Hi! You are such an excellent clinical assistant, helping me move through my records quickly and effectively. Please transcribe the report / result and then craft a message for me that I can use to communicate a summary and action points in the medical record.
The type of report is: {formmenu: Holter Monitor; Cardiac Stress Test; EKG; Ultrasound Abdomen; Ultrasound Pelvis; Ultrasound Abdomen and Pelvis; Echocardiogram; Level III Sleep Study; Specialist Doctor Consultation; MRI Body; MRI Head; CT Body; CT Head; X-Ray; Mammogram; Operative Report; Bone Mineral Density\ ; Ultrasound Thyroid/Neck; Other; name=Type of Report; multiple=yes}
{formtoggle: name=If Specialist Doctor...; default=no}{formtext: name=WRITE IN TYPE OF SPECIALIST}{endformtoggle}
The Structure of the Extraction and Summary Should Be According To:
{formmenu: Female Pelvic Ultrasound: Basic Information
Date of examination: (Insert Date from Report)
Type of ultrasound: (Insert Data from Report)
Reason for examination: (Insert Data from Report)
Pelvic Ultrasound Components
Uterus:
Size/dimensions: (Insert Result)
Endometrial thickness: (Insert Result)
Endometrial character: (Insert Result)
Myometrial abnormalities: (Insert Result)
Ovaries:
Right ovary size: (Insert Result)
Right ovary findings: (Insert Result)
OVARIAN VOLUME: (Insert Result)
Left ovary size: (Insert Result)
Left ovary findings: (Insert Result)
OVARIAN VOLUME: (Insert Result)
Other pelvic findings: (Insert Result)
Impression/Interpretation
Summary of findings: (Insert Result)
Recommendations
Follow-up recommendations: (Insert Result); Abdo Ultrasound: Basic Information
Date of examination: (Insert Date from Report)
Type of ultrasound: (Insert Data from Report)
Reason for examination: (Insert Data from Report)
Abdominal Ultrasound Components
Liver:
Size: (Insert Result)
Echogenicity: (Insert Result)
Focal lesions: (Insert Result)
Other findings: (Insert Result)
Hepatic steatosis? (Insert Result)
Gallbladder:
Appearance/Structure: (Insert Result)
Stones: (Insert Result)
Polyps: (Insert Result)
Focal lesions: (Insert Result)
Other findings: (Insert Result)
Biliary tree:
Common bile duct diameter: (Insert Result)
Abnormalities: (Insert Result)
Pancreas:
Visualization: (Insert Result)
Appearance/Structure: (Insert Result)
Fatty infiltration: (Insert Result)
Focal lesions: (Insert Result)
Other findings: (Insert Result)
Spleen:
Size: (Insert Result)
Appearance/Structure: (Insert Result)
Focal lesions: (Insert Result)
Other findings: (Insert Result)
Kidneys:
Right kidney size: (Insert Result)
Stones: (Insert Result)
Appearance/Structure: (Insert Result)
Other findings: (Insert Result)
Left kidney size: (Insert Result)
Stones: (Insert Result)
Appearance/Structure: (Insert Result)
Other findings: (Insert Result)
Bladder:
Filling: Prevoid volume (Insert Result), post-void (Insert Result), residual (Insert Result)
Wall thickness: (Insert Result)
Appearance/Structure: (Insert Result)
Focal lesions: (Insert Result)
Other findings: (Insert Result)
Abdominal aorta:
Diameter: (Insert Result)
Other findings: (Insert Result)
Impression/Interpretation
Summary of findings: (Insert Result)
Recommendations
Follow-up recommendations: (Insert Result); Female Abdo/Pelvis Ultrasound: Basic Information
Date of examination: (Insert Date from Report)
Type of ultrasound: (Insert Data from Report)
Reason for examination: (Insert Data from Report)
Abdominal Ultrasound Components
Liver:
Size: (Insert Result)
Echogenicity: (Insert Result)
Focal lesions: (Insert Result)
Other findings: (Insert Result)
Hepatic steatosis? (Insert Result)
Gallbladder:
Appearance/Structure: (Insert Result)
Stones: (Insert Result)
Polyps: (Insert Result)
Focal lesions: (Insert Result)
Other findings: (Insert Result)
Biliary tree:
Common bile duct diameter: (Insert Result)
Abnormalities: (Insert Result)
Pancreas:
Visualization: (Insert Result)
Appearance/Structure: (Insert Result)
Fatty infiltration: (Insert Result)
Focal lesions: (Insert Result)
Other findings: (Insert Result)
Spleen:
Size: (Insert Result)
Appearance/Structure: (Insert Result)
Focal lesions: (Insert Result)
Other findings: (Insert Result)
Kidneys:
Right kidney size: (Insert Result)
Stones: (Insert Result)
Appearance/Structure: (Insert Result)
Other findings: (Insert Result)
Left kidney size: (Insert Result)
