Transcript

[SYSTEM INSTRUCTION: You are a medical AI scribe applying an Instruction Layer. 1. Identify any 'Meta Directions' (formatting instructions, corrections, ignore-rules, or section-creation rules) dictated by the doctor. 2. Do NOT treat Meta Directions as clinical facts. Instead, use them as strict rules to shape the final note. 3. Apply formatting instructions (e.g., bullet points, conciseness). 4. Apply correction instructions (e.g., overriding a pain score or symptom). If there are conflicting facts/instructions, follow the LATEST applicable Meta Direction. 5. Apply ignore instructions (e.g., omit specific brand names). 6. Move information to the section explicitly requested. If requested to place information in 'Procedure', 'Internal Notes', 'Orders/Follow-up', 'Coding', etc., you MUST dynamically create those sections in your output if they aren't in the standard template. 7. Do not invent unsupported clinical information. Preserve existing normal dictation behavior. 8. Output all detected Meta Directions as a JSON list of strings within a [[META_DIRECTIONS_START]]...[[META_DIRECTIONS_END]] block at the very end of your response.
9. If the transcript explicitly states 'The clinical notes are' (or similar), you MUST use ONLY that explicitly dictated content to fully fill out the clinical note sections. Additionally, if explicit dictation for CLINICAL NOTES is detected, you MUST append the following exact block to the very end of your response:
[[SUGGESTED_BY_DOCTOR_START]]
<exact dictated text for the clinical notes>
[[SUGGESTED_BY_DOCTOR_END]]
The text inside the delimiters MUST be a VERBATIM, character-for-character copy from the transcript. Do NOT fix typos, do NOT reformat, and do NOT correct medical terms. Do NOT output 'Suggested by Doctor:' in the main text. Do NOT extract dictated text for other sections like summary, orders, or coding.]

[TRANSCRIPT]
Okay, this is a follow-up for, uh, patient's name is David Okafor, date of birth
is April 3rd, 1970. Insurance is Sun Life, member ID is SL2245871.

So David's coming in today for his diabetes and, uh, also his blood pressure,
he's been having some knee pain too, we'll get to that. Last time I saw him
was, I think, about ten weeks ago, we bumped his metformin up to 1000
twice a day and started him on lisinopril 10 milligrams for the blood
pressure.

So, chief complaint today, follow-up diabetes and hypertension, plus new
onset right knee pain for the past, he's saying about three weeks now.

He says his sugars have actually been better, he's logging them, mostly
running 120 to 140 fasting now, which is an improvement. Blood pressure
he says he hasn't been checking at home as much as he should, but he
feels fine, no headaches, no chest pain, no shortness of breath.

Knee pain, he says it started after he was doing some yard work, no
specific injury he can point to, it's more on the inside of the knee, worse
going up and down stairs, some swelling he's noticed in the evenings. No
locking, no giving way. He's been taking Tylenol for it which helps a
little.

Okay, exam. Blood pressure today, 138 over 88. Heart rate 74. Weight is
down four pounds since last visit, which is good, he's at 212 now.

Knee exam, mild effusion on the right, tender along the medial joint line,
no instability with varus or valgus stress, range of motion is preserved
but painful at the extremes, negative McMurray.

Alright so assessment. Type 2 diabetes, improved control, we'll call this
E11.65 still since he's not quite at goal. Hypertension, still not fully
controlled, I10. And then the knee, this looks like medial meniscus strain
versus early degenerative changes, going to code this as M25.561, pain in
right knee, for now until we get imaging.

Plan. Continuing the metformin as is since he's improving. Going to
increase the lisinopril to 20 milligrams daily since he's still not at
goal. For the knee, ordering an X-ray of the right knee first before we
jump to an MRI, so that's CPT 73562, weight bearing three views. Depending
on what that shows we may need an MRI down the line which I'd expect
would need prior authorization from Sun Life given imaging history.
Recommending ice, activity modification, and switching from Tylenol to
naproxen 500 twice daily as needed, we'll watch his kidney function given
that he's diabetic and on an ACE inhibitor.

For the patient summary, let him know his diabetes numbers are moving in
the right direction, we're adjusting his blood pressure medication since
he's still running a bit high, and we want to get an X-ray of his knee to
figure out what's going on there before deciding if he needs anything
further like an MRI.

Follow-up, let's bring him back in six weeks to recheck blood pressure and
go over the knee X-ray results. If the X-ray shows something significant
we'll get him in sooner. Also have someone call him in two weeks just to
check he's tolerating the higher lisinopril dose okay.