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To tell you after dinner how are you well it's only called a 12 hour wait to come in suddenly you have a and you might say yeah so just got yeah okay I see that when first thing is I see done at the hospital she was on the bus I see walked to the shop for alcohol today I was on the pd things did like did my swell up and the crew was there did ecg because he all signed through then the crew was then called about 10 minutes afterwards doesn't recall calling out on his physical phone she put in twitch and then what laying on his sofa bed in his property day evening a bit of call so completely different to the he got a whole new 1 like the h gaze he wasn't really following commands yeah so obviously like he is being t o h he's also complaining of a really bad headache right okay so he thinks it's ongoing and not doing okay so stroke when do you watch stroke do I have a strike now he's able to walk but when we kind of ask him to pull forward push away like the strike the strength isn't that which arm by activation why I don't think so however I had a strict notion mhmm gait so that's why I was kind of there do we know do we to do he doesn't remember a weakness and an altered nature an old age that we have in a combination yeah okay and then a new confusion and fire like front of yeah yeah you look at that range absolutely so it's a bit like correct you do like do we isn't it nice so hence the confusion burden mate right well let's let's go over a little bit more thanks we've got the stool here how do you she's a nurse I'm sorry you're in hospital yeah I realized that alright fine well that's good we're just having a quick look at you just to make sure you haven't had a stroke I've just tried to rest it I've been in a minute about a mini stroke I was I'm sorry to say that yes my functions aren't normal right in what way I've had a mump things I'm finding it difficult to mull like they do see when did you know you had the first full mull when's that night is that today or is that what's been going on for a while yeah right yeah thanks a lot thank you you're welcome thank you yeah I'm good I I'm I'm I'm I'm I'm classed as watch that when you're no you're not now in a bit unemployable oh really why is that and and difficult looks sexy very difficult darren what's your date of birth darling 21 0 9 6 2 and what are you allergic to nothing nothing okay and what month were you on he was admitted to here got a sunburn yeah self freedom and how old are you I'm trying to I'm trying to read it but was it oh I think it's even I can read that quite huge no that's showing my heart yeah that's your heart rhythm that's it no we need them so we're here we're here darren because they your crew thought you were having a stroke I think I might have I might have had a mini stroke maybe in the past yeah but I don't think it's causing what's going on at the moment it might be a follow on maybe maybe some alcohol will make things a bit worse I think quite questionable I think you probably need a bit of time to add a smooth get the booze out of your system then we can have another look at things in the morning is that okay that's a weird lot of your time oh no certainly not wasting your time don't worry we gotta make sure that you're okay gary yeah that's our fault I can know that I don't like so I'd rather be at home no not working your time we'll try and get you home in the early morning once you've had a good snooze there is that alright it was I think it was but I can't remember what's happening don't worry my my memory is so bad have a little snooze for it and we'll we'll get rid this all today sure okay have a look at your blood test okay nice to meet you see you later see you thank you darren so if if I if you the word present for 5 mhmm so oh sorry okay yeah if if I was just under 5 though that that hasn't been very nice I could see yeah so you don't you don't need to spend any course time because he is on a yeah crazy seeing it so she start making homeostasis exactly and then you've got a sterile yeah you've got a sterile so I feel like yes riding to get up the second yeah just reassurance yeah it's just a huge lounge room in fact can have a second crew out for someone which is during a tour we've been doing my head 2 3 impression yeah so on examination atypical findings of tremor, weakness which is bilateral and paroxysmal with episodes of 5 out of 5 power and complete acidity full stop as gait assessment reveals broad based ataxic gait but I think these findings are my impression most likely alcohol related weakness no clinical evidence of focal neurology currently plan hand back to ed the title of the note is stroke call to a and e recess

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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.