Responsible Consultant: Dr. Eleanor Vance
Presenting Complaint: PSA readings 6.2 ng/mL, dated 28 October 2024. eGFR readings 65 mL/min/1.73m², dated 28 October 2024.
History of Presenting Complaint: 68-year-old male presenting with increased urinary frequency and nocturia over the past 6 months. Reports needing to urinate every 1-2 hours during the day and 2-3 times per night. No urgency, incontinence, dysuria, or haematuria. Flow is slightly reduced, no hesitancy or straining. No terminal dribbling or sensation of incomplete emptying. No PR bleeding. Appetite and weight stable. No pain.
Past Medical History: Hypertension, managed with Lisinopril 10mg daily. Previous appendectomy in 1982.
Allergies: None known.
Medications: Lisinopril 10mg daily.
Social History: Retired accountant. Lives with wife. Drinks alcohol socially, approximately 2-3 units per week. Non-smoker. Good performance status.
Family History: Father had prostate cancer diagnosed at age 75.
Examination:
- Chaperone: Nurse present.
- DRE: Prostate feels enlarged, smooth, and non-tender.
Observations:
- BP: 138/82 mmHg
- HR: 78 bpm
- SpO2: 98% on room air
Plan: Discussed the findings with the patient. Advised further investigations including repeat PSA in 3 months and consideration of further imaging if PSA continues to rise. Discussed lifestyle modifications to manage symptoms. Will review in clinic in 3 months.
Responsible Consultant: [Name of Responsible Consultant]
Presenting Complaint: [PSA readings] [date of PSA readings] [eGFR readings] [date of eGFR] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
History of Presenting Complaint: [include the patient's age and details of the presenting complaint i.e. LUTS, Frequency, Urgency, Nocturia, Incontinence, Dysuria, Haematuria, Flow, Spitting/spraying, intermittency, hesitancy, straining, terminal dribbling, complete void sensation, double voiding, PR bleeding, appetite, weight loss, pain with location and duration and sensation changes as though you are writing to the GP] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Past Medical History: [past medical history, details of previous surgeries] (Include if explicitly mentioned in transcript, context or clinical note, else say None remarkable.)
Allergies: [details of allergies and reaction to allergies] (Include if explicitly mentioned in transcript, context or clinical note, else say None known)
Medications: [details of current medications] (Include if explicitly mentioned in transcript, context or clinical note, else say None.)
Social History: [include details of employment, performance status, care needs, alcohol, smoking, hobbies or other relevant social history] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Family History: [details of family history] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Examination: (Only include if explicitly mentioned in transcript or clinical note, else omit section entirely.)
- Chaperone: [details of chaperone] (Only include if explicitly mentioned in transcript or clinical note, else omit section entirely.)
- DRE: [details of digital rectal examination] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Observations: (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
- BP: [blood pressure readings] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
- HR: [heart rate] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
- SpO2: [oxygen saturation] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Plan: [details of the management plan as though 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.)