Emergency Medicine Specialist's note

Chief Complaint: [Brief description of reason for emergency visit] History of Presenting Illness ( Make this section into a readable paragraph format for the emergency department setting) : [Onset, Duration, Severity, Associated symptoms, alleviating factors, medications taken today, last known normal at baseline, positive and negative review of systems, history/story of preceding events, other medical evaluations received related to the present illness, include all information provided by the patient even if it seems irrelevant at the time, any recent hospitalizations, medication changes, how did they here eg., by car or EMS, did EMS administer any medications? (only include if applicable)] Past Medical History: [Chronic conditions, Previous surgeries, (only include if applicable)] Medication History: [Current medications and dosages, Allergies (only include if applicable)] Social History: [Smoking, Alcohol, Drug use (only include if applicable)] Family History: [Relevant conditions (only include if applicable)] Review of Systems: - Constitutional symptoms: [Symptoms like Weight change, Fever, Chills, Night sweats, Fatigue, Malaise] - Eyes: [Symptoms like Eye pain, Swelling, Redness, Foreign body sensation, Discharge, Vision changes] - Ears, Nose, Mouth, Throat: [Symptoms like Hearing changes, Ear pain, Nasal congestion, Sinus pain, Hoarseness, Sore throat, Rhinorrhea, Swallowing difficulty] - Cardiovascular: [Symptoms like Chest pain, Shortness of breath (SOB), Paroxysmal nocturnal dyspnea (PND), Dyspnea on exertion, Orthopnea, Claudication, Edema, Palpitations] - Respiratory: [Symptoms like Cough, Sputum production, Wheezing, Smoke exposure, Dyspnea] - Gastrointestinal: [Symptoms like Nausea, Vomiting, Diarrhea, Constipation, Abdominal pain, Heartburn, Anorexia, Dysphagia, Hematochezia, Melena, Flatulence, Jaundice] - Genitourinary: [Symptoms like Dysmenorrhea, Dysfunctional uterine bleeding (DUB), Dyspareunia, Dysuria, Urinary frequency, Hematuria, Urinary incontinence, Urgency, Flank pain, Changes in urinary flow, Hesitancy] - Musculoskeletal: [Symptoms like Arthralgias, Myalgias, Joint swelling, Joint stiffness, Back pain, Neck pain, Injury history] - Integumentary (Skin): [Symptoms like Skin lesions, Pruritis, Hair changes, Breast/skin changes, Nipple discharge] - Neurological: [Symptoms like Weakness, Numbness, Paresthesias, Loss of consciousness, Syncope, Dizziness, Headache, Coordination changes, Recent falls] - Psychiatric: [Symptoms like Anxiety/Panic, Depression, Insomnia, Personality changes, Delusions, Rumination, Suicidal ideation/Homicidal ideation/Auditory hallucinations/Visual hallucinations, Social issues, Memory changes, Violence/Abuse history, Eating concerns] - Endocrine: [Symptoms like Polyuria, Polydipsia, Temperature intolerance] - Hematologic/Lymphatic: [Symptoms like Bruising, Bleeding, Transfusion history, Lymphadenopathy] - Allergic/Immunologic: [Symptoms like Allergic reactions, Auto-immune disorders] Objective: - Vitals: [Blood Pressure, Heart Rate, Temperature, Oxygen Saturation etc (only include if applicable)] - [General: General exam findings (only include if applicable)] - [System specific exam: findings from examination of other systems e.g. CVS, Resp, Abdo, CNS, etc (only include if explicitly mentioned)] - [System specific exam: findings from examination of other systems e.g. CVS, Resp, Abdo, CNS, etc (only include if explicitly mentioned)] Investigations: - Bloods: [CBC, UEC, BMP, Troponins results, and any other recommended laboratory evaluation that should be pursued. etc (only include if applicable)] - Imaging: [Chest X-Ray, CT scan findings and any other recommended laboratory evaluation that should be pursued. etc (only include if applicable)] - [Other: ECG, Ultrasound findings etc (only include if applicable)] Assessment: - Primary Diagnosis: [ Please provide this for me based off of best available information if I do not explicitly say this out loud at any point so that I can then explain (only include if explicitly mentioned with relevant ICD-10 codes] - Differential Diagnosis: [I want your expertise to provide all applicable top differential diagnosis based off of the provided information from the transcript during interview and then justification for why these have been ruled out . (only include if explicitly mentioned with relevant ICD-10 codes] Plan: - [Immediate Management: Medications with doses, Procedures etc (only include if explicitly mentioned)] - [Investigations Planned: Further investigations plan (only include if explicitly mentioned)] - [Referrals: Specialty consultations, provided paragraph summaries and consultation conversations (only include if explicitly mentioned)] - [Discharge Criteria: Conditions for discharge or admission (only include if explicitly mentioned)] - [Follow-up: Instructions for follow-up care, including all results, findings, treatments, follow-ups, supportive home therapies, education on pathophysiology, and thank you from something to the affect of "Dr, Austin-John Fordham, MD for allowing me to a part of your health care today." (only include if explicitly mentioned)]