Responsible Clinician: Dr. Eleanor Vance
Presenting Complaint: Haematuria and lower urinary tract symptoms. eGFR is 65.
History of Presenting Complaint: Dear Dr. Jones, I am writing to you today regarding Mr. David Miller, a 68-year-old gentleman who presented with a 3-month history of intermittent painless haematuria. He also reports lower urinary tract symptoms including nocturia (2-3 times per night), frequency (every 2-3 hours), and urgency. His urinary flow is slightly reduced. He denies any bowel habit changes, including PR bleeding. His appetite is good, and he reports no weight loss. He experiences mild suprapubic discomfort, which is intermittent and not related to any specific activity.
Past Medical History: Hypertension, well-controlled with medication. Previous prostatectomy for benign prostatic hyperplasia 5 years ago.
Allergies: No known drug allergies.
Medication: Amlodipine 5mg once daily, Tamsulosin 0.4mg once daily.
Social History: Retired. Lives with his wife. Non-smoker, occasional alcohol consumption. Good performance status. No care needs.
Family History: Father had prostate cancer.
Examination: Chaperone present. Digital rectal examination revealed a small, firm prostate. No palpable masses.
Investigations: Urinalysis showed microscopic haematuria. Flexible cystoscopy performed today, with findings of mild bladder inflammation. Consent obtained, and chaperone present. Ultrasound scan of the kidneys and bladder showed no hydronephrosis or significant abnormalities. Blood pressure 130/80, heart rate 72 bpm, oxygen saturation 98% on room air.
Plan: Dear Dr. Jones, I have arranged for a repeat urine sample and a PSA test. I have discussed the findings with Mr. Miller and explained the need for further investigation. We will review the results in two weeks. I have advised him to increase his fluid intake and to avoid any irritants. I will also be discussing the possibility of further investigations such as a CT scan if the PSA is elevated.
Date: 1 November 2024
Responsible Clinician: [Name of responsible clinician]
Presenting Complaint: [describe the patient's presenting complaint including eGFR if mentioned] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
History of Presenting Complaint: [As if in a letter to the GP, describe history of presenting complaint including haematuria details and duration; lower urinary tract symptoms such as flow, nocturia, frequency, urgency; bowel habits including PR bleeding; appetite status good or poor; weight loss status; details, location and duration of any pain] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Past Medical History: [past medical history] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Allergies:[allergies including reaction to allergies if mentioned] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Medication: [list current medications and doses] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Social History: [include if mentioned employment status, performance status, care needs, alcohol intake, smoking habits, menopause status, children details, delivery details, hobbies or other relevant social history] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Family History: [family history or lack of] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Examination: [include chaperone details and details of any examination e.g. digital rectal examination] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Investigations: [Urinalysis results] [flexible cystoscopy findings including consent and chaperone details] [ultrasound scan findings] [blood pressure, heart rate and oxygen saturation if relevant] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Plan: [management plan as if writing to the GP] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
(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 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 the transcript.)