Scribe BC - BG Followup
**REASON FOR VISIT:**
The patient presents today for a routine follow-up to manage their type 2 diabetes.
**INTERIM HISTORY:**
The patient reports stable blood sugars over the past three months, with an average glucose reading of 145 mg/dL. They are using a continuous glucose monitor (CGM) and report no significant hypoglycemic events. The patient denies any new microvascular or macrovascular complications.
**PAST MEDICAL HISTORY:**
* Type 2 Diabetes Mellitus
* Hypertension
* Hyperlipidemia
**MEDICATIONS:**
* Metformin 1000mg twice daily
* Lisinopril 20mg daily
* Atorvastatin 40mg daily
**ALLERGIES:**
* NKDA
**PHYSICAL EXAMINATION:**
* BMI: 32 kg/m²
* Blood pressure: 130/80 mmHg
* Fundoscopic exam: no signs of diabetic retinopathy
* Foot exam: intact sensation, no ulcers
**INVESTIGATIONS:**
* HbA1c: 7.2% (October 28, 2024)
* Lipid panel: within normal limits (October 28, 2024)
* Urine microalbumin: negative (October 28, 2024)
**IMPRESSION:**
* Type 2 Diabetes Mellitus, well-managed
* Hypertension, controlled
* Hyperlipidemia, controlled
**PLAN:**
* Continue current medication regimen.
* Encourage patient to maintain current diet and exercise routine.
* Review CGM data and provide guidance on glucose management.
* Discuss potential risks and side effects of medications.
* Schedule annual eye exam and foot exam.
**FOLLOW-UP:**
* Follow-up appointment in three months to review HbA1c and assess overall diabetes management.
"This document was created using AI Ambient Scribe and Front-End Speech Recognition software and may include incorrect spelling/words. Consent for usage of AI was obtained by patient/guardian."
Scribe BC - BG Followup
**REASON FOR VISIT:**
[describe the primary reason for the patient's current visit, including any specific concerns or complaints they are presenting with during this follow-up appointment] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.)
**INTERIM HISTORY:**
[document significant medical events, changes in symptoms, new diagnoses, or hospitalizations that have occurred since the last consultation; include details about the progression or resolution of previous issues, and any new symptoms or health concerns. if the visit is for diabetes, make sure to include the following (if they were discussed) in this section (not under Investigations): blood sugars or continuous glucose monitoring results, microvascular and macrovascular complications, hypoglycemia.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.)
**PAST MEDICAL HISTORY:**
[list all significant past medical conditions, including chronic diseases, previous hospitalizations, and any other relevant health issues] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.)
**MEDICATIONS:**
[list all current medications, including dosage, frequency, route, and any recent changes; include over-the-counter medications, supplements, and details of medication adherence, side effects, or allergies] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.)
**ALLERGIES:**
[list all known allergies to medications, food, or environmental substances, specifying the type of reaction] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.)
**PHYSICAL EXAMINATION:**
[detail findings from the physical examination relevant to the patient's endocrine condition and overall health; include specific system-based findings as appropriate. do not include findings here that were mentioned by the patient in the history, only include findings that the physician mentions on their examination] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.)
**INVESTIGATIONS:**
[summarize results of any recent laboratory tests, imaging studies, or other diagnostic investigations; include dates of tests and interpretation of findings relevant to the patient's condition. for diabetes visits, do not include glucose monitoring (capillary or CGM) numbers here; include these numbers instead under the Interim History section] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.)
**IMPRESSION:**
[provide a concise summary of the patient's current endocrine status and other relevant medical conditions; include differential diagnoses or diagnostic considerations if applicable. do not include medical conditions that are irrelevant to the current endocrine condition] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.)
**PLAN:**
[outline the proposed management strategy, including medication adjustments, lifestyle recommendations, further investigations, referrals to other specialists, and patient education; clearly state the rationale for each component of the plan. when discussing medications, make sure to include potential risks and side effects that were mentioned] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.)
**FOLLOW-UP:**
[specify the timing and purpose of the next follow-up appointment; include any instructions for the patient regarding monitoring, symptom vigilance, or when to seek immediate medical attention] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.)
"This document was created using AI Ambient Scribe and Front-End Speech Recognition software and may include incorrect spelling/words. Consent for usage of AI was obtained by patient/guardian."
(Never come up with your own patient details, assessment, plan, interventions, evaluation, or 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.)