Consultatie

Medische voorgeschiedenis: -------------------------- - [Patient's past medical history, inserted by date] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Copy the past medical history word by word from contextual notes under the heading "Medische voorgeschiedenis"] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [If uploaded in contextual notes, make a summary of the last consult and add it here] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Medical history: including past medical and surgical history relevant to the current complaints] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Family history relevant to current complaints] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Relevant social history including smoking, alcohol, drug use, occupational exposures] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Allergies, including reactions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Immunization history and status] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Other relevant history or contributing factors] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Double check: exams from context must not be placed here. Summarize an exam only if it is relevant, important, and explicitly mentioned as past information.) Huidige problematiek: --------------------- (Never use bullet points to write this section. Use full sentences and paragraph format. Group symptoms that belong together.) [Mention patient symptoms or the reason for this consult] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Mention reasons for visit, chief complaints such as requests, symptoms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Mention duration, timing, location, quality, severity, context of complaint] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Mention factors that worsen or alleviate symptoms, including self-treatment attempts and effectiveness] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Progression of symptoms over time] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Previous episodes of similar symptoms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Impact on daily activities] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Associated symptoms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Thuistherapie: -------------- - [Medication patient is taking] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Prescribed medications, OTC drugs, supplements] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Klinisch onderzoek: ------------------- - [Clinical exam findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Vital signs such as pulse, BP, temperature] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Physical or mental state examination findings, system-specific] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Each system should be separated line by line.) - [BMI] (Only include if explicitly mentioned or if weight and length are directly provided in transcript, contextual notes or clinical note; otherwise omit completely. Do not calculate unless explicitly stated.) Onderzoeken: ------------ (Never use bullet points in this section. Leave a blank line between different exams.) [Mention exams discussed or performed during the consultation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. If an exam is uploaded in contextual notes, copy the protocol word for word.) Besluit: -------- (Use medical terminology. Write as a narrative, not bullet points.) [Summary of patient’s symptoms, main diagnosis, summary of exams done to establish diagnosis, differential diagnosis, treatment and diagnostic plan including planned exams, medical treatments, medication details (type, dosage, outcomes, side effects if mentioned), lifestyle modifications (diet, alcohol/tobacco cessation, physical activity), referrals, follow-up appointments] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraphs.) [Additional issues or conditions: Follow the same structure as above if applicable.] [Additional notes: - [Patient education provided] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Instructions for monitoring symptoms and when to seek urgent care] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Any specific patient or family concerns addressed] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] Planning : ---------- - [Diagnostic and treatment plan in bullet points] (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 the transcript, contextual notes or clinical note; 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. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; simply omit the placeholder or section. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)