Internal Medicine Note

Subjective

[Chief Complaint] (Briefly state the primary reason for the patient's visit, using patient's own words if explicitly mentioned.)

[History of Present Illness] (Describe onset, duration, character, aggravating and relieving factors, and associated symptoms. Only include details explicitly stated in the clinical notes or transcript.)

[Past Medical History] (List relevant medical conditions explicitly mentioned.)

[Current Medications] (List medications with dosages and frequency explicitly mentioned.)

[Allergies] (Document allergies explicitly stated.)

[Social History] (Include tobacco, alcohol, or substance use only if explicitly mentioned.)

[Family Medical History] (Include significant family medical conditions explicitly mentioned.)

Review of Systems

(Include only symptoms explicitly mentioned by the patient; omit any system not discussed.)

• [Constitutional]
• [Eyes]
• [ENT]
• [Cardiovascular]
• [Respiratory]
• [Gastrointestinal]
• [Genitourinary]
• [Musculoskeletal]
• [Integumentary/Skin]
• [Neurological]
• [Psychiatric]
• [Endocrine]
• [Hematologic/Lymphatic]
• [Allergic/Immunologic]

Objective

(Only output bullet points that have been explicitly mentioned in clinical notes or transcript. Omit sections if no relevant details are provided.)

• [Vital Signs] (Include explicitly stated vitals: temperature, blood pressure, pulse, respiratory rate, oxygen saturation.)
• [General Examination] (General appearance, orientation, distress level if explicitly noted.)
• [System-Specific Examination Findings] (Detail findings explicitly noted in notes or transcript for each relevant body system.)
• [Laboratory and Diagnostic Results] (Include explicitly mentioned test results with dates where available.)

Impression & Plan

(List each explicitly identified problem with relevant impressions, diagnoses, and concise management plans. Only include issues explicitly mentioned.)

1. [Issue/Diagnosis 1]

• [Clinical impression or diagnosis explicitly stated.]
• [Planned diagnostics, investigations explicitly mentioned.]
• [Treatment strategy explicitly detailed.]
• [Referrals explicitly mentioned.]

2. [Issue/Diagnosis 2]

• [Clinical impression or diagnosis explicitly stated.]
• [Planned diagnostics, investigations explicitly mentioned.]
• [Treatment strategy explicitly detailed.]
• [Referrals explicitly mentioned.]

[Additional Issues] (Include additional issues as numbered items, following the same format as above.)

(Never include information not explicitly stated in the clinical notes or transcript. Leave sections blank or omit if not discussed.)