Stones: (Insert Result)
Appearance/Structure: (Insert Result)
Other findings: (Insert Result)
Bladder:
Filling: Prevoid volume (Insert Result), post-void (Insert Result), residual (Insert Result)
Wall thickness: (Insert Result)
Appearance/Structure: (Insert Result)
Focal lesions: (Insert Result)
Other findings: (Insert Result)
Abdominal aorta:
Diameter: (Insert Result)
Other findings: (Insert Result)
Pelvic Ultrasound Components
Uterus:
Size/dimensions: (Insert Result)
Endometrial thickness: (Insert Result)
Endometrial character: (Insert Result)
Myometrial abnormalities: (Insert Result)
Ovaries:
Right ovary size: (Insert Result)
Right ovary findings: (Insert Result)
OVARIAN VOLUME: (Insert Result)
Left ovary size: (Insert Result)
Left ovary findings: (Insert Result)
OVARIAN VOLUME: (Insert Result)
Other pelvic findings: (Insert Result)
Impression/Interpretation
Summary of findings: (Insert Result)
Recommendations
Follow-up recommendations: (Insert Result)
\n; Sleep Study Report
Basic Information
Date of study: (Insert Result from Report)
Type of study: Level III (home sleep study)
Duration of recording: (Insert Result from Report)
Reason for study: Rule out sleep apnea, assess sleep quality, fragmentation, periodicity, limb movements
Sleep Architecture
Total sleep time (min): (Insert Result from Report) minutes ((Insert Result from Report) hours (Insert Result from Report) minutes)
Sleep efficiency (%): (Insert Result from Report)%
Sleep latency (min): (Insert Result from Report)h:(Insert Result from Report)m
REM latency (min): (Insert Result from Report)% (Insert Result from Report)h:(Insert Result from Report)m
Time in stages (% or min):
N1: (Insert Result from Report)
N2: (Insert Result from Report)
N3 (deep sleep): (Insert Result from Report)
REM: (Insert Result from Report)% ((Insert Result from Report) hour (Insert Result from Report) minutes)
Number of awakenings: (Insert Result from Report)
Arousal index (events/hr): (Insert Result from Report)
WASO (Wake After Sleep Onset): (Insert Result from Report) minutes
Respiratory Parameters
Apnea-Hypopnea Index (AHI): (Insert Result from Report) events/hour (Interpretation: (Mild/Moderate/Severe (Insert Result from Report))
Respiratory Disturbance Index (RDI): (Insert Result from Report) events/hour
Obstructive apnea index: (Insert Result from Report) events/hour
Central apnea index: (Insert Result from Report)
Mixed apnea index: (Insert Result from Report)
Hypopnea index: (Insert Result from Report)
Oxygen saturation:
Baseline: (Insert Result from Report)
Mean: (Insert Result from Report)%
Minimum: (Insert Result from Report)%
Maximum: (Insert Result from Report)%
Time below 90% (min or %): (Insert Result from Report) minutes ((Insert Result from Report) %)
Time below 88% (min or %): (Insert Result from Report) minutes ((Insert Result from Report) %)
Time below 80% (min or %): (Insert Result from Report) minutes ((Insert Result from Report) %)
Oxygen desaturation index (ODI): (Insert Result from Report) minutes ((Insert Result from Report) %)
Cardiac Parameters
Mean heart rate: (Insert Result from Report) bpm
Minimum heart rate: (Insert Result from Report) bpm
Maximum heart rate: (Insert Result from Report) bpm
Cardiac arrhythmias: (Insert Result from Report)
Movement Parameters
Periodic limb movements index (PLMI): (Insert Result from Report)
PLM arousal index: (Insert Result from Report)
Periodicity: (Insert Result from Report)% (above or below expected value of <2%)
Positional Data
Supine AHI: (Insert Result from Report)
Non-supine AHI: (Insert Result from Report)
Positional dependency: (Insert Result from Report)
Interpretation
Diagnosis: (Insert Result from Report)
Severity assessment: (Insert Result from Report) (AHI (Insert Result from Report) events/hour)
Contributing factors: Sleep fragmentation ((Insert Result from Report)%, expected <15%)\; Periodicity ((Insert Result from Report)%, above expected value of <2%)
Recommendations
Treatment recommendations: (Insert Transcribed Result from Report)
Follow-up suggestions: (Insert Transcribed Result from Report)
Lifestyle modifications: (Insert Transcribed Result from Report)\ ; default=Echocardiogram Report Extraction
Please extract all relevant information from the echocardiogram report uploaded to the context window.
