Subjective:
- Patient presents with a chief complaint of a persistent headache, described as a dull ache located in the frontal region, which began approximately 2 weeks ago. The headache is intermittent, occurring several times a week, and lasts for several hours each time. Associated symptoms include mild sensitivity to light and occasional nausea.
- Patient reports a history of hypertension, diagnosed 5 years ago, which is well-managed with medication. The hypertension does not significantly impact daily activities.
- No history of previous TIAs or strokes.
- Patient has an upcoming appointment with a cardiologist next month.
Objective:
- Blood pressure: 130/80 mmHg, Pulse: 78 bpm, Temperature: 37°C.
- Neurological examination reveals normal power, sensation, and movements in all extremities and the face.
- No joint range of motion limitations or pain reported.
Assessment & Plan:
1. Headache
- Possible tension headache or migraine. Rule out other causes.
- Advised patient to keep a headache diary to track frequency, triggers, and severity.
- Discussed over-the-counter pain relief options.
- Scheduled a follow-up appointment in 2 weeks.
2. Hypertension
- Confirmed diagnosis of hypertension.
- Continue current medication regimen.
- Advised patient on lifestyle modifications, including diet and exercise.
- Monitor blood pressure regularly at home.
- Reviewed the importance of medication adherence.
- Provided counselling on the risks of uncontrolled hypertension.
3. Past TIA
- Not applicable.
4. Upcoming Cataract Surgery
- Not applicable.
5. Current Medications
- Amlodipine 5mg daily for hypertension.
Subjective:
- [describe patient's chief complaints including onset, duration, recurrence, and associated symptoms] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a list of bullet points.)
- [document the patient's history of other long-standing conditions or symptoms, including duration and impact on daily activities] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a list of bullet points.)
- [detail past medical history, specifically focusing on relevant events such as previous TIAs or strokes, including dates and associated symptoms] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a list of bullet points.)
- [include information about upcoming appointments or planned medical procedures] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a list of bullet points.)
Objective:
- [record vital signs or physical examination findings, including any measurements taken] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a list of bullet points.)
- [document findings from neurological examination, including power, sensation, and movements in extremities and face] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a list of bullet points.)
- [describe findings related to joint range of motion and pain] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a list of bullet points.)
Assessment & Plan:
1. [describe the specific condition or symptom being assessed, e.g., tingling sensation] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.)
- [provide a clinical assessment or differential diagnosis for the condition] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a list of bullet points.)
- [detail the proposed plan of action, including consultation with supervisors or referral to specialists] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a list of bullet points.)
- [outline follow-up plans, including communication with the patient] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a list of bullet points.)
2. [describe the specific condition or symptom being assessed, e.g., hand shaking/Dupuytren's contracture] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.)
- [document the confirmed diagnosis] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a list of bullet points.)
- [provide advice or recommendations regarding management, including criteria for intervention] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a list of bullet points.)
- [document the current status of the condition and any immediate referral decisions] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a list of bullet points.)
- [record counselling provided to the patient regarding the condition] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a list of bullet points.)
3. [describe the specific past medical condition being assessed, e.g., past TIA] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.)
- [document current medications or treatments related to the past condition and their purpose] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a list of bullet points.)
4. [describe the specific condition or upcoming procedure being assessed, e.g., cataracts] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.)
- [document scheduled tests or appointments related to the condition] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a list of bullet points.)
- [outline the plan for treatment based on test results] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a list of bullet points.)
5. [describe the category of information, e.g., current medications] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.)
- [list all current medications with dosages if specified] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a list of bullet points.)
(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 the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)