Noah Ariki attends for a new patient appointment.
Current concerns or challenges:
- Patient reports experiencing chronic lower back pain, which has been ongoing for six months. The pain is exacerbated by prolonged sitting and standing.
Health Goals:
- Patient aims to reduce pain levels and improve mobility.
PMHx:
- Hypertension, diagnosed five years ago. Patient is currently taking Lisinopril 20mg daily.
- Asthma, managed with an albuterol inhaler as needed.
PSHx:
- Appendectomy at age 16.
Recent hospital visits and why:
- No recent hospital visits.
Current Specialists involved:
- Cardiology
Medication reconciliation done Y/N:
- Yes
Allergies:
- NKDA
ADRs:
- No known adverse drug reactions.
Immunisation history:
- Up-to-date on all recommended vaccinations, including annual influenza and COVID-19 boosters.
Screening up to date:
- Yes
Smoking/vaping history:
- Patient is a former smoker, quit 10 years ago. No current vaping.
Alcohol history:
- Patient drinks alcohol socially, approximately 2-3 drinks per week.
Current work/school:
- Patient is a software engineer, working remotely.
Family History:
- Father: History of coronary artery disease. Mother: Type 2 diabetes.
Connection and whanau:
- Patient is married with two children.
Dashboard updated?
- Yes
Classifications updated?
- Yes
Physical Assessment:
- BP: 130/80 mmHg, HR: 78 bpm, RR: 16, Temp: 37.0°C. BMI: 28. Tenderness to palpation in the lumbar region. Range of motion slightly limited due to pain.
[insert patient full name] attends for a new patient appointment.
Current concerns or challenges:
- [describe current concerns or challenges] (only include describe current concerns or challenges if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Health Goals:
- [describe health goals] (only include describe health goals if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
PMHx:
- [describe past medical history] (only include describe past medical history if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
PSHx:
- [describe past surgical history] (only include describe past surgical history if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Recent hospital visits and why:
- [describe recent hospital visits and reasons] (only include describe recent hospital visits and reasons if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Current Specialists involved:
- [mention current specialists involved] (only include mention current specialists involved if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Medication reconciliation done Y/N:
- [mention if medication reconciliation done with "yes" or "no"] (only include mention if medication reconciliation done if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Allergies:
- [mention allergies] (only include mention allergies if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
ADRs:
- [mention adverse drug reactions] (only include mention adverse drug reactions if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Immunisation history:
- [describe immunisation history] (only include describe immunisation history if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Screening up to date:
- [mention if screening is up to date] (only include mention if screening is up to date if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Smoking/vaping history:
- [describe smoking/vaping history] (only include describe smoking/vaping history if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Alcohol history:
- [describe alcohol history] (only include describe alcohol history if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Current work/school:
- [describe current work or school status] (only include describe current work or school status if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Family History:
- [describe family history] (only include describe family history if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Connection and whanau:
- [describe connection and whanau] (only include describe connection and whanau if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Dashboard updated?
- [mention if dashboard updated] (only include mention if dashboard updated if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Classifications updated?
- [mention if classifications updated] (only include mention if classifications updated if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Physical Assessment:
- [describe physical assessment findings] (only include describe physical assessment findings if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
(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 include 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 with "-", depending on the format, as needed to capture all the relevant information from the transcript.)
