Patient Information:
- John Doe
- 45
- Male
- 123456
Presenting Complaint:
- Abdominal pain and bloating for the past two weeks.
History of Presenting Complaint:
- The patient reports a gradual onset of abdominal pain, which has been persistent and worsening over the last two weeks. The pain is described as a dull ache, primarily in the lower abdomen, and is associated with bloating and occasional nausea.
Past Medical History:
- Appendectomy in 2010, hypertension.
Medications:
- Lisinopril 10 mg daily, multivitamin.
Allergies:
- Penicillin (rash).
Family History:
- Father had colon cancer at age 60.
Social History:
- Works as an accountant, non-smoker, drinks alcohol socially, no recreational drug use.
Review of Systems:
- Positive for abdominal discomfort and bloating. Negative for fever, weight loss, or changes in bowel habits.
Physical Examination:
- Vital signs: BP 130/85, HR 78, Temp 98.6Β°F. General appearance: alert and oriented. Abdominal examination: mild tenderness in the lower quadrants, no rebound tenderness, normal bowel sounds.
Investigations:
- Ordered abdominal ultrasound and complete blood count.
Impression:
- Possible diverticulitis or other gastrointestinal pathology.
Plan:
- Start on a clear liquid diet, prescribe antibiotics (Ciprofloxacin and Metronidazole), and schedule a follow-up in one week. Educate the patient on signs of complications and when to seek immediate care.
Patient Information:
- [patient name] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [patient age] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [patient gender] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [patient ID] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Presenting Complaint:
- [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.)
History of Presenting Complaint:
- [details of the presenting complaint, including onset, duration, severity, and associated symptoms] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Past Medical History:
- [describe past medical history, previous surgeries] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Medications:
- [mention medications and herbal supplements] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Allergies:
- [mention allergies] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Family History:
- [details of any relevant family medical history] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Social History:
- [describe social history, including occupation, lifestyle, smoking, alcohol use, and recreational drug use] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Review of Systems:
- [details of review of systems, including any relevant positive or negative findings] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Physical Examination:
- [details of physical examination findings, including vital signs, general appearance, and system-specific examinations] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Investigations:
- [details of any investigations ordered or reviewed, including blood tests, imaging, and other diagnostic tests] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Impression:
- [clinical impression or differential diagnosis based on the history and examination] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Plan:
- [details of the management plan, including any treatments, referrals, follow-up arrangements, and patient education] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)