New Patient Template - Dr.Gerschman

Chief Complaint

New Patient Visit

Template

I had the pleasure of seeing [Patient Name] accompanied by [Accompaniment Details] at [Clinic Name] on [Date of Appointment (MMMM-DD-YYYY)]. My provisional diagnosis is [Provisional Diagnosis]. HISTORY OF PRESENTING ILLNESS: [[Provide a detailed narrative of the patient's presenting illness, including onset, duration, frequency, severity, and associated symptoms. Include any relevant history of previous symptoms, treatments, and investigations. Mention any recent interventions such as physiotherapy or medications, and summarize findings from imaging or other diagnostic tests. Include any relevant systemic symptoms or lack thereof.] Example: Jane, a 7-year-old female in Grade 2, presented with a 6-month history of left ankle pain, worsening in the evenings after activities such as running and playing, and also upon waking. She has morning stiffness lasting about 15 minutes. The pain, initially severe with constant limping, has slightly improved over the past 3 months but remains significant most evenings, usually resolving with ice and Advil. The pain is localised to the anterior ankle without recollection of injury at onset. There was no history of preceding illness. She has also developed more recent right ankle pain for the past month. Previously, she experienced left wrist pain last fall, which resolved but recurs with excessive activity. For the past month she's had physiotherapy. They noticed some slight swelling but that's not something mom or Jane noted. They have been working on some strengthening. She's been taking ibuprofen 200 mg once daily on most days. Jane had an Xray in December 2023 that suggested there was a "nodule" (?soft tissue swelling) overlying the lateral malleolus. Ultrasound more recently showed some mild tenosynovitis in the extensor digitorum tendons. She's been otherwise well with no fevers or rashes noted. She did have one fever that lasted a day but that seems to have been a one off. She's had no abdominal complaints or oral ulcers. She's not had any problems with her eyes.] SCHOOL & SPORT PARTICIPATION: [Describe the patient's school grade and participation in sports or physical activities. Include the frequency and type of activities, and any limitations or changes due to the presenting illness.] PAST MEDICAL HISTORY: [Provide a detailed narrative of the patient's past medical history, including any chronic conditions, previous surgeries, hospitalizations, known drug allergies, food allergies or intolerances, developmental concerns, learning or attention issues, and immunization status. Use a narrative paragraph style to maintain consistency with the input content.] Current medications reported by the patient include: 1.) [drug_name/Supplement] [Dosage] [Frequency] 2.) [drug_name/Supplement] [Dosage] [Frequency] FAMILY AND SOCIAL HISTORY: [Provide a narrative description of the patient's living situation, including location and household members. Include details about each family member's age and any known medical issues. Specify if there are any smokers in the home, the presence of siblings, and any relevant medical conditions they may have. Note any additional family medical history, including conditions not present in the patient but relevant to family members. Mention the presence or absence of pets and any significant family medical history related to specific conditions such as JIA, RA, IBD, or psoriasis.]. PHYSICAL EXAMINATION: [[Begin with a general statement about the patient's overall appearance and well-being. Include specific measurements such as height, weight, and BMI.] [For the musculoskeletal examination, provide detailed observations for each joint or area examined. Include comparisons between left and right sides, noting any differences in warmth, thickness, range of motion, and pain. Mention any specific joints or areas with abnormalities, such as the wrist, ankle, or midfoot. Describe any tenderness, swelling, or other notable findings.] [Conclude with a summary of the remainder of the examination, noting any normal findings or negative results, such as the absence of oral ulcers, skin lesions, or nail pitting.]] IMPRESSION/PLAN: [[Provide a detailed narrative of the clinical findings, including suspected conditions and their implications. Discuss any diagnostic tests ordered, such as bloodwork or imaging, and their purpose. Include details of any treatments initiated, such as medications, along with precautions and patient education provided. Outline follow-up plans, including timelines for reviewing test results and assessing treatment response. Mention any additional screenings or referrals planned if the diagnosis is confirmed. Specify any documentation to be provided, such as school letters, contingent on diagnosis confirmation.] Example: The clinical findings suggest chronic inflammatory arthritis of the left ankle and also probably of the left wrist. This is concerning for a possible inflammatory arthropathy such as Juvenile Idiopathic Arthritis (JIA). This would be an oligoarticular presentation. I've asked for screening bloodwork but explained that in many cases it is normal. A left ankle contrast MRI is to be booked at BC Children Hospital within 2-3 weeks to confirm the diagnosis of inflammatory arthritis. The findings are still somewhat subtle so I think the additional imaging will be useful. A trial of naproxen 275 mg BID has been initiated as an anti-inflammatory, with GI and rash (pseudoporphyria) precautions reviewed. The patient has been advised to continue activity as tolerated and to hold off on further physiotherapy at this time. Patient education was provided, including resources from the Arthritis Society & Cassie and Friends. A follow-up is scheduled for 3-4 weeks to review MRI results and clinical response to naproxen. I did explain that if the diagnosis is confirmed we'll likely need to consider additional treatments. Ophthalmology screening for uveitis will be arranged after MRI if JIA is confirmed. A school letter regarding the probable JIA diagnosis will be provided if diagnosis confirmed. ] Thank you for your kind referral.