVESTIGATIONS
Laboratory Results
* HbA1c: 8.5% (previous 7.9%)
* Creatinine: 98 µmol/L (stable)
* eGFR: 65 mL/min/1.73m²
Imaging Studies
* Duplex Ultrasound, Right Leg Arteries (1 November 2024): Significant flow reduction in right common iliac artery, consistent with known 80% stenosis. Patent femoropopliteal bypass graft with good flow.
ASSESSMENT
68-year-old male
* Chronic limb ischaemia, right leg
* Worsening claudication, Rutherford class 3
* Critical right common iliac artery stenosis (80%)
* Patent femoropopliteal bypass graft
* Type 2 Diabetes Mellitus
* Insulin dependent, suboptimal control (HbA1c 8.5%)
* Diabetic neuropathy, mild
* Hypertension
* Controlled on 2 antihypertensive agents
* Left ventricular hypertrophy, mild
* Hyperlipidaemia
* On statin therapy
PLAN
* Investigations planned
* CT angiogram aorta and bilateral lower limb arteries
* Referral for formal treadmill test
* Treatments planned
* Optimise diabetic control: Liaise with endocrinology, consider insulin regimen adjustment
* Continue current antihypertensive and statin therapy
* Referrals
* Endocrinologist for diabetes management
* Lifestyle recommendations
* Supervised exercise programme
* Smoking cessation reinforcement
TTO
Nil
FOLLOW-UP DATE
1 February 2025
DOCTORS TO BE COPIED IN
Dr Sarah Lee (GP), Dr Mark Jones (Endocrinologist)
Comments
Patient educated on importance of diabetes control and smoking cessation. Discussed risks and benefits of potential revascularisation procedures.
(All notes should be listed without full stops at the end of the sentence.)
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(Generate notes in telegraphic style. Use short phrases, no filler words. Omit articles such as the, a, an. Summarised, concise format preferred.)
PATIENT
[Full name of patient] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
DATE OF CONSULTATION
[Date of consultation] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
PLACE OF CONSULTATION
[Location of consultation including whether the patient was seen in rooms or in hospital, and if so, which rooms or which hospital] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
PROBLEM LIST
[Patient age] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else leave the placeholder blank and do not omit the heading.) -year-old [male or female] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else leave the placeholder blank and do not omit the heading.)
[Duplicate of the Assessment section from the last patient encounter as indicated in the contextual notes, reproduced word for word] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Duplicate word for word.)
NEW CONCERNS/COMPLAINTS
[New complaints or concerns raised by the patient, or confirmation that no new complaints were raised] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
CLINICAL EXAMINATION
[New relevant clinical findings and absence of relevant findings where applicable] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
SPECIAL INVESTIGATIONS
Laboratory Results
[New completed laboratory investigations with results] (Only include completed investigations with results if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Planned or ordered investigations should be documented under the Plan section.)
Imaging Studies
[New completed imaging investigations with results] (Only include completed investigations with results if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Planned or ordered investigations should be documented under the Plan section.)
Other
[New completed investigations not listed under laboratory or imaging, including electrocardiogram and echocardiogram, with results] (Only include completed investigations with results if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Planned or ordered investigations should be documented under the Plan section.)
ASSESSMENT
[Patient age]-year-old [male or female]
[Updated problem list based on the Problem List section of this note, incorporating new findings from today's history, examination, and investigations while retaining original wording, with each problem named clearly, stratified by severity or risk stage, and including control status where relevant] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Do not invent or infer a diagnosis. Write as a multi-level bullet-point list using concise clinical wording without filler words. If the patient is diabetic, include type of diabetes, insulin use, level of glycaemic control based on HbA1c, and any evidence of diabetic complications. If the patient has hypertension, include whether it is controlled, the number of antihypertensive agents, and any evidence of target organ damage. If the patient has chronic obstructive pulmonary disease, include severity according to GOLD classification if lung function tests are available and frequency of exacerbations. Include relevant imaging findings and previous interventions under the corresponding condition.)
PLAN
[Investigations planned, treatments planned, and any other relevant actions including counselling, referrals, and lifestyle recommendations] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as a multi-level bullet-point list.)
TTO
[To take out medications] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else leave the placeholder blank and do not omit the heading.)
FOLLOW-UP DATE
[Follow-up date] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else leave the placeholder blank and do not omit the heading.)
DOCTORS TO BE COPIED IN
[Names of all doctors involved in the patient's care to whom the report should also be sent] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
Comments
[Patient education, monitoring and management instructions, and any specific patient or family concerns addressed during the consultation] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else leave the placeholder blank and do not omit the heading.)