Internal Medicine - Follow Up

Reason for Referral [Reason for referral, including patient age and referring physician. Start each sentence with a capital letter.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Update [Provide an update of the patient's history and related presenting illness, including diagnosis, treatment, and anything else. Include patient age. Include medications if mentioned. Use paragraph form for this section. Start each sentence with a capital letter.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Physical Examination [Record the patient's vital signs and physical examination findings, organized by body system. Paragraph form. Start each sentence with a capital letter.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Summary [Summarize the key points discussed with the patient, including advice given, referrals made, and plans for follow-up. Include medication changes or if continuing with the same. Use paragraph form. Start each sentence with a capital letter.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Plan 1. [Plan item 1] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) 2. [Plan item 2] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) 3. [Plan item 3] (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.)