Situation

At the moment, I am taking care of a patient, whose name is [PATIENT NAME]. My foremost concern around this patient's health involves [SPECIFIC CONCERN]. This concern is substantiated by multiple symptoms that the patient is presenting, which include [PATIENT SYMPTOMS].

Background

Patient has a history of [HEALTH CONDITIONS]. Recent past medical procedures are [MEDICAL PROCEDURES]. Patient's current medications are [MEDICATIONS].

Assessment

On assessment, the patient's vital signs are [VITAL SIGNS]. Patient reports a pain score of [PAIN SCORE]. Additional findings include [ADDITIONAL ASSESSMENT FINDINGS].

Recommendation

Taking into account the present circumstances and the medical history of the patient, the advice given is that the patient should be given the treatment that is presently recommended.