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How are you I'm fine are you okay alright so tell me what happened do do you remember what what happened I I collapsed in the bank you collapsed in the bank no they they put me up on the floor I'm not and and do you remember you know the last thing that happened just before the collapse no I was just away from the were you standing yeah okay did you feel dizzy at all a little bit I think a little bit okay anxiety was ordering me out a bit they helped me to always put me in the banking okay that was during the last 9 this morning yeah okay okay what what time did that happen what time did that collapse happen about about 9 this morning okay half past 9 right okay and did you have breakfast in the morning biscuits that's all coffee and biscuits okay is that your normal yeah breakfast okay alright that's it biscuits and coffee okay yeah been up for years were you standing for a long time before it happened about half an hour half an hour oh I mean were you waiting for something I'm waiting for the oh okay okay and you felt a bit dizzy you said little bit and it broke because of the arm and I remember that the next thing I do I was in in the back on the floor okay so you collapsed and then you got back and you were on the floor yeah were you confused initially no okay so you remember that you were you remembered where you were yeah okay has this happened before no that he fell and not be 7 conscious of 2 years in june mhmm at my house which he ended up cutting his head and then we found out well I've been asking for help about it but it was through that and the argo when they were doing the covid jabs they're the ones that helped push because it happened more yes he has got better memory loss and it has happened more than once okay alright and the times it has happened it was always a collapse not just yet should I press collapse and then come back that's the thing he's not on the tablet try to catch you in june no catch you he started coming around the 1 the the o'clock in the could take that because I wouldn't that and get my daughter like compresses that because of the blood and everything okay put it on the corner of the my kitchen door and when you when you got back you know when you when you regained your your consciousness was there any pain anywhere no okay do you know if you hit your head at all what do you know whether you hit your head or not any pain to think okay but oh it wasn't bad there okay I had a phone call from you I'm sorry the doors are shut because of the army that's a that's a button or something the doors and people come out and probably not on the carpet mhmm okay alright right so no 1 no 1 I mean no 1 from the family was there with you when it happened but it seems that it has happened before yeah at mine like you're okay isn't it yeah and I've saw jewish primary pressure yeah okay alright did you feel your heart you know beating hard or fast just before it happened no no okay so generally if you're lying and you want to get you know you want to sit up and get up do you get dizzy then I do how many people sitting on the stretcher or no I mean so when you're at home and you're on bed and you get up suddenly to stand up do you get dizzy no okay you never okay so tell me about your other medical problems have you got high blood pressure yeah I could take 1 tablet a day okay do you I take some 07:00 in the morning do you have them with you the tablets do you have them with you now no he's got 2 large 1 you've got the list there I'm not sure if this is yours or mine these are the ones that it's on so amlodipine 5 mg taken the midrand yeah there was so last time when he was in hospital 2 years ago as you said the doctor started him on some medicine for the dizziness it it's not it's not mentioned here that's all he takes that's all he takes okay you don't have problems with blood sugar have you ever had issues with your heart have you ever had problems with your heart no okay oh boy ziplock every morning heart you've never had a heart attack or anything like that no that's why I say that it happened this morning or was it yesterday today today I was gonna say I took him yesterday afternoon because he had to have blood pressure yesterday 4 4 7 he's yeah yeah he's collapsed yesterday afternoon so yeah we we we don't really know how I mean the the the amount of time when he went out we don't really know was it would you say it was just minutes or seconds what would you say it just happened within seconds or minutes yeah it was just sec just quick I don't know right so according to the blood test so the blood tests were okay you do have you know you do have kidney impairment but that's not new it's been going on for a while yeah okay your other blood tests I mean your inflammatory markers aren't really that high your white cells are just you know a bit raised these these are cells that you know they arise when there's an infection have you been feeling unwell lately no you know any sore throat or a runny nose no I'm not tired I walk my bed a long time in the fresh air okay so you haven't been feeling under the weather what about you know any problems weaning no okay so that hasn't changed any changes in your bowel habits sometimes I say 2 days ago and you had more than okay so we don't really have any problems now any I think we we we need to investigate as to why this happened so ideally we'd ask someone who was there when it happened to tell us for how long it was and to tell us more but since no 1 was there with you we can't really do that what we'll do now is that we'll do a 24 hour tape okay that doesn't have to take place while you are in the hospital so you can go home and you'll come back and get the tape fitted we'll get the report we'll do your blood pressure now while you're lying and while you're standing and see if there's any difference okay yeah and I and I think I mean if there isn't any obvious injury I think we really need to do a ct head is that alright is that alright okay can I just listen to your chest yeah please thank you this is from the back so I'm just gonna come back to the chest thank you taking a nice deep breath for me it's anthony anthony anthony taking a deep breath for me in and out and again and out and again and and out and out and last 1 and out and out good alright thank you that sounds okay alright right so I think yeah we'll just we'll make it a 72 hours take just to be mhmm right so does he have does he live on his own yeah has he got cares or someone may okay I do still to info okay ever fall in his house no it's always been out but was it don't know yesterday we had particularly hot with it no I have to be outside all the time in the fresh air fresh air is done with the doctor stuff sometimes yeah the right yeah fine right so yeah we we'll do these just request these investigations and go alright thank you I'll grab someone to do that for you alright I'll grab someone to take your blood pressure when you sit up and when you're laid down sat and stood up alright I'll pop you in 1 of the rooms to do it can I give you a hand I'll pop you in 1 of the rooms to get your blood pressure taken I'll give you a raise alright you want to wager on it do you want to wager on the race you're not a betting man no thanks to your chances hop in there I'll send someone in is that alright I'll send someone to just check your blood pressure

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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.