Clinician's Specialty: General Practitioner
History:
1. Patient presents with a 3-day history of a persistent, productive cough.
Cough is described as chesty, producing yellow-green phlegm. Severity is moderate, impacting sleep.
Duration: 3 days.
Recent illness: Patient recently recovered from a mild common cold approximately 5 days ago.
Associated symptoms: Mild sore throat, fatigue, and occasional sneezing. No fever reported.
Current treatments and their effects: Patient has been taking over-the-counter cough suppressants with minimal relief. Increased fluid intake has helped with throat soreness.
Treatment planned for Issue 1: Prescribed amoxicillin 500mg three times daily for 7 days.
2. Patient reports intermittent lower back pain, exacerbated by prolonged sitting or standing.
Pain is a dull ache, sometimes sharp with movement. Severity is mild to moderate, rated 4/10 on average.
Duration: Approximately 2 weeks.
Recent events: Patient moved heavy furniture last week.
Associated symptoms: No radiation to legs, no numbness or tingling. Slight stiffness in the mornings.
Current treatments and their effects: Patient has been using paracetamol occasionally with some pain reduction. Applied heat packs which provide temporary relief.
Treatment planned for Issue 2: Advised rest, application of heat, and referred for physiotherapy assessment.
Past history:
Relevant past medical conditions: No significant past medical history. No known allergies.
Family history:
Relevant past family history: Mother has type 2 diabetes. Father had hypertension. No family history of respiratory conditions.
Examination:
Findings from the physical examination: Patient appeared comfortable, not acutely distressed. Lungs clear to auscultation bilaterally, no wheezes or crackles. Throat mildly red, no exudates. Lumbar spine showed full range of motion, no tenderness on palpation. Neurological examination of lower limbs unremarkable.
Negative findings mentioned on examination: No fever. No lymphadenopathy. No signs of respiratory distress.
- Vital signs listed: T 36.8°C, Sats 98% on air, HR 72 bpm, BP 120/80 mmHg, RR 16 breaths/min.
- Physical or mental state examination findings:
- General: Alert and oriented, cooperative.
- Respiratory: Normal chest expansion, no accessory muscle use.
- Musculoskeletal: Spinal contours normal, no scoliosis. Muscle strength 5/5 in bilateral lower extremities.
Plan:
Patient advised to complete the course of antibiotics for the cough. Continue with rest and heat application for back pain, with a physiotherapy referral to be arranged. Follow-up in 1 week or sooner if symptoms worsen.
History:
1. [Detailed description for symptom 1] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Symptom quality and severity] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Symptom duration] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Recent illnesses or events] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Associated symptoms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Current treatments and their effects] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Treatment planned for Issue 1 (only if applicable)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
2. [Detailed description for symptom 2] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Symptom quality and severity] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Symptom duration] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Recent illnesses or events] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Associated symptoms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Current treatments and their effects] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Treatment planned for Issue 2 (only if applicable)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
3. [Detailed description for symptom 3] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Symptom quality and severity] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Symptom duration] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Recent illnesses or events] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Associated symptoms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Current treatments and their effects] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Treatment planned for Issue 3 (only if applicable)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
4. [Detailed description for symptom 4] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Symptom quality and severity] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Symptom duration] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Recent illnesses or events] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Associated symptoms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Current treatments and their effects] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Treatment planned for Issue 4 (only if applicable)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
5. [Detailed description for symptom 5] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Symptom quality and severity] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Symptom duration] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Recent illnesses or events] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Associated symptoms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Current treatments and their effects] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Treatment planned for Issue 5 (only if applicable)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Past history: (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Relevant past medical conditions, surgeries, hospitalisations, medications and ongoing treatments] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Possible medication side effects if explicitly mentioned] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Family history: (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Relevant past family history and social history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Examination: (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Findings from the physical examination, including vital signs and any abnormalities] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Negative findings mentioned on examination] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Only put examination findings in once] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Vital signs listed, eg. T , Sats %, HR , BP , RR , (as applicable)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Physical or mental state examination findings, including system specific examination] (Only include if applicable, and use as many bullet points as needed to capture the examination findings) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Plan:
[Summarise treatment plan for all problems detailed above] (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 transcript or context, else omit section entirely. Never come up with your own patient details, assessment, plan, interventions, evaluation, or next steps—use only the transcript, contextual notes, or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)
