Overview & History:
The patient, a 45-year-old female, presented with complaints of persistent fatigue and occasional dizziness over the past month. She has a history of hypertension and hyperlipidemia, managed with medication. Recently, she reported a decrease in energy levels and difficulty concentrating. No recent changes in medication or lifestyle were noted.
Hair, Skin & Nails:
The patient's skin appeared pale with a slightly dry texture. No rashes, lesions, or pressure injuries were observed. Hair distribution was normal, and nails were intact with no signs of clubbing or cyanosis.
Head & Neck:
The head was symmetrical with no visible abnormalities. Facial movements were normal, and there was no tenderness upon palpation. Lymph nodes were non-palpable, and the neck exhibited a full range of motion without stiffness.
Eyes & Vision:
The eyes were aligned, and pupils were equal, round, and reactive to light. Conjunctiva was clear, and visual acuity was 20/20 with corrective lenses.
Ears:
The ear canals were clear with no wax build-up or discharge. Hearing was intact bilaterally, and tympanic membranes appeared normal.
Nose & Sinus:
Nasal mucosa was moist and pink, with no septum deviation or discharge. Sinus areas were non-tender upon palpation.
Mouth & Throat:
Lips, teeth, and gums were in good condition. The tongue and palate appeared normal, and the uvula was midline. Tonsils were not enlarged, and there was no odour. Swallowing was normal without discomfort.
Thoracic β Cardiovascular, Respiratory, Breasts, Lymph:
Heart sounds were regular with no murmurs. Peripheral pulses were strong, and capillary refill was less than 2 seconds. Respiratory rate was normal, with clear breath sounds and no wheezing or crackles. Breasts were symmetrical with no lumps or skin changes. Lymph nodes in the axillary and supraclavicular regions were non-tender and non-palpable.
Abdomen:
The abdomen was soft and non-tender with normal bowel sounds. No distension, organ enlargement, or masses were noted. There were no surgical scars or hernias.
Genitourinary:
Urination patterns were normal with no incontinence or discharge. No reproductive organ examination was indicated.
Rectum:
A digital rectal examination was not performed, and no abnormalities were reported.
Extremities and Musculoskeletal System:
Extremities were symmetrical with no swelling or deformities. Muscle strength and range of motion were normal. Gait was steady, and there were no signs of inflammation or joint tenderness.
Neurological:
The patient was alert and oriented to person, place, and time. Cranial nerve function was intact, reflexes were normal, and coordination was good. Motor strength and sensory response were within normal limits.
Overview & History:
[Enter a summary of the patientβs presenting concerns, relevant history, and overall status at the time of assessment] (include only if explicitly mentioned; write as a paragraph in full sentences. Describe the reason for examination, previous medical history relevant to current assessment, recent changes in health, current complaints, and any contributing factors or relevant background details.)
Hair, Skin & Nails:
[Enter findings related to the condition of the hair, skin, and nails] (include only if examined. Describe in full sentences the colour, texture, temperature, moisture, turgor, integrity, lesions, bruising, rashes, scars, pressure injuries, or abnormalities. Comment on hair distribution, scalp condition, and nail appearance.)
Head & Neck:
[Enter findings related to the inspection and palpation of the head and neck] (include only if assessed. Note head symmetry, size, facial movements, tenderness, lymph node palpation, and range of motion in the neck. Mention any visible swelling, abnormalities, or neck stiffness.)
Eyes & Vision:
[Enter findings related to the eyes and vision assessment] (include only if performed. Describe eye alignment, pupil size and reactivity, conjunctiva appearance, discharge, field of vision, and visual acuity. Mention use of corrective lenses if applicable.)
Ears:
[Enter findings related to the ears and auditory system] (include only if examined. Document ear canal condition, hearing status, presence of discharge, wax build-up, tenderness on palpation, and tympanic membrane appearance.)
Nose & Sinus:
[Enter findings related to nasal and sinus structures] (include only if assessed. Describe the condition of nasal mucosa, patency of nares, septum deviation, discharge, bleeding, or tenderness over sinus areas.)
Mouth & Throat:
[Enter findings related to oral cavity and throat] (include only if examined. Include inspection of lips, teeth, gums, tongue, palate, uvula, and tonsils. Note presence of lesions, inflammation, dental hygiene, or odour. Mention swallowing ability and any discomfort.)
Thoracic β Cardiovascular, Respiratory, Breasts, Lymph:
[Enter findings related to the thorax and upper torso systems] (include only if examined. For cardiovascular: document heart sounds, rhythm, murmurs, peripheral pulses, and capillary refill. For respiratory: include respiratory rate, breath sounds, presence of wheezing or crackles, and chest expansion. For breasts: note any asymmetry, lumps, or skin changes. For lymph: assess axillary and supraclavicular lymph nodes for swelling or tenderness.)
Abdomen:
[Enter findings from abdominal inspection, palpation, percussion, and auscultation] (include only if assessed. Describe the contour, bowel sounds, tenderness, guarding, distension, organ enlargement, and presence of masses. Note any surgical scars or hernias.)
Genitourinary:
[Enter findings related to urinary or reproductive health if assessed or relevant] (only include if examination performed or details are provided. Describe urination patterns, incontinence, discharge, or abnormalities. Note reproductive organ examination findings only if medically indicated and appropriate.)
Rectum:
[Enter findings related to rectal assessment] (include only if examination performed. Describe tone, presence of haemorrhoids, masses, tenderness, or bleeding. Note whether digital rectal examination was conducted and findings if applicable.)
Extremities and Musculoskeletal System:
[Enter findings related to limbs, joints, and muscle function] (include only if examined. Comment on symmetry, swelling, strength, range of motion, deformities, gait, and signs of inflammation. Mention joint tenderness or limitations.)
Neurological:
[Enter findings from neurological assessment] (include only if performed. Describe level of consciousness, orientation, cranial nerve function, reflexes, coordination, motor strength, and sensory response. Note any signs of neurological impairment or abnormalities.)
(Never come up with your own patient findings, descriptions, history, or conclusions β 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 that the information has not been mentioned in your output β just leave the relevant placeholder or omit the paragraph completely. Use as many bulletpoints, sentences and paragraphs as needed.)
