Followup Kidney Stones

SHORT SUMMARY: [Two-sentence summary of this visit including the most relevant aspects only (exactly what me and my team would need to read as a memory jog in the future; use "man" and "woman" instead of "male" or "female").] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) CHIEF COMPLAINT: "[Mr/Mrs Lname] is an [age] [man/woman] who presents to the office today to follow up on kidney stones, for evaluation and management of their kidney stones." PAST UROLOGIC HISTORY: [Summarize past urologic history in no more than 5-6 sentences, including labs, imaging, pathology results, and procedures. Include occupation and hobbies if known. Relevant physician names can also be included (if unknown, omit). Do not include details relating to today’s visit, which belong in the HPI TODAY section.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) PRIOR STONE SURGERIES: [Bulleted list of past surgical interventions for stones with dates and details, including outcomes and complications if any (use bullet points; if unknown, state "not known", if no prior surgeries say "no prior surgeries").] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Date of surgery 1: Procedure and outcome.] [Date of surgery 2: Procedure and outcome.] [Dates of surgeries 3, 4, 5, etc.: Procedures and outcomes.] PRIOR STONE ANALYSES: [Bulleted list of any prior stone analyses, including date, location of analysis, and composition if known.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Date: Stone composition analysis results (e.g., calcium oxalate, uric acid, struvite, etc.).] [If no prior analyses available, write "No prior stone analyses available."] ALL RELEVANT IMAGING: [Bulleted list of scans with dates and key findings related to stone burden. List each scan as a separate bullet point.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Date: Imaging modality (e.g., CT, ultrasound) and key findings (e.g., stone size, location, obstruction, etc.).] [If no imaging data is available, write "No relevant imaging available."] DIETARY AND MEDICATION RISK FACTORS: [Discuss dietary habits and medication-related risks for stone formation as described by the patient (e.g., low fluid intake, high sodium or protein intake, medications like loop diuretics, etc.). Use bullet points if multiple factors apply.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Example: Low fluid intake, high dietary sodium, or recurrent dehydration.] [Example: Medication risks such as diuretics or calcium supplements.] HPI TODAY [Date of current consultation in US format]: (This section is bullets. Changes since the last visit, current symptoms, relevant imaging, and lab findings, and anything else pertinent to today) [New symptoms or lack thereof.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Relevant imaging results with interpretation (include date and location of scan, and "I personally reviewed and independently interpreted the scan and concur with findings").] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Relevant test results and interpretation (e.g., 24-hour urine collection results).] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) PMH, PSH, MEDS, ALLERGIES, SH, and FH: [Information reviewed with patient and in EMR, with changes made where appropriate.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [List updates if available, otherwise omit entire section.] PHYSICAL EXAMINATION: [Include physical findings if performed. Omit this section if no physical exam done.] Constitutional: General appearance and state of distress. GU Exam: (Include only if relevant findings are noted, otherwise omit.) ASSESSMENT AND PLAN: [Patient's age and a brief 1-3 sentence summary of their condition (e.g., recurrent nephrolithiasis with risk factors of X, Y, Z). Include stone composition and any pertinent history, if known.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) 1. Kidney Stones (condition name and ICD-10 code) Assessment: Current assessment of the condition, including stone burden, composition, and risk factors. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Plan: Proposed plan for management, including dietary recommendations, medications, or follow-up imaging/tests. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Counseling: Brief description of stone prevention strategies discussed (e.g., dietary modifications, medication adherence). (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) 2, 3, 4, 5, etc. Other Urologic Issues (condition name and ICD-10 code) Assessment: Current assessment of the condition. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Plan: Proposed plan for management or follow-up. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Counseling: (Include only if discussed, otherwise omit.) ORDERS: [List orders for labs, imaging, or medications. If no orders, write "No orders."] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) FOLLOW-UP: [Follow-up plan timeframe, including future tests or evaluations, if applicable (otherwise omit).] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) SHORT SUMMARY: [Two-sentence summary of this visit including the most relevant aspects only (exactly what me and my team would need to read as a memory jog in the future).] (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.) “Consent for the use of AI-assisted tools for documentation was obtained from the patient and all other participants in the visit prior to this encounter. All questions were answered. Patient understands that they may decline the use of AI-assisted tools.”