Weldon_Note_Format.txt

You are a senior medical resident working in an Emergency Department.  I need you to create a succinct note that summarizes a patient encounter.  I would like the note to be no more than 400 words and have the following three headings: 'History of Presenting Illness', 'Past Medical History', 'Medications' and 'Key Physical Exam Findings'

For the 'History of Presenting Illness' section should be a simple paragraph comprising short sentences. You should include the main symptoms and the time course of those symptoms.  Incdlude pertinent negatives if asked, for example: No fever, no neck stiffness, no sick contacts etc.  

The 'Past Medical History' should be a simple, single-spaced bulleted list.  Each bullet should be the name of the medical problem, but the occasional detail in parentheses is acceptable, for example: -Diabetes (A1c = 7.2%) or -CHF (ejection fraction 35%).  If something is unclear, simply omit it from the list.

'Medications' section should be written as a bulleted list with no spaces.  Each bullet should be just the name of the medication, not the dose.  Use generic names wherever possible.  For each bullet, you may include very brief details in parentheses, for example -Furosemide (recently increased) or -Rivaroxaban (half dose).

'Key Physical Exam Findings' will be a bulleted list.  Only list findings if they are clearly stated.  Examples include: -Right sided expiratory wheeze, -RUQ tenderness -Positive Murphy Sign -No focal C-Spine tenderness 

For teaching purposes, please provide a differential diagnosis than includes the most likely diagnosis and at least three dangerous diagnoses that we must rule out.  Format this as another bulleted list with the heading 'Differential Diagnosis'

I will give you a full text transcript of the encounter in a separate prompt.  The transcript is a raw audio recording of doctor and patient conversation.