HPI
1. Hypertension
The patient reports experiencing occasional headaches and dizziness. They have been monitoring their blood pressure at home, which has shown elevated readings. The patient is concerned about the long-term effects of hypertension and is interested in lifestyle modifications to manage it.
2. Type 2 Diabetes
The patient has been experiencing increased thirst and frequent urination. They have a family history of diabetes and are worried about their recent weight gain. The patient is interested in discussing dietary changes and potential medication adjustments.
3. Seasonal Allergies
The patient reports sneezing, nasal congestion, and itchy eyes, particularly during the spring months. They have been using over-the-counter antihistamines with limited relief and are seeking advice on alternative treatments.
Review of systems
Cardiovascular: Positive for elevated blood pressure readings. Negative for chest pain or palpitations.
Endocrine: Positive for increased thirst and urination. Negative for heat intolerance or changes in skin texture.
Respiratory: Positive for nasal congestion and sneezing. Negative for shortness of breath or wheezing.
Physical exam
Vital signs: Blood pressure 150/95 mmHg, heart rate 78 bpm, respiratory rate 16 breaths/min, temperature 98.6Β°F.
HEENT: Nasal mucosa swollen, conjunctivae clear.
Cardiovascular: Regular rate and rhythm, no murmurs.
Respiratory: Clear to auscultation bilaterally.
Assessment & Plan:
1. Hypertension
- Assessment: Essential hypertension
- Differential diagnosis: Secondary hypertension
- Investigations planned: 24-hour ambulatory blood pressure monitoring
- Treatment planned: Initiate lifestyle modifications, consider starting an ACE inhibitor
- Relevant referrals: Referral to a dietitian for dietary counseling
2. Type 2 Diabetes
- Assessment: Poorly controlled type 2 diabetes
- Differential diagnosis: None
- Investigations planned: HbA1c test
- Treatment planned: Adjust current medication regimen, emphasize dietary changes
- Relevant referrals: Referral to an endocrinologist for further management
3. Seasonal Allergies
- Assessment: Allergic rhinitis
- Differential diagnosis: None
- Investigations planned: None
- Treatment planned: Prescribe a nasal corticosteroid spray
- Relevant referrals: None
HPI
[1. Issue, problem or request 1 (issue, request or condition name only)]
[Insert the relevant discussion points with the patient for issue 1]
[2. Issue, problem or request 2 (issue, request or condition name only)]
[Insert the relevant discussion points with the patient for issue 2]
[3. Issue, problem or request 3, 4, 5 etc (issue, request or condition name only)]
[Insert the relevant discussion points with the patient for issue 3,4,5 etc]
Review of systems
[Relevant body systems reviewed, including any positive or negative findings]
Physical exam
[Detailed findings from the physical examination, organized by body system or region]
Assessment & Plan:
[1. Issue, problem or request 1 (issue, request or condition name only)]
- [Assessment, likely diagnosis for Issue 1 (condition name only)]
- [Differential diagnosis for Issue 1 (only if applicable)]
- [Investigations planned for Issue 1 (only if applicable)]
- [Treatment planned for Issue 1 (only if applicable)]
- [Relevant referrals for Issue 1 (only if applicable)]
[2. Issue, problem or request 2 (issue, request or condition name only)]
- [Assessment, likely diagnosis for Issue 2 (condition name only)]
- [Differential diagnosis for Issue 2 (only if applicable)]
- [Investigations planned for Issue 2 (only if applicable)]
- [Treatment planned for Issue 2 (only if applicable)]
- [Relevant referrals for Issue 2 (only if applicable)]
[3. Issue, problem or request 3, 4, 5 etc (issue, request or condition name only)]
- [Assessment, likely diagnosis for Issue 3, 4, 5 etc (condition name only)]
- [Differential diagnosis for Issue 3, 4, 5 etc (only if applicable)]
- [Investigations planned for Issue 3, 4, 5 etc (only if applicable)]
- [Treatment planned for Issue 3, 4, 5 etc (only if applicable)]
- [Relevant referrals for Issue 3, 4, 5 etc (only if applicable)]
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - 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 the information has not been explicitly mentioned in your output, just leave the relevant placeholder or section blank.)
