Essentials PHA Female

OVERALL_INSTRUCTIONS

[use singular third person pronouns] [include age, gender, reason for visit when stated] [put in GP name only when stated]

Chief Complaint

[Brief chief complaint or reason for visit]

Template

Subjective: - [Current issues, reasons for visit, history of presenting complaints etc] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Past medical history, previous surgeries] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise state nothing new.) [Family history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise state nothing new) [Medications] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Supplements] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Social history] (work/education, family, exercise, hobbies, diet, sleep, alcohol, smoking, drug use) [Allergies] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Review of Systems: - Constitutional symptoms: [Symptoms like Weight change, Fever, Chills, Night sweats, Fatigue, Malaise] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Eyes: [Symptoms like Eye pain, Swelling, Redness, Foreign body sensation, Discharge, Vision changes] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Ears, Nose, Mouth, Throat: [Symptoms like Hearing changes, Ear pain, Nasal congestion, Sinus pain, Hoarseness, Sore throat, Rhinorrhea, Swallowing difficulty] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Cardiovascular: [Symptoms like Chest pain, Shortness of breath (SOB), Paroxysmal nocturnal dyspnea (PND), Dyspnea on exertion, Orthopnea, Claudication, Edema, Palpitations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Respiratory: [Symptoms like Cough, Sputum production, Wheezing, Smoke exposure, Dyspnea] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Gastrointestinal: [Symptoms like Nausea, Vomiting, Diarrhea, Constipation, Abdominal pain, Heartburn, Anorexia, Dysphagia, Hematochezia, Melena, Flatulence, Jaundice] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Genitourinary: [Symptoms like Dysmenorrhea, Dysfunctional uterine bleeding (DUB), Dyspareunia, Dysuria, Urinary frequency, Hematuria, Urinary incontinence, Urgency, Flank pain, Changes in urinary flow, Hesitancy] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Musculoskeletal: [Symptoms like Arthralgias, Myalgias, Joint swelling, Joint stiffness, Back pain, Neck pain, Injury history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Integumentary (Skin): [Symptoms like Skin lesions, Pruritis, Hair changes, Breast/skin changes, Nipple discharge] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Neurological: [Symptoms like Weakness, Numbness, Paresthesias, Loss of consciousness, Syncope, Dizziness, Headache, Coordination changes, Recent falls] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Psychiatric: [Symptoms like Anxiety/Panic, Depression, Insomnia, Personality changes, Delusions, Rumination, Suicidal ideation/Homicidal ideation/Auditory hallucinations/Visual hallucinations, Social issues, Memory changes, Violence/Abuse history, Eating concerns] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Endocrine: [Symptoms like Polyuria, Polydipsia, Temperature intolerance] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Hematologic/Lymphatic: [Symptoms like Bruising, Bleeding, Transfusion history, Lymphadenopathy] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Allergic/Immunologic: [Symptoms like Allergic reactions, Auto-immune disorders] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Physical Examination: [Physical or mental state examination findings, including vitals and system specific examination] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Height [insert ht in cm, inches, both if both stated]. Weight [insert weight in kg and in lb if mentioned]. Body fat (Aim to achieve less than 25%). Body Fat Rating = [high risk, high, or normal]. Muscle mass if mentioned. visceral fat if mentioned. Waist Hip Ratio = [Ideal WHR for women = 0.80 or lower] Blood Pressure = (goal less than 130/80. Ideal is less than 120/80). Pulse beats per minute [number]. Appears well. MSE: [insert only if discussed: Good eye contact, appropriate affect, speech normal RRT, thoughts organized, good insight]. Neurological: [insert only if discussed: gait is normal, pupils are equal, round, and reactive to light, and patellar deep tendon reflexes are normal and equal bilaterally]. ENT: bilateral tympanic membranes normal, throat appears normal, no cervical lymphadenopathy is palpable, no goitre or palpable thyroid abnormality. Chest: lungs are clear with good air entry bilaterally, work of breathing is normal and the patient is speaking in full sentences. Cardiovascular: normal S1 and S2 are heard, no extra heart sounds or murmurs are appreciated, radial pulses are strong and regular bilaterally, and there is no peripheral edema noted. Abdomen: soft, nontender, and nondistended, no rebound or guarding is present and no hepatosplenomegaly is appreciated. Skin: no abnormal moles, no rashes, skin is intact. Breast exam: [notes on what was done and found, or put declined]. Pelvic exam: [note if done and findings, or put not done]. **Mental health screening** PHQ9 score (screening for depression) =   [number]. Score: None 0-4. Mild 5-9. Moderate 10-14. Moderate-severe 15-19. Severe 20+  GAD7 score (screening for anxiety) =   [number]. **Score:** None 0-4. Mild 5-9. Moderate 10-14. Moderate-Severe 15+. [Investigations with results] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Hearing: Vision: ECG: **Labwork** (done on month, day, year): Complete blood count: normal. (this is a blood test that gives important information about your red and white blood cells as well as a blood clotting factor called platelets). Ferritin: normal. (marker of iron stores). HbA1c . A HbA1c result of 5.5-5.9% indicates patient at risk for future diabetes. 6.0% is pre-diabetes. 