Asterisks test output

OVERALL_INSTRUCTIONS

Chief Complaint

[Insert chief complaint or reason for referral]

Template

Pediatric Rheumatology Outpatient Note Dear Doctors, We saw [patient's full name] in the Pediatric Rheumatology follow up clinic on [today's date]. [patient's first name] is a [patient's age] [patient's sex] who was accompanied by their [relationship of accompanying person to patient, e.g., mother, father, or parents]. The patient provided verbal consent to use the AI scribe during this visit, understanding its purpose, potential benefits, and limitations, as well as the need for a temporary audio recording for documentation and associated privacy and security risks. DIAGNOSIS: 1. [previous rheumatologic diagnoses, including details from the patient's medical history or context] DISEASE ASSESSMENT SCORES: Physician global assessment of disease activity [physician's global assessment of the patient's disease activity] CURRENT MEDICATIONS: 1. [patient's current home medications, including details on dosage, frequency, and route, as well as any over-the-counter supplements or herbal remedies] MEDICATION CHANGES MADE TODAY: [details of any medication changes discussed or made during the current visit, including new medications, dosage adjustments, or discontinuation of medications, and reasons for these changes] INTERVAL HISTORY: Symptoms: [summary of symptoms experienced by the patient since the last visit, including onset, duration, character, aggravating and alleviating factors, and any changes in symptom severity or frequency, along with details from previous visit status] Medication adherence & tolerance: [information regarding the patient's adherence to their medication regimen, any difficulties or side effects experienced with medications, and strategies for improving adherence or managing side effects] Functional status: The patient has [mild, moderate or severe] limitations in daily activities, including [specific examples of limitations in daily activities such as school attendance, participation in sports, self-care, or social interactions] Last eye exam: [date and findings of the patient's last eye examination, including any abnormalities or specific concerns related to their condition] Review of Systems: [a comprehensive review of other body systems for any new or changed symptoms, including general, dermatologic, cardiovascular, respiratory, gastrointestinal, genitourinary, neurological, endocrine, and hematologic systems] Immunizations: [status of the patient's immunizations, including any recent vaccinations or upcoming immunization needs] PHYSICAL EXAMINATION: [patient's vital signs, including blood pressure, heart rate, respiratory rate, temperature, height, and weight] On general examination [patient's full name] looks well. On head and neck exam, pupils were equal and reactive to light. No conjunctival or scleral injection. There was no facial rash, oral ulcers or cervical lymphadenopathy. No nasal ulcers or perforation. Tympanic membranes are clear. Oropharynx is clear with no erythema or exudates. No palatal petechiae or ulcers. No generalized lymphadenopathy. On cardiovascular exam, there were normal heart sounds with no murmurs appreciated and lungs were clear bilaterally. Abdomen was soft, nontender with no organomegaly. Skin is clear with no rashes. No nail changes. No nail fold capillary changes. Negative hair pull test. MSK exam: TMJ exam is normal. Cervical and axial spine exam is normal. No scoliosis. Peripheral joint exam is normal with no tender joints, restricted joints, swollen joints, enthesitis. Normal gait including toe and heel walking. Strength full in upper and lower extremities to confrontational muscle testing. No focal neurologic findings. INVESTIGATIONS: [details of any investigations discussed or ordered during the visit, including laboratory tests, imaging studies, or other diagnostic procedures, and their purpose or findings] IMPRESSION: [summary of the patient's current disease status, including relevant findings from the interval history and physical examination, and the current overall clinical impression and plan] PLAN: 1. [detailed plan for ongoing management, including any new or adjusted treatments, referrals to other specialists, further investigations, patient education, and follow-up arrangements] FOLLOW UP: Thank you for involving me in the care of [patient's full name]. Please do not hesitate to contact us for any questions or concerns. Sincerely,.