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Lisa gerald alpha236230 33 year old lady presenting complaint medical history adhd learning disabilities laparoscopic salpingectomy 2022 with domestic violence asthma allergies rigvedilian next plan on mirena current medications symbicort 200 x 6 turbuhaler 2 inhalations twice per day mirtazapine 15 once at night phenergan 25 mg at night for sleep espergulahex dexerol d 3 1 to be taken per day anus suppositories as required equasym aquasym xl 2 10 mg tablets once per day ptsd chronic widespread pain fnd background investigations chest x-ray clear lung fields full blood count white cells in neutrophils normal ecg sinus rhythm rate 81 no signs of ischemia or pulmonary embolism hi I'm rob oliver hi rob gastro intrinsic doctors 1 of the medical needs how are you tell me yeah okay hi I'm rob 1 of the doctors nice to meet you nice to meet I'm not pain in here now and your back I was starting to sweat again really been shivering shaky and feeling hot and cold yeah I've been like that for a few days for a few days I even had to have a shower because I was too hot really this morning oh wow okay been really hot for a few days you've been feeling cold or just hot I had cold sugars but I also it's more of the hot I had a temperature of 39.9 mhmm why day I'm sorry if I'm dizzy fever fine and when was that literally last night last night and then it was 37.4 I was doctors I actually my doctor told me I was fired up me and my son almost died oh god of pneumonia from got it but I remember all night having coughing fits and struggling to breathe yeah yeah sore throat I brought up blood oh gee for a few days yeah okay when you cough were you coughing anything else up other than blood it was like not a lot it was just a bit of brain mhmm gunk so sorry should we just yeah good idea good idea what's the other part brown from the nipple wasn't a lot it was normally blood it wasn't bright red it was bright red blood bright red blood okay right and then that bit of brown stuff in it okay and this has all been happening over the last few days yeah 3 days or so yeah I'd show a bit normally I'm up at past 5 in the morning I've got adhd mhmm so normally I'm up yeah I'm fine but the last few days actually dragged my eyes at the bed really because my language is what I have it's okay yeah it's alright I've not been wanting to start already any trouble with your waterworks or anything like that alright you've got asthma yeah and you're feeling more wheezing yeah you have a lot more I've been taking my puffs a lot more have you how many how many times a day have you taken it over really as needed a month so you're normally meant to take like 2 puffs twice a day yeah 8 times a day 8 times a day yeah and I've took over that because I couldn't control my breath puffs 4 times a day is that right or do you take 4 puffs I take 4 puffs twice a day 4 puffs twice a day but I am starting to sweat again let's feel feel me I'm starting to sweat again yeah yeah oh you are hot you're hot or 3 nights ago I thought that I had an sti not true but no signs and stna nothing like that no okay so it's all yeah I didn't I just ran it in my throat so it's it literally come from my throat chest throat okay and then change your bowels at all I've ibs okay that's good but is it worse than normal or no I can't really go fine you're perfect yeah I've got a really bad pain in my head at the moment your mother but I suffer with migraines do you or yeah then usually I have a functional seizure really when you have when you're ill yeah then you get get them to take your temperature give give him some paracetamol to work right my music's running don't worry it's okay gonna have a quick look at you do you mind no that's absolutely fine interest is that okay I'll leave it there yeah let's start okay I'm just getting up there together at home yeah got 2 other kids oh sorry yeah this 1 teach a training day today oh I see so they weren't happy that she on a friday that's cheeky isn't it yeah but they wouldn't happy that she's off yeah fine your other kids yeah yeah very jealous like that listen to your heart first okay get really sore when you take a big breath yeah in your back in your lower back yeah yeah let's take big deep breaths for her eve that's her wanna get that followed no no it's it's it's just actually looks fine because we've not got any

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Medical ST5 Miller Clerking
[Current Date] [Current Time]

Presenting Complaint:
[The reason for attendance in 1-3 words]

History of Presenting Complaint:
[Chronological narrative of current illness using short, clear sentences. Include:
- Onset, character, location, radiation, timing, exacerbating/relieving factors
- Associated symptoms
- Impact on daily activities
- Previous similar episodes
- Relevant collateral history from relatives/carers
- Any relevant background from other healthcare professionals
Do not repeat patient's name throughout. Be concise and tell a chronological story to the reader. Do not include subjective descriptions of the symptoms e.g. "severe" or use unnecessarily long words.]

Past Medical History:
[Bulleted list of significant medical conditions with relevant details:]
• [Condition with year if mentioned]
• Diabetes mellitus - latest HbA1c: [value] mmol/mol ([date])
• Asthma/COPD - latest spirometry: FEV1 [value], FVC [value] ([date])
• [Previous surgeries with dates]
• [Other significant medical history]

Drug History:
• [Drug name] [dose][units] [route] [frequency]
• [Example: Omeprazole 20mg PO OD]
• [Example: Clopidogrel 75mg PO OD]

Recently Stopped Medications: [If relevant]
• [Medication] - stopped [date/reason]

Allergy History:
[If allergies mentioned:]
• [Allergen] - [Reaction type] ([severity if mentioned])
• NKDA [if no known drug allergies stated]

Social History:
[Living situation. Who they live with, housing type, if mentioned]
[Mobility. Walking aids, stairs, transfers, if mentioned]
[Carers. Formal/informal care arrangements, if mentioned]
[Occupation. Current/previous if relevant, if mentioned]
[Smoking. Never/Ex-smoker/Current - pack years if mentioned]
[Alcohol. Units per week/Never/Ex-drinker - if mentioned]
[Functional Status: Impact on activities of daily living, if mentioned]

On Examination:
[General Appearance. Alert, well/unwell, distressed, if mentioned]
Observations:: [If mentioned - HR, BP, Temp, RR, O2 sats (do not use subscripts)]
• Abdomen: [Inspection, palpation, percussion, auscultation findings. If not commented upon, document as normal]
• Cardiovascular: [Heart sounds, murmurs, peripheral pulses, oedema. If not commented upon, document as normal]
• Respiratory: [Chest expansion, percussion, auscultation. If not commented upon, document as normal]
• Neurological: [If examined.]
• Other: [Any other relevant examination findings, if mentioned]

Investigations:
• [Test name] ([date, if mentioned, do not include include today's date on results, list without a date]): [Result without units]
• [Example: Hb 85]
• [Imaging type] ([date, if mentioned]): [Key findings]
• [Example: CT Abdomen/Pelvis (15/03/24): Sigmoid diverticulosis, no perforation]

Impression:
[Main diagnosis]
Differential Diagnoses: [Only if multiple possibilities discussed]
[Secondary issues. Relevant comorbidities affecting management. If mentioned]

Management Plan:
1. [A numbered list documenting the management plan to be undertaken, if mentioned, include:
- Immediate management/monitoring,
- Investigation requests,
- Treatment interventions - medications, procedures,
- Discharge planning/follow-up arrangements,
- Patient education/lifestyle advice,
- Referrals to other specialties if needed,
- Which ward or specialty the patient would be best admitted to e.g. "Respiratory Bed",
- Escalation plan that was discussed - whether the patient is suitable for CPR, ITU and/or NIV.]

Any additional information?

PII Redaction

Detect patient name and MRN locally, send placeholders externally, then re-apply them on the server.

Patient Name MRN

Mark extraction as reviewed.