Dear Dr. Emily Carter,
Oliver Jones is a 6-year-old who was seen for respirology consultation today.
Reason for referral: Recurrent wheezing and suspected asthma.
History of Presenting Illness:
- Oliver has been experiencing recurrent episodes of wheezing, particularly at night and during exercise. He has had a persistent cough for the past 2 weeks.
- History of asthma exacerbations: Yes, Oliver has had three asthma exacerbations in the past year, requiring oral steroids on each occasion.
- History of wheezing episodes: Yes, Oliver has had multiple wheezing episodes, often triggered by viral infections and exercise.
- History of emergency department visits for respiratory issues: Yes, Oliver has visited the emergency department twice in the past year for severe wheezing.
- History of oral steroid courses for respiratory issues: Yes, Oliver has received multiple courses of oral steroids for asthma exacerbations.
- History of hospitalizations for respiratory issues: No, Oliver has not required hospitalisation for respiratory issues.
Past Medical History:
- Oliver was born full term and has no significant past medical history.
Medications:
- Currently taking salbutamol inhaler as needed.
Allergies:
- No known allergies.
Immunizations:
- Up to date with all immunisations.
Family History:
- Father has asthma.
Social History:
- Lives with both parents and has one sibling. Non-smoker.
Environmental Exposures:
- Occasional exposure to pets (cat).
Assessment and Plan:
- In summary, Oliver Jones is a 6-year-old male who was seen in consultation today for recurrent wheezing and suspected asthma. He has a history of wheezing episodes triggered by viral infections and exercise, and has required oral steroids on multiple occasions. There is a family history of asthma.
Plan:
1. Initiate inhaled corticosteroid (ICS) therapy with a spacer device.
2. Prescribe a short-acting beta-agonist (SABA) inhaler for rescue use.
3. Provide education on asthma triggers and management.
4. Schedule a follow-up appointment in 4 weeks.
"I reviewed asthma pathophysiology, triggers, asthma control, medications (reliever vs. controller) and side effects. I explained the risks of inhaled corticosteroids including but not limited to oral thrush, reduction in growth/height and rarely adrenal insufficiency. I went through proper inhaler technique including dose counting. I provided the family with a written asthma action plan and explained when to seek medical attention including red flags symptoms that warrant presenting to the emergency department or calling 911.
Thank you very much for the referral.
Dr. Sarah Chen
Consultant Paediatric Respirologist
Dear Dr. [Referring provider name],
[Patient Name] is a [Patient Age] who was seen for respirology consultation today.
Reason for referral: [Include primary reason for referral] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
History of Presenting Illness:
- [describe current issues, reasons for visit, discussion topics, history of presenting complaints etc] (only include describe current issues, reasons for visit, discussion topics, history of presenting complaints etc if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [specifically include any history of asthma exacerbations] (only include specifically include any history of asthma exacerbations if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [specifically include any history of wheezing episodes] (only include specifically include any history of wheezing episodes if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [specifically include any history of emergency department visits for respiratory issues] (only include specifically include any history of emergency department visits for respiratory issues if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [specifically include any history of oral steroid courses for respiratory issues] (only include specifically include any history of oral steroid courses for respiratory issues if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [specifically include any history of hospitalizations for respiratory issues] (only include specifically include any history of hospitalizations for respiratory issues if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Past Medical History:
- [describe past medical history, previous surgeries] (only include describe past medical history, previous surgeries if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Medications:
- [mention medications and herbal supplements] (only include mention medications and herbal supplements 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.)
Immunizations:
- [mention immunizations] (only include mention immunizations 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.)
Social History:
- [describe social history] (only include describe social history if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Environmental Exposures:
- [describe environmental exposures] (only include describe environmental exposures if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Assessment and Plan:
- In summary, [Patient Name] is a [Patient age] [Patient Sex] who was seen in consultation today for [reason for referral]. [Summary of patient's condition and relevant history including primary symptoms, duration and most likely diagnosis or differential diagnoses. If reason for referral was asthma, include whether there was any wheezing in the past and benefit to ventolin or oral steroids. Also please include whether the patient has a history of atopy such as eczema, seasonal or food allergies and if there is an immediate family history of asthma.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Plan:
1. [plan item 1] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
2. [plan item 2] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
3. [plan item 3] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
4. [plan item 4] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
"I reviewed asthma pathophysiology, triggers, asthma control, medications (reliever vs. controller) and side effects. I explained the risks of inhaled corticosteroids including but not limited to oral thrush, reduction in growth/height and rarely adrenal insufficiency. I went through proper inhaler technique including dose counting. I provided the family with a written asthma action plan and explained when to seek medical attention including red flags symptoms that warrant presenting to the emergency department or calling 911.
Thank you very much for the referral.
[Insert clinician name]
[Insert clinician credentials]
(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, depending on the format, as needed to capture all the relevant information from the transcript.) the transcript.)
