s/p Appendectomy 3 days
Subjective:
- Patient reports mild abdominal pain and tenderness at the incision site.
- No significant past medical history. Previous appendectomy 3 days ago.
- Currently taking paracetamol for pain management.
- No known allergies.
- Two bowel movements since surgery, normal consistency.
Objective:
- Vital signs: BP 120/80 mmHg, HR 78 bpm, Temp 37°C, RR 16 breaths/min.
- Physical examination: Mild tenderness around the incision site, no signs of infection.
- Wound assessment: Incision site clean, dry, and intact with minimal erythema.
- Drain output: No drains present.
- Laboratory results: WBC count within normal range.
- Urine output: Adequate, approximately 1500 ml/day.
Assessment:
- Postoperative diagnosis: Uncomplicated appendicitis.
- No complications noted.
- Progress since surgery: Healing well, pain is manageable with medication.
Plan:
- Continue paracetamol as needed for pain.
- Wound care: Keep incision site clean and dry, change dressing daily.
- Activity restrictions: Avoid heavy lifting for 2 weeks.
- Follow-up appointment in 1 week.
- No additional tests or consultations required at this time.
s/p [name of surgery] [number of days since surgery] (only include number of days since surgery if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Subjective: (don't use a lead-in for any of the bullet points below, just include the relevant information as is.)
- [describe current issues, reasons for visit, discussion topics, history of presenting complaints etc] (only include describe current issues, reasons for visit, discussion topics, history of presenting complaints etc if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [describe past medical history, previous surgeries] (only include describe past medical history, previous surgeries if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [mention medications and herbal supplements] (only include mention medications and herbal supplements if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [describe social history] (only include describe social history if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [mention allergies] (only include mention allergies if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [mention how many bowel movements since the surgery, if any] (include only if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Objective: (don't use a lead-in for any of the bullet points below, just include the relevant information as is.)
- [vital signs] (only include vital signs if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [physical examination findings] (only include physical examination findings if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [wound assessment] (only include wound assessment if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [drain output] (only include drain output if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [laboratory results] (only include laboratory results if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [imaging results] (only include imaging results if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [mention how much is their urine output] (only include if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Assessment: (don't use a lead-in for any of the bullet points below, just include the relevant information as is.)
- [postoperative diagnosis] (only include postoperative diagnosis if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [complications] (only include complications if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [progress since surgery] (only include progress since surgery if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Plan: (don't use a lead-in for any of the bullet points below, just include the relevant information as is.)
- [medications] (only include medications if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [wound care instructions] (only include wound care instructions if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [activity restrictions] (only include activity restrictions if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [follow-up appointments] (only include follow-up appointments if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [additional tests or consultations] (only include additional tests or consultations if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
(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 include 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.)