Diagnosis:
[diagnoses in numbered points] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in numbered points. Try to keep it concise.)
Management:
[management details in numbered points, including procedures if procedure codes are provided in context/notes] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in numbered points.)
[summary of any information sent by text message or email] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
History of Presenting Complaint:
[start with whether this is a new consultation or follow up, if mentioned] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
[reasons for visit, chief complaints such as requests, symptoms etc] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
[duration, timing, location, quality, severity, context of complaint] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
[factors that worsen or alleviate symptoms, including self-treatment attempts and effectiveness] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
[progression of symptoms over time] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
[previous episodes: detail any past occurrences, management, and outcomes] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
[impact on daily activities, work, and lifestyle] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
[associated symptoms, including focal and systemic features] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
(Present information in paragraphs using full sentences, not dot points.)
Past Medical History:
[procedure] on [date] ([additional details]) (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
[medical condition] ([current treatment], [specialist care]) (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Medication History:
[drug history] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Social History:
[living situation] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
[sleep quality and contributing factors] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
[work profile or retired status] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Family History:
[family history] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Allergies:
[allergy status] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
[accompanied by a relative/friend during consultation] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write a note if present.)
Physical Examination:
[mention if examination was performed in the presence of a female chaperone] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
[vital signs if applicable] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
[physical or mental state examination findings, including system-specific examination(s) if applicable] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
[focus on tympanic membrane, external canal, tonsil if examined] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
[flexible fiberoptic laryngoscopy findings and details of procedure, see below] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. After obtaining verbal consent, the flexible endoscope was inserted into the [left or right] naris, which was grossly normal. Nasopharynx grossly normal without mass or lesion. Posterior pharynx symmetric without mass or lesion. The base of tongue is normal and symmetric. Vallecula is clear. The epiglottis and aryepiglottic folds are crisp and without mass or lesion. The supraglottic inlet is unobstructed. The true vocal folds are fully mobile and symmetric without mass or lesion. The visualized subglottis is patent. The pyriform sinuses are clear and without pooling of secretions. The patient tolerated the procedure well without complication.)
[scope exceptions and pertinent positive/negative findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
[neck examination, if applicable] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
[tuning fork tests, if performed] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
[balance tests – Rombergs, Untenbergers, Head thrust, Cerebellar tests, Dix-Hallpike, Epleys, Nystagmus – if performed] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
(Specifically mention if the examination was performed in the previous consultation.)
Investigations:
[investigations, including radiology scans, hearing results, blood test results] (Only include completed investigations with results explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Do not include planned investigations.)
[previous imaging] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Impression:
[diagnosis] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
[anatomical finding and potential intervention] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
[differential diagnosis] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Discussion:
(The diagnosis and treatment options are discussed with the patient in detail. Following which the patient decides to go ahead with the following plan.) (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Plan:
[treatment: medication, dosage, frequency, duration, treatment planned] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
[arrange tests or planned investigations] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
[obtain previous imaging and review together in timeframe] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
[procedure under specialist if condition met] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
[consider intervention prior to procedure if condition met] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
[relevant actions such as counselling, referrals etc.] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
[review in next clinic in timeframe] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
If any surgery or risks of surgery are discussed during the consultation, then list the risks for that particular operation as follows:
FESS or endoscopic sinus surgery:
"The specific procedure risks of endoscopic sinus surgery include but are not limited to: bleeding, infection, CSF leak, meningitis, brain injury, visual loss or double vision, watery eyes, pain, altered breathing and smell including loss of smell. You are aware that your symptoms may recur and surgery will not cure your condition, but may improve your medical management."
Septoplasty:
"The specific risks for septoplasty surgery include but are not limited to: bleeding, infection, septal perforation, altered shape of the nose, altered sensation (which may be permanent) to the nose and teeth, altered breathing and sense of smell. Occasionally the result does not meet expectations (further surgery is only required in a small number of cases). This is not a cure for rhinitis and further medical treatment is often necessary."
Turbinate surgery:
"The specific risks for Turbinate surgery include but are not limited to: bleeding, infection, altered sensation of the nose and teeth, altered breathing and sense of smell. The results are not permanent. Turbinate surgery will not cure rhinitis and you may need to continue on medical treatments."
(Information mentioned in the context is from the previous consultation and can be used to augment the current consultation. But specifically mention if the examination was performed in the previous consultation.)
(Avoid using short forms, for example PMHx.)
(Generate the paragraph title in plain text, not bold or italics.)
(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 section blank.)
(Use as many full sentences as needed to capture all the relevant information from the transcript.)