Basic Information
- Date of examination:
- Type of echocardiogram (TTE/TEE/Stress/other):
- Reason for examination:
- Interpreting physician:
Technical Quality
- Study quality:
- Limitations:
Left Ventricle
- Size/dimensions:
- Wall thickness:
- Mass index:
- Systolic function:
- Ejection fraction (%):
- Regional wall motion abnormalities:
- Diastolic function:
- E/A ratio:
- E/e' ratio:
- Deceleration time:
- Diastolic grade:
Right Ventricle
- Size:
- Systolic function:
- TAPSE:
- RV S':
- FAC:
- Estimated RVSP (if TR present):
Atria
- Left atrial size:
- Volume index:
- Diameter:
- Right atrial size:
Valves
- Mitral valve:
- Structure:
- Function:
- Regurgitation (grade):
- Stenosis (if present):
- Aortic valve:
- Structure:
- Function:
- Regurgitation (grade):
- Stenosis (if present):
- Valve area (if stenosis):
- Mean/peak gradients (if stenosis):
- Tricuspid valve:
- Structure:
- Function:
- Regurgitation (grade):
- Pulmonic valve:
- Structure:
- Function:
- Regurgitation (grade):
Great Vessels
- Aortic root dimension:
- Ascending aorta:
- Descending aorta:
- IVC size and collapsibility:
Other Findings
- Pericardium:
- Intracardiac masses/thrombi:
- Congenital abnormalities:
- Other abnormalities:
Interpretation/Conclusion
- Summary of findings:
- Comparison to prior studies (if available):
Recommendations
- Follow-up recommendations:
- Additional testing suggested:
BOLD any abnormal findings or results outside normal ranges.; Colon Cancer Screening Report
Please extract all relevant information from the colon cancer screening report uploaded to the context window.
### Basic Information
- Date of examination:
- Type of screening:
- Colonoscopy
- FIT (Fecal Immunochemical Test)
- FOBT (Fecal Occult Blood Test)
- Cologuard/FIT-DNA
- CT Colonography
- Flexible Sigmoidoscopy
- Reason for examination:
- Performing physician (for colonoscopy):
- Interpreting healthcare provider:
### For Colonoscopy/Sigmoidoscopy
- Preparation quality:
- Extent of examination:
- Withdrawal time:
- Findings:
- Polyps:
- Location:
- Size:
- Morphology:
- Removal method:
- Masses:
- Diverticula:
- Hemorrhoids:
- Inflammatory changes:
- Vascular patterns:
- Other abnormalities:
- Interventions performed:
- Complications:
### For FIT/FOBT
- Test methodology:
- Result (positive/negative):
- Quantitative value (if available):
- Reference range:
### For Cologuard/FIT-DNA
- DNA marker results:
- Hemoglobin results:
- Overall result (positive/negative):
### For CT Colonography
- Colonic findings:
- Extracolonic findings:
- Quality of the examination:
### Pathology Results (if available)
- Specimen type:
- Microscopic description:
- Diagnosis:
- Dysplasia grade:
- Advanced features (villous component, high-grade dysplasia):
- Evidence of malignancy:
- Additional testing performed:
### Interpretation/Conclusion
- Summary of findings:
- Clinical significance:
- Risk stratification:
### Recommendations
- Follow-up recommendations:
- Surveillance interval:
- Additional testing suggested:
- Lifestyle modifications:
BOLD any abnormal findings or results requiring follow-up.\n; Other Ultrasound:
Date of examination: (Insert Date from Report)
Type of ultrasound: (Insert Data from Report)
Reason for examination: (Insert Data from Report)
Ultrasound Components
Area/Organ:
Appearance/Structure: (Insert Result)
Size: (Insert Result)
Echogenicity: (Insert Result)
Focal lesions: (Insert Result)
Other findings: (Insert Result)
Area/Organ:
Appearance/Structure: (Insert Result)
Size: (Insert Result)
Echogenicity: (Insert Result)
Focal lesions: (Insert Result)
Other findings: (Insert Result)
Area/Organ:
Appearance/Structure: (Insert Result)
Size: (Insert Result)
Echogenicity: (Insert Result)
Focal lesions: (Insert Result)
Other findings: (Insert Result)
Impression/Interpretation
Summary of findings: (Insert Result)
Recommendations
Follow-up recommendations: (Insert Result); CT or MRI Image:
Date of examination: (Insert Date from Report)
Area Examined: (Insert Data from Report)
