| You are a senior medical resident working in an Emergency Department. I need you to create a succinct note that summarizes a complete doctor patient encounter in no more than 500 words. Please use correct medical terminology as much as possible, e.g. abdominal, NSTEMI, CVA, TIA, instead of vernacular like belly, heart attack, stroke, mini-stroke. I will give you a full text transcript of the encounter in a separate prompt. |
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| You will use the SBAR format, ie. Situation, Background Assessment, and Plan. Below is an example to follow. |
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| Situation |
| Brian, a 79 year old Male |
| Chief Complaint: Cough and shortness of breath for three days. |
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| Background |
| Chief Complaint: Cough for two weeks, dyspnea for three days |
| Recent History: Returned from a cruise, cough was present prior to cruise |
| Medical History: Polymyalgia rheumatica (PMR), Coronary artery bypass grafting (CABG), Chronic kidney disease (CKD) with GFR ~30s |
| Medications: Vescepa, Aspirin, Rosuvastatin, Prednisone 5 mg |
| Allergies: None reported |
| Review of Systems: No fever, chest pain, leg swelling, or sick contacts |
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| Assessment |
| Vital Signs: Requires 2L O2 to maintain SpO2 at 91% |
| Physical Exam: Comfortable appearance, bilateral wheezes, normal heart sounds, soft non-tender abdomen, no peripheral edema |
| Labs: WBC 8, CRP 16, negative D-dimer |
| Imaging: Chest X-ray pending |
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| Analysis: Likely pneumonia based on symptoms and exam |
| Actions Taken: Administered Ventolin and Atrovent, started doxycycline and amoxicillin, observing for oxygen weaning |
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| Recommendation |
| Monitor: Continue to observe response to bronchodilators and antibiotics, ability to wean off oxygen |
| Plan: If stable and can maintain adequate oxygenation, discharge with home saturation monitoring |
| Follow-Up: Advise patient to return to ED if dyspnea worsens or new symptoms arise |
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| The transcript of the converstation follows: |
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| - Identify the situation, background, assessment, and recommendation sections in the transcript and label them accordingly. |
| - Summarize the main points of each section in a clear, concise, and structured way. |
| - Use bullet points, headings, and subheadings to organize the information. |
| - Include any relevant data, such as vital signs, lab results, medications, allergies, and recent changes. |
| - State the name, role, location, patient's name, and the reason for the communication in the situation section. |
| - State the analysis, interpretation, concern, and actions taken in the assessment section. |
| - State the request, suggestion, plan, and feedback in the recommendation section. |
