Date: [DD/MM/YYYY]
PATIENT DEMOGRAPHICS
Name: [Patient's Name] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
DOB: [Patient's Date of Birth] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Age: [Patient's Age] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Gender: [Patient's Gender] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Referred by: [Referring Physician or Source] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
PRESENTING COMPLAINT
[Describe the main complaint or reason for the visit] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
HISTORY OF PRESENTING COMPLAINT
Duration: [Duration of the complaint] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Site: [Location of the complaint] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Onset: [Onset of the complaint] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Character: [Character of the complaint] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Radiation: [Radiation of the complaint] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Associated symptoms: [Associated symptoms] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Aggravating factors: [Aggravating factors] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Relieving factors: [Relieving factors] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
ENT SPECIFIC SYMPTOMS
Ear:
- Pain: [Ear pain details] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Discharge: [Ear discharge details] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Hearing loss: [Hearing loss details] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Tinnitus: [Tinnitus details] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Vertigo: [Vertigo details] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Nose:
- Obstruction: [Nasal obstruction details] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Discharge: [Nasal discharge details] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Epistaxis: [Epistaxis details] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Smell disturbance: [Smell disturbance details] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Facial pain/pressure: [Facial pain/pressure details] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Throat:
- Sore throat: [Sore throat details] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Dysphagia: [Dysphagia details] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Voice changes: [Voice changes details] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Snoring/sleep apnoea: [Snoring/sleep apnoea details] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
PAST MEDICAL HISTORY
[Details of past medical history] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
PAST SURGICAL HISTORY
[Details of past surgical history] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
MEDICATIONS
Current: [List of current medications] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Allergies: [List of allergies] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
SOCIAL HISTORY
Smoking: [Smoking status] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Alcohol: [Alcohol consumption details] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Occupation: [Occupation details] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
FAMILY HISTORY
[Details of family history] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
EXAMINATION
General appearance: [General appearance details] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Ear examination:
Right: [Right ear examination details] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Left: [Left ear examination details] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Nose examination:
External: [External nose examination details] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Anterior rhinoscopy: [Anterior rhinoscopy details] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Posterior rhinoscopy: [Posterior rhinoscopy details] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Oral cavity and oropharynx:
Dentition: [Dentition details] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Tongue: [Tongue details] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Tonsils: [Tonsils details] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Posterior pharyngeal wall: [Posterior pharyngeal wall details] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Neck examination:
Lymph nodes: [Lymph nodes details] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Thyroid: [Thyroid details] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
INVESTIGATIONS
[Details of investigations] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
IMPRESSION
[Clinical impression] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
PLAN
[Management plan] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
[Clinical Name]
[Clinician role]
(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.)
(Give ICD 10 codes at the end)