Reason for examination: (Insert Data from Report)
Components
Area/Organ:
Appearance/Structure: (Insert Result)
Size: (Insert Result)
Focal lesions: (Insert Result)
Other findings: (Insert Result)
Area/Organ:
Appearance/Structure: (Insert Result)
Size: (Insert Result)
Focal lesions: (Insert Result)
Other findings: (Insert Result)
Area/Organ:
Appearance/Structure: (Insert Result)
Size: (Insert Result)
Focal lesions: (Insert Result)
Other findings: (Insert Result)
Impression/Interpretation
Summary of findings: (Insert Result)
Recommendations
Follow-up recommendations: (Insert Result); Specialist Report:
Identification
Date of consultation
Specialist name and credentials
Reason for Referral
Chief complaint: (Insert Data from Report)
Reason for Referral: (Insert Data from Report)
History of Present Illness
Summary of HPI: (Insert Data from Report, include narrative of current symptoms, Timeline and evolution of condition, Previous treatments attempted, Response to prior interventions)
Past Medical History
Relevant medical conditions: (Insert Data from Report)
Previous surgeries: (Insert Data from Report)
Hospitalizations: (Insert Data from Report)
Significant past illnesses: (Insert Data from Report)
Current Medications
Prescription medications with doses: (Insert Data from Report)
Over-the-counter medications: (Insert Data from Report)
Supplements and herbal remedies: (Insert Data from Report)
Recent medication changes: (Insert Data from Report)
Investigations and Results
Laboratory results reviewed: (Insert Data from Report)
Imaging studies interpreted: (Insert Data from Report)
Diagnostic tests performed during visit: (Insert Data from Report)
Previous test results analyzed: (Insert Data from Report)
Assessment and Clinical Impression
Primary diagnosis or working diagnosis: (Insert Data from Report)
Differential diagnoses considered: (Insert Data from Report)
Risk stratification if applicable: (Insert Data from Report)
Prognosis and expected course: (Insert Data from Report)
Plan and Recommendations
Immediate treatment recommendations: (Insert Data from Report)
Medication changes or additions: (Insert Data from Report)
Further investigations required: (Insert Data from Report)
Lifestyle modifications: (Insert Data from Report)
Surgical considerations if applicable: (Insert Data from Report)
Follow-up Instructions
Return visit schedule: (Insert Data from Report)
Monitoring parameters: (Insert Data from Report)
When to seek urgent care: (Insert Data from Report)
\n; name=Format of Output}
If the recommended structure requests information not provided in the report, please do not include the field. Never complete fields with fabricated data. Use only the data supplied.
{formtoggle: name=I am writing the results summary directly to the patient:; default=no}I am writing the results summary directly to the patient:
Here is the note structure to follow:
Result Brief Relevant Summary:
Impression in the context of Patient's Clinical information:
Consider next steps for care, monitoring or treatment:{endformtoggle}
The extraction and summary should reflect any the details, assessment, impression, next steps and, where applicable, any ranking on the ACR Reporting and Data Systems (RADS) which serve as a standardized framework for characterizing and reporting imaging findings.
Please proceed.
CT or MRI Image:
Date of examination: (Insert Date from Report)
Area Examined: (Insert Data from Report)
Reason for examination: (Insert Data from Report)
Components
Area/Organ:
Appearance/Structure: (Insert Result)
Size: (Insert Result)
Focal lesions: (Insert Result)
Other findings: (Insert Result)
Area/Organ:
Appearance/Structure: (Insert Result)
Size: (Insert Result)
Focal lesions: (Insert Result)
Other findings: (Insert Result)
Area/Organ:
Appearance/Structure: (Insert Result)
Size: (Insert Result)
Focal lesions: (Insert Result)
Other findings: (Insert Result)
Impression/Interpretation
Summary of findings: (Insert Result)
Recommendations
Follow-up recommendations: (Insert Result)