Cardiologist
Past Medical History
* Hypertension, 2010
* Hypercholesterolemia, 2015
* Type 2 Diabetes Mellitus, 2018
Social History
* Non-smoker
* Drinks alcohol occasionally, 1-2 units per week
* Lives with wife, independent in activities of daily living
Family History
* Father: History of coronary artery disease, died at age 72
* Mother: Alive, history of hypertension
Drugs
* Aspirin 75mg daily
* Atorvastatin 20mg nocte
* Lisinopril 10mg daily
* Metformin 500mg twice daily
Dear Dr. [GP's Name],
It was a pleasure to review this 78-year-old patient. The patient presented with progressive shortness of breath on exertion and chest pain over the past 6 months. Symptoms have worsened recently, now experiencing shortness of breath at rest. The patient denies any recent fevers, cough, or other respiratory symptoms. The patient reports a history of intermittent claudication in the left leg, but this has not worsened recently.
Examination
* Blood pressure: 140/80 mmHg
* Heart rate: 72 bpm, regular
* Cardiac auscultation: Grade III/VI systolic ejection murmur heard best at the right upper sternal border, radiating to the carotids.
* Peripheral pulses: 2+ and equal bilaterally.
* No peripheral oedema.
ECG: Sinus rhythm, left ventricular hypertrophy, no acute ST-T wave changes.
Echo: Severe aortic stenosis (valve area 0.7 cm2, mean gradient 55 mmHg, peak gradient 75 mmHg), left ventricular hypertrophy, normal left ventricular systolic function (EF 60%).
CT TAVI: Aortic valve is trileaflet, severe calcification, annulus diameter 23mm. MAC is present. Transfemoral approach is feasible.
Coronary angiogram: Mild non-obstructive coronary artery disease.
Impression
* Severe symptomatic aortic stenosis.
* The natural history of severe aortic stenosis was explained, including the risks and benefits of TAVI intervention.
Plan
* Discussed the case at the multidisciplinary team meeting.
* Patient is suitable for TAVI.
* Schedule patient for pre-TAVI assessment.
* Inform the patient of the plan and obtain consent.
* Follow up in 2 weeks.
Past Medical History
[Insert past medical history here like a list with one disease below the other, year only.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Social History
[Insert social history here.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Family History
[Insert family history here.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Drugs
[Insert list of current medications including dosages and frequency.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Greet the GP and mention that it was a pleasure to review this patient (mention the age). Then insert detailed structured history of present complaint.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Examination
[Insert cardiovascular examination here.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
ECG: [Insert ECG findings.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Echo: [Insert echocardiogram findings here.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
CT TAVI: [Insert CT TAVI findings here, mention whether the aortic valve is trileaflet or bicuspid, whether there is MAC (if mentioned), whether the transfemoral option is feasible.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Coronary angiogram: [Insert coronary angiogram here.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Impression
[Insert clinical impressions here, structured. Also insert that natural history of severe aortic stenosis was explained, with benefits and risks of TAVI intervention.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Plan
[Insert structured plan with steps.] (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.)