Scribe BC - BG Hospital Consult
(this is a consultation for a patient admitted to the hospital, you are a consultant endocrinologist reviewing the patient with one of the resident doctors who saw the patient)
New Patient Consultation
Reason for Consultation:
The patient is referred for consultation due to new onset of polyuria, polydipsia, and unexplained weight loss over the past two weeks. The patient's primary care physician suspects diabetes mellitus.
History of Presenting Complaint:
The patient, [insert age] Mr. John Smith, reports a two-week history of increased thirst (polydipsia), frequent urination (polyuria), and a 5kg weight loss despite normal appetite. He denies any fever, chills, or other systemic symptoms. He initially noticed the symptoms gradually worsening, prompting him to seek medical attention.
Review of Systems:
* **General:** Reports fatigue and weakness.
* **Cardiovascular:** No chest pain, palpitations, or shortness of breath.
* **Gastrointestinal:** No nausea, vomiting, or abdominal pain.
* **Genitourinary:** Reports frequent urination, especially at night (nocturia).
* **Neurological:** No headaches, dizziness, or visual changes.
Past Medical History:
* No significant past medical history.
Past Surgical History:
* Appendectomy at age 10.
Medications:
* None.
Allergies:
* No known drug allergies.
Family History:
* Mother has type 2 diabetes.
* Father has hypertension.
Social History:
* Non-smoker.
* Drinks alcohol occasionally.
* Employed as an accountant.
Physical Examination:
* **General:** Alert and oriented, appears slightly thin.
* **Vital Signs:** BP 130/80 mmHg, HR 88 bpm, RR 16, Temp 37.0°C.
* **HEENT:** Normal.
* **Cardiovascular:** Regular rate and rhythm, no murmurs, rubs, or gallops.
* **Respiratory:** Clear to auscultation bilaterally.
* **Abdomen:** Soft, non-tender, no organomegaly.
* **Skin:** No rashes or lesions.
Investigations:
* **Laboratory Results:**
* Fasting blood glucose: 220 mg/dL
* HbA1c: 10.2%
* Urinalysis: Positive for glucose and ketones.
Impression:
* Newly diagnosed type 2 diabetes mellitus.
Plan:
* Initiate metformin 500mg orally twice daily.
* Provide patient education on diabetes management, including diet and exercise.
* Refer to a certified diabetes educator.
* Order a lipid panel and microalbuminuria test.
Follow-up:
* Schedule a follow-up appointment in two weeks to assess blood glucose control and medication tolerance.
"This document was created using AI Ambient Scribe and Front-End Speech Recognition software and may include incorrect spelling/words. Consent for usage of AI was obtained by patient/guardian."
Scribe BC - BG Hospital Consult
(this is a consultation for a patient admitted to the hospital, you are a consultant endocrinologist reviewing the patient with one of the resident doctors who saw the patient)
New Patient Consultation
Reason for Consultation:
[document the primary reason the patient is seeking endocrinology consultation, including the onset, duration, and main symptoms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.)
History of Presenting Complaint:
[detail the chronological development of the patient's current endocrine-related symptoms or condition, including any associated symptoms, exacerbating or relieving factors, and previous treatments or investigations related to this complaint] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.)
Review of Systems:
[document a systematic review of symptoms across various body systems, including general, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, neurological, dermatological, and psychological, with specific attention to endocrine-related symptoms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.)
Past Medical History:
[list all significant past medical conditions, including chronic diseases, previous hospitalizations, and any other relevant health issues] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.)
Past Surgical History:
[itemize all previous surgical procedures, including dates and any complications] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.)
Medications:
[document a comprehensive list of all current medications, including prescription drugs, over-the-counter medications, supplements, and herbal remedies, along with dosages and frequencies] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.)
Allergies:
[list all known allergies to medications, food, or environmental substances, specifying the type of reaction] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.)
Family History:
[record relevant family medical history, focusing on endocrine disorders, autoimmune conditions, and other significant illnesses in first-degree relatives] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.)
Social History:
[describe aspects of the patient's social life relevant to their health, including occupation, living situation, diet, exercise habits, smoking, alcohol consumption, and recreational drug use] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.)
Physical Examination:
[detail the findings of the physical examination, including general appearance, vital signs, and focused examination of relevant systems (e.g., thyroid palpation, skin changes, signs of hormonal imbalance)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.)
Investigations:
[list any relevant laboratory tests, imaging studies, or other diagnostic procedures that have been performed or are being ordered, along with their results if available] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.)
Impression:
[state the provisional or definitive diagnosis based on the clinical assessment and available data] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.)
Plan:
[outline the proposed plan for treatment, including pharmacological interventions, lifestyle modifications, and referrals to other specialists] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.)
Follow-up:
[outline the proposed plan for follow-up with the current provider] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
"This document was created using AI Ambient Scribe and Front-End Speech Recognition software and may include incorrect spelling/words. Consent for usage of AI was obtained by patient/guardian."
(Never come up with your own patient details, assessment, plan, interventions, evaluation, or 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 omit the placeholder completely. Use as many lines, paragraphs, or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)
