Clinical Summary Documentation Template

Patient Demographics:
- Name: John Doe
- Date of Birth: 15 March 1980
- Gender: Male
- Identification Number: 123456789
Medical History:
- Past Medical History: Hypertension, Type 2 Diabetes, Appendectomy in 2010
- Family History: Father had coronary artery disease, mother has osteoporosis
- Social History: Non-smoker, occasional alcohol use, works as an accountant, lives with family
- Allergies: Penicillin
Current Clinical Status:
- Chief Complaint: Persistent cough and shortness of breath
- History of Present Illness: The patient reports a persistent cough for the past two weeks, accompanied by shortness of breath, especially during physical exertion. No fever or chest pain reported.
- Medications: Metformin 500mg daily, Lisinopril 10mg daily
Diagnostic Findings:
- Laboratory Tests: Elevated blood glucose levels, HbA1c at 7.5%
- Imaging Studies: Chest X-ray shows mild bilateral infiltrates
- Specialist Consultations: Pulmonologist consultation recommended for further evaluation
Assessment:
- Diagnoses: Acute bronchitis, poorly controlled Type 2 Diabetes
- Problem List: Persistent cough, shortness of breath, elevated blood glucose levels
Plan of Care:
- Treatment Plan: Prescribe a course of antibiotics for bronchitis, adjust diabetes medication to improve glycemic control, recommend increased physical activity
- Rehabilitation Plan: Not applicable
- Prognosis: Good, with adherence to treatment and lifestyle modifications
Progress Notes:
- Clinical Progress: Patient to be reviewed in two weeks to assess response to antibiotics and changes in diabetes management
- Updates to Plan of Care: Adjustments to be made based on follow-up results
Summary and Recommendations:
- Executive Summary: The patient presents with symptoms of acute bronchitis and poorly controlled diabetes. Immediate treatment initiated with antibiotics and medication adjustments.
- Recommendations: Follow-up with GP in two weeks, consider referral to a pulmonologist if symptoms persist.