6.5% is diabetes. Kidney function tests (GFR and creatinine): normal. GFR . Uric acid/urate (can indicate gout risk): normal. Calcium: normal. Liver function tests: normal. Cholesterol: normal. Your test results and medical information were used to calculate your statistical risk for cardiovascular disease and strokes in the next 10 years (Framingham Risk Score). **Risk level:** X risk of having a significant cardiovascular event in the next ten years. If LDL >=3.5 in primary prevention settings for low-risk patients with FRS 5-9.9% or intermediate risk patients, consider therapy. Also recommended with LDL-C >=5.0. Tg > 1.5. For dyslipidemia assessment, refer to Apo-B or non-HDL-C. If Apo-B >=1.05 in primary prevention setting for low risk patients with FRS 5-9.9% or intermediate risk patients, consider therapy. Therapy also suggested for low-risk patients with Apo-B>=1.45. Thyroid function: normal. Urinalysis: normal. Assessment & Plan: [1. Issue, problem or request 1 (issue, request or condition name only)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Assessment, likely diagnosis for Issue 1 (condition name only)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Differential diagnosis for Issue 1] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Investigations planned for Issue 1] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Treatment planned for Issue 1] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Relevant referrals for Issue 1] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [2. Issue, problem or request 2 (issue, request or condition name only)] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Repeat the above structure for each additional issue or condition identified.) - [Assessment, likely diagnosis for Issue 2 (condition name only)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Differential diagnosis for Issue 2] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Investigations planned for Issue 2] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Treatment planned for Issue 2] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Relevant referrals for Issue 2] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [3. Issue, problem or request 3, 4, 5 etc (issue, request or condition name only)] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Repeat the above structure for each additional issue or condition identified.) - [Assessment, likely diagnosis for Issue 3, 4, 5 etc (condition name only)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Differential diagnosis for Issue 3, 4, 5 etc] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Investigations planned for Issue 3, 4, 5 etc] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Treatment planned for Issue 3, 4, 5 etc] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Relevant referrals for Issue 3, 4, 5 etc] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Preventative Care** 1. Colon cancer screening: For individuals at average risk, screening typically begins at age 50 with a stool test and continues every 1–2 years until age 75. **Last screening test**: date. **Recommendation**:  Please arrange with your family doctor when due. Please follow up with your family doctor should you notice any changes to your bowel movements (eg: blood, black stools). 2. Breast cancer screening: Alberta guidelines recommend initiating breast imaging at age 45 and repeating every 2 years until approximately age 75, or until screening is no longer considered beneficial based on overall health and life expectancy. **Last screening test**:     date. **Recommendation**:   Please arrange with your family doctor when due. Please follow up with your family doctor if any new concerns arise. 3. Cervical cancer screening: Screening generally begins at the age of 25 and is performed every 3 years with Pap testing or every 5 years with HPV testing, when available. Screening may be discontinued after age 69 if prior results have been consistently normal. **Last screening test**:     date. **Recommendation**:   Please arrange with your family doctor when due. 4. Osteoporosis: Bone density assessment is recommended for all women aged 65 and older. For women under 65, earlier screening may be considered if risk factors are present, such as a history of fractures, low body weight, smoking, or certain medical conditions. To reduce risk of low bone density, do regular strength and resistance training, consume adequate vitamin D (800-2000IU daily) and Calcium (go to https://osteoporosis.ca/calcium-calculator/ to see how much calcium supplement is recommended for you based on your age, gender and diet), don’t smoke, and limit alcohol). **Last screening test**:     date. **Recommendation**: Please arrange with your family doctor when due. 5. Skin health: Practicing "sun sense" includes avoiding sun exposure during peak intensity hours (10 a.m. to 3 p.m.), wearing protective clothing, a hat, and sunglasses, and applying broad-spectrum sunscreen with SPF greater than 30. - **Recommendation:** Conduct a monthly skin self-examination using the ABCDE criteria: _A: Asymmetry – benign moles are typically symmetrical._ _B: Border – benign moles have clearly defined, sharp borders._ _C: Color – benign moles are usually uniform in color._ _D: Diameter – benign moles are generally smaller than 6 mm._ _E: Evolution – benign moles do not typically change in size, shape, and color over time._ 6. Eye health: See your optometrist every 2 years. 7. Dental health: Have a dental exam at least once per year and dental cleaning at least twice a year. 9. Hearing: your screening audiogram was . 10. Immunization is an effective preventative health strategy. _Seasonal Flu Vaccine: It is suggested to get the seasonal flu vaccine every October to optimize protection throughout the flu season. It is also recommended that you protect yourself with the COVID vaccine around the same time._ _Routine Vaccinations: Adults should get the Diphtheria, Tetanus, and Pertussis (Tdap) vaccine once, followed by the Td vaccine every 10 years._ _Vaccinations for Individuals over 50: If you are over the age of 50, it is recommended to get the Shingrix and Prevnar-20 vaccines to protect against Shingles and pneumonia, respectively._ 11. Healthy Living: Eating well and staying active are key strategies to lower your risk of heart disease, diabetes, cancer, dementia, and osteoporosis. - Nutrition: Aim for a diet rich in vegetables, fruits, whole grains, legumes, nuts, and seeds. Limit red meat to occasional servings and try to avoid processed meats (such as bacon, ham, deli meats, and hot dogs). Minimize highly processed foods and sugar-sweetened drinks. - Exercise: Adults should aim for at least 150 minutes per week of moderate-intensity activity. Strength-training exercises at least twice per week help maintain bone and muscle health. - Alcohol: No amount of alcohol comes without risk, but if you choose to drink, minimize risk by trying to limit alcohol consumption to 2 drinks per week. _Final note: Estate Planning ensures your wishes are carried out if you become ill or after your death. Key documents include a will (for property and finances), a personal directive (for healthcare decisions), and power of attorney (for financial decisions). Keeping these documents up to date provides clarity and peace of mind for you and your loved ones._