Re: John Smith, 12/03/1960
Diagnosis:
1. Ischaemic Cardiomyopathy: Stable, EF 35%
2. Hypertension: Controlled
3. Hyperlipidaemia: Controlled
Medications:
1. Amlodipine 5mg daily
2. Bisoprolol 2.5mg daily
3. Atorvastatin 20mg nocte
4. Ramipril 5mg daily
Recommendations:
1. Continue current medications.
2. Repeat echocardiogram in 6 months.
3. Review in cardiology clinic in 6 months.
It was a pleasure reviewing Mr. Smith today. He presented today for a routine follow-up appointment. He reports no new symptoms, and denies any chest pain, shortness of breath, or palpitations. He states he is tolerating his medications well.
Mr. Smith has a history of ischaemic cardiomyopathy diagnosed in 2018, with an ejection fraction of 35%. He underwent a percutaneous coronary intervention (PCI) in 2018. He has been stable on his current medication regimen for the past year. He has no history of cardiac arrest or hospitalisation for heart failure in the last year. He has had an implantable cardioverter defibrillator (ICD) implanted in 2019. He has had no ICD firings or shocks.
Mr. Smith reports that he walks for 30 minutes, three times a week. He denies any limitations due to his medical conditions. He is able to perform all activities of daily living without difficulty.
Mr. Smith is a non-smoker and drinks alcohol socially. He is married and lives with his wife. He is retired and enjoys gardening.
Physical Examination:
Patient is alert and oriented to person, place, and time. Blood pressure 130/80 mmHg, heart rate 68 bpm, regular. General examination reveals no acute distress. Cardiovascular examination reveals normal heart sounds, no murmurs, rubs, or gallops. Respiratory examination reveals clear lung fields bilaterally. Abdominal examination is soft, non-tender, and there is no hepatosplenomegaly.
Investigations:
1. ECG: Normal sinus rhythm.
2. Blood tests: Normal electrolytes, renal function, and liver function tests. HbA1c 6.2%. LDL cholesterol 2.1 mmol/L.
3. Device interrogation: ICD function is normal. No shocks or inappropriate therapies delivered.
Assessment and Plan:
1. Ischaemic Cardiomyopathy: Mr. Smith's ischaemic cardiomyopathy is stable. His ejection fraction remains at 35%. He is asymptomatic and tolerating his medications well. Continue current medications. Repeat echocardiogram in 6 months. Review in cardiology clinic in 6 months. Patient was educated on the importance of medication adherence and regular follow-up.
Patient Education:
1. Importance of medication adherence.
2. Regular follow-up appointments.
3. Lifestyle modifications, including regular exercise and a healthy diet.
Thank you very much for involving me in the care of John Smith. Please do not hesitate to contact me should you have any questions.
Yours sincerely,
Dr. Emily Carter, Consultant Cardiologist
Re: [patient name], [patient date of birth]
Diagnosis:
[list all current diagnoses including any relevant details such as type, status, and measurements] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as list.)
Medications:
[list all current medications including dosages and purposes] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as list.)
Recommendations:
[summary of follow-up plan, investigations required, and any new medications] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in numbered bullet points and continue numbering consistently across all items.)
[describe the pleasure of reviewing the patient, reason for visit, and patient's self-reported symptoms or lack thereof] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.)
[document patient's history of specific conditions, treatments received, and current status including any prophylactic measures] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.)
[describe patient's exercise habits, any limitations due to medical conditions, and specific details about how these conditions affect their daily activities] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.)
[social history details] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a narrative in full sentences.)
Physical Examination:
[document physical examination findings in the following order: patient orientation, vital signs, general examination, cardiovascular, respiratory, abdominal exam. Include only what's stated in the transcript. If JVP not elevated is mentioned, state "JVP was not elevated". If no hepatosplenomegaly is mentioned, state "There was no hepatosplenomegaly". Do not use bullet points; write as a continuous narrative.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Investigations:
[document investigation results. List numerically in paragraph format using appropriate units (U/L, ms, mmol/L etc). If ECG findings are present, summarise in one sentence. If device interrogation is included, write findings in full sentence format. Never use bullet points. Use line-by-line narrative format.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Assessment and Plan:
[for each issue, write a numbered list where each number corresponds to an issue summarised from the presenting complaint or transcript. Each item should be followed by a detailed narrative paragraph including assessment, reasoning, treatments, medications, investigations, patient education given, and next steps. Do not use bullet points.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Patient Education:
[document any education provided to the patient. List each educational point on a new line and number each item.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Thank you very much for involving me in the care of [patient name]. Please do not hesitate to contact me should you have any questions.
Yours sincerely,
[Clinician name and 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 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.)