General Practitioner Template

UK History Template

A professional General Practitioner template for healthcare professionals.

About this template

The UK History Template is a comprehensive documentation tool designed for General Practitioners to capture detailed patient histories and examination findings. This template facilitates the recording of current issues, past medical history, medications, social history, and allergies. It also includes sections for examination findings across various systems, diagnosis, and a detailed treatment plan. This template is particularly useful for GPs seeking to streamline their documentation process while maintaining high-quality patient care.

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History: - The patient, a 45-year-old male, presented with persistent headaches and dizziness over the past two weeks. He reports no recent trauma or changes in vision. The patient has a history of hypertension and underwent appendectomy five years ago. - Current medications include Lisinopril 10mg daily and a multivitamin supplement. - The patient is a non-smoker, consumes alcohol occasionally, and works as an accountant. He exercises regularly. - No known drug allergies. Examination: - The patient appeared well-nourished and in no acute distress. Vital signs: BP 140/90 mmHg, HR 78 bpm, Temp 98.6°F. - Head and neck examination revealed no abnormalities. Pupils were equal and reactive to light. - Cardiovascular examination showed regular heart rhythm with no murmurs. - Respiratory examination was unremarkable with clear lung fields. - Abdominal examination was normal with no tenderness or masses. - Musculoskeletal examination showed full range of motion in all joints. - Neurological examination was normal with intact cranial nerves. - Skin examination revealed no rashes or lesions. Diagnosis: - Primary diagnosis: Tension-type headache. - Secondary diagnoses: Hypertension. - Differential diagnoses: Migraine, sinusitis. Plan: - Initiate treatment with acetaminophen 500mg as needed for headache relief. Continue Lisinopril for hypertension management. - Advise lifestyle modifications including stress management techniques and regular exercise. - Schedule a follow-up appointment in two weeks to reassess symptoms and blood pressure control. - Educate the patient on headache triggers and the importance of medication adherence. - Order a complete blood count and basic metabolic panel to rule out any underlying conditions.

History: - [describe current issues, reasons for visit, discussion topics, history of presenting complaints etc] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [describe past medical history, previous surgeries] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [mention medications and herbal supplements] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [describe social history] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [mention allergies] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Examination: - [describe general appearance and vital signs] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [describe findings from head and neck examination] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [describe findings from cardiovascular examination] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [describe findings from respiratory examination] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [describe findings from abdominal examination] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [describe findings from musculoskeletal examination] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [describe findings from neurological examination] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [describe findings from skin examination] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Diagnosis: - [list primary diagnosis] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [list secondary diagnoses] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [list differential diagnoses] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Plan: - [describe treatment plan, including medications, therapies, and lifestyle modifications] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [describe follow-up plans and referrals] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [mention patient education and counselling provided] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [mention any diagnostic tests or procedures ordered] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)

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