ENT Outpatient Consultation and Laryngoscopy Note

Chief Complaint: [Brief description of the patient's chief complaint] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write on a single line.) Assessment: [Clinician's explicitly stated summary of the patient including demographics, relevant medical history, presenting symptoms, examination findings, endoscopic findings, laboratory results, imaging results, primary diagnosis and differential diagnoses being considered] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Never invent or infer a diagnosis. Write as a single flowing paragraph in the following order: write as "[Patient name] is a [age] [sex] with a history of [relevant medical history], presenting with [brief current symptoms]. Examination showed [notable physical examination findings]. Scope demonstrated [endoscopic findings], labs remarkable for [significant laboratory results]. Imaging showing [relevant imaging results]. Clinical picture consistent with [clinician's explicitly stated primary diagnosis], although [clinician's explicitly stated differential diagnoses] are within the differential diagnosis.") Subjective: History of Presenting Illness: [Introduction identifying the patient by name, age and sex and the reason Otolaryngology was consulted] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a single opening sentence in the following format: write as "[Patient name] is a [age] [sex] presenting with the above chief complaint for which Otolaryngology is consulted.") [Reason for visit and chief complaints including symptoms and specific requests] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a list with each item on a new line.) [Duration, timing, location, quality, severity and context of the presenting complaint] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a list with each item on a new line.) [Factors that worsen or alleviate symptoms including any self-treatment attempts and their effectiveness] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a list with each item on a new line.) [Progression of symptoms over time including how they have changed or evolved] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a list with each item on a new line.) [Previous episodes of similar symptoms including timing, management and outcomes] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a list with each item on a new line.) [Impact of symptoms on the patient's daily activities, work and quality of life] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a list with each item on a new line.) [Associated focal and systemic symptoms accompanying the presenting complaint] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a list with each item on a new line.) [Contributing factors including relevant past medical history, surgical history, prior investigations and treatments related to the presenting complaint] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a list with each item on a new line.) [Relevant social history including occupation, lifestyle factors and social circumstances] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a list with each item on a new line.) [Relevant family history including conditions that may relate to the presenting complaint] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a list with each item on a new line.) [Relevant exposure history including environmental, occupational or infectious exposures] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a list with each item on a new line.) [Immunisation history and current immunisation status] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a list with each item on a new line.) [Any other relevant subjective information not captured above] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a list with each item on a new line.) Objective: Physical Examination: [Pertinent positive and negative findings from the physical examination excluding any endoscopy findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a list with each finding on a new line.) Flexible Fibreoptic Laryngoscopy: [Pertinent positive and negative findings from the flexible fibreoptic laryngoscopy] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Begin with the following verbatim consent and preparation statement before listing findings: write as "After obtaining verbal consent, the nasal passage(s) were prepared with a topical mixture of 4% topical lidocaine and 0.05% oxymetazoline." Then write findings as a list with each finding on a new line.) Plan: [Interventions or procedures planned for the patient] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a list with each item on a new line.) [Investigations planned for the patient] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a list with each item on a new line.) [Treatments planned for the patient] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a list with each item on a new line.) [Other relevant actions including counselling, consults and referrals] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a list with each item on a new line.) [Follow-up timing and arrangements] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "Follow up outpatient as needed". Write on a single line beginning with "Follow up outpatient" followed by the timing if mentioned.)