History
Face to face consultation.
Patient attended alone.
Patient presents today with a cough and shortness of breath.
Patient is concerned about the cough and is worried it might be something serious. They are hoping to get some medication to help.
The cough is impacting their sleep and ability to work.
Patient reports a dry cough, worse at night. No fever or chest pain. No recent travel. No known allergies. No history of asthma or COPD.
No red flag symptoms.
Patient is a smoker, 20 cigarettes per day for 30 years.
Patient has tried over-the-counter cough medicine with no relief.
Past medical history: Hypertension, controlled with medication.
[examination findings]
T: 37.1°C, Sats 98%, HR 88 bpm, BP 140/85 mmHg, RR 18 breaths/min.
Chest auscultation: Mild wheezing in the left lung.
Impression:
1. Cough. Acute bronchitis.
- Rule out pneumonia.
2. Hypertension. Controlled.
Plan:
- Chest X-ray.
- Prescribe Salbutamol inhaler 100mcg, 2 puffs as required.
- Advise smoking cessation support.
- Review blood pressure in 2 weeks.
- Advised to call 111 if symptoms worsen or if they develop chest pain or difficulty breathing.
- Follow up in 2 weeks.
- Advised to seek immediate medical attention if they experience severe chest pain, difficulty breathing, or coughing up blood.
Heidi notetaking used.
Suggestions:
Consider pneumonia as a differential diagnosis given the patient's smoking history and wheezing. The chest X-ray is appropriate. Smoking cessation advice is essential. Review blood pressure control at the follow-up appointment. Consider offering nicotine replacement therapy or referral to a smoking cessation clinic. Management of acute bronchitis is in line with NICE guidelines. No red flags were mentioned and acted upon.
History
[state if face to face or telephone consultation (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
[if F2F state if alone or who is attending with the patient (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
[summary of the presenting issue/problem (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
[what the patient is concerned or worried about, what thoughts they had and what they were hoping or expecting from the consultation (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
[how the problem(s) are impacting on them at work, at home, emotionally (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
[any additional information or answers given to relevant questions asked about symptoms (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
[Presence or absence of red flag symptoms relevant to the presenting complaint (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
[Relevant risk factors (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
[what they have tried already including medication or therapies (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
[any relevant past medical history (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
(do not leave blank lines between text in history. use patient name at start if known but then do not keep repeating it through the history. make a summary of the points if some things are repeated)
[examination findings]
[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.)]
[Investigations with results (Only include if applicable and if mentioned) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
Impression:
[1. Issue, problem or request 1 (issue, request or condition name only)]. [Assessment, likely diagnosis for Issue 1 (condition name only) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Differential diagnosis for Issue 1 (include only if applicable) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
[2. Issue, problem or request 2 (issue, request or condition name only)]. [Assessment, likely diagnosis for Issue 2 (condition name only) (Only include if mentioned) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Differential diagnosis for Issue 2 (include only if applicable) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
[3. Issue, problem or request 3, 4, 5 etc (issue, request or condition name only)]. [Assessment, likely diagnosis for Issue 3, 4, 5 etc (condition name only) (Only include if mentioned) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Differential diagnosis for Issue 3, 4, 5 etc (include only if applicable) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
Plan:
- [Investigations planned for Issue 1 (include only if applicable and if mentioned) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Treatment planned for Issue 1 (include only if applicable and if mentioned) (do not add detail of which pharmacy the medication is being sent to) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Relevant referrals for Issue 1 (include only if applicable and if mentioned) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Investigations planned for Issue 2 (include only if applicable and if mentioned) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Treatment planned for Issue 2 (include only if applicable and if mentioned) (do not add detail of which pharmacy the medication is being sent to) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Relevant referrals for Issue 2 (include only if applicable and if mentioned) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Investigations planned for Issue 3, 4, 5 etc (include only if applicable and if mentioned) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Treatment planned for Issue 3, 4, 5 etc (include only if applicable and if mentioned) (do not add detail of which pharmacy the medication is being sent to) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Relevant referrals for Issue 3, 4, 5 etc (include only if applicable and if mentioned) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Follow up plan (noting timeframe if stated or applicable) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Safety netting advice given (for example, if mentioned, state which symptoms would mean they need to call back GP OR call 111 (non-life threatening) for out of hours GP or if deteriorates to attend A&E/call 999 in life-threatening emergency (include only the advice/options which are mentioned in transcript or contextual notes)) (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.)
[add here: "Heidi notetaking used."]
Suggestions:
(at the end here please add in suggested diagnosis / diagnoses based on patient history/examination/other data and add in suggested management IF this differs from what has been explicitly stated or advised. If no examination has occurred that would have helped this can be commented upon. If medication that was given was not following guidelines this can be commented on, or suggestions for correct medication or treatment can be stated. If no safety net has been offered or review time period stated and this is clinically relevant this should also be commented upon. Specifically mention if red flag symptoms have been mentioned and not acted upon and what those red flags might indicate.)
(management of conditions based on uk general practice guidelines/NICE CKS, if there are relevant sources of information on management indicate and reference to these here and provide links if you have them)
