```
OVERVIEW:
[Summarize from Contextual data] (do not include any data from transcription)
[write in bullet points preceded by a dash]
NOTABLE COMORBIDITIES:
[Past medical and surgical history, highlighting any previous rheumatologic diagnoses, treatments, surgeries, hospitalizations, outcomes, etc. (mention if available) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
(write in bullet points preceded by a dash)
PRIOR PERTINENT MEDICATIONS:
[prior medications, listing reasons for cessation such as intolerance or inefficacy (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
[write each medication in a separate line preceded by a dash]
CURRENT PERTINENT MEDICATIONS:
[Current medications, including any disease-modifying antirheumatic drugs (DMARDs), biologic agents, pain management medications, supplements, etc. (mention if available) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
[write each medication in a separate line preceded by a dash]
INTERVAL HISTORY:
(Detailed history including onset, duration, severity, pattern of joint involvement, morning stiffness, aggravating/alleviating factors, associated systemic symptoms)
(mention in comparison to previous visit if stated)
(do not include any contextual data)
(Do not include any quoted phrases)
(do not include patient's own words)
(do not include discussions about investigations)
(write in bullet points preceded by a dash)
RELEVANT FAMILY HISTORY:
[copy from contextual data] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
RELEVANT SOCIAL HISTORY:
(include occupation, smoking, alcohol, living situation, exercise) (only if available) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
PHYSICAL EXAMINATION:
[copy from contextual data] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[write in bullet points preceded by a dash]
PERTINENT LABS:
(Summarize and abbreviate labs)
(do not include normal ranges)
(do not include units of measurement)
(always include dates of the investigations in between brackets)
(write abnormal findings in Italic)
[list only abnormal findings in CBC, (state otherwise normal) (include latest result and comparison to previous values) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
-[list immunologic testing such as ANA, Smith, RNP, SCL70, SSA, SSB, C3, C4, dsDNA, RF, CCP, ESR, CRP, myositis panel, scleroderma panel (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
-[ESR/CRP (include latest result and comparison to previous values) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
-[C3, C4 (include latest result and comparison to previous values) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
-[dsDNA (include latest result and comparison to previous values) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
-[Urinalysis and urine protein/creatinine ratio (include latest result and comparison to previous values) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
-[Creatine kinase (include latest result and comparison to previous values) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
-[uric acid (include latest result and comparison to previous values) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
PERTINENT DIAGNOSTICS:
[include Xray, CT scan, PET scan, MRI, PFTs, Echo, swallow study, DEXA scan, Biopsy/pathology results (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
[write in bullet points preceded by a dash]
ASSESSMENT:
(write rheumatologic issue or condition in uppercase preceded by a pound sign)
[Rheumatologic Issue or Condition, and comment on progress/whether doing well or not (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
[Assessment, including the likely diagnosis and rationale based on subjective and objective findings (mention if available) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
[Differential diagnosis (include only if explicitly mentioned) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] [list in a continuous paragraph]
[do not include any plans in the assessment section]
PLAN:
(bullet point format)
(do not include any contextual data)
[Investigations planned, specifying any additional laboratory tests, imaging, or functional assessments needed for a definitive diagnosis or treatment planning (mention if available) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
[Medical treatment planned, including details, for e.g., the type of DMARDs, biologics, pain management strategies, dosage, expected outcomes, potential side effects, etc. (mention if applicable and available) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
[Lifestyle modifications, including dietary advice, physical activity recommendations, any specific instructions related to the rheumatologic disorder, etc (mention only if applicable and available) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
[Physical or occupational therapy referrals, if needed for joint protection strategies, mobility enhancement, etc. (mention if applicable and available) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
[Follow-up appointments, covering the expected timeline for review, monitoring response to treatment, and adjustment of management plans, etc. (mention only if applicable and available) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
[Mention any referrals (mention if applicable and available) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
[write in bullet points preceded by a dash]
[Additional Rheumatologic Issues or Conditions (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
PLAN:
(bullet point format)
(do not include any contextual data)
[Investigations planned, specifying any additional laboratory tests, imaging, or functional assessments needed for a definitive diagnosis or treatment planning (mention if available) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
[Medical treatment planned, including details, for e.g., the type of DMARDs, biologics, pain management strategies, dosage, expected outcomes, potential side effects, etc. (mention if applicable and available) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
[Lifestyle modifications, including dietary advice, physical activity recommendations, any specific instructions related to the rheumatologic disorder, etc (mention only if applicable and available) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
[Physical or occupational therapy referrals, if needed for joint protection strategies, mobility enhancement, etc. (mention if applicable and available) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
[Follow-up appointments, covering the expected timeline for review, monitoring response to treatment, and adjustment of management plans, etc. (mention only if applicable and available) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
[Mention any referrals (mention if applicable and available) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
[write in bullet points preceded by a dash]
[immunosuppression due to drug therapy (include as a problem if the patient is on immunosuppression and list monitoring needed) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
FOLLOW UP:
[follow up scheduled (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
INSTRUCTIONS:
[generate brief patient instructions using plan (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 transcript or context, 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 for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)
