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So the next patient is gladys tatton alpha190322 investigations crp 127 sodium 130 troponin 4,158 and 5,862 alp 155 inr 1.1 white cells 18.4 with neutrophils 15. Chest x-ray raised raised right hemidiaphragm no focal consolidation small left pleural effusion medical history hypertension osteoarthritis gastroesophageal reflux disease knee osteoarthritis medications list paracetamol 1 of no current repeat medication no allergies I'm I'm I'm 1 of the medical registrars oh yeah nice to meet you how are you feeling fine I bet feeling better good I understand you're having chest pain yeah I think I have sleep as well and when did that start chest pain sorry when did the chest pain start yesterday okay and can you describe the pain to me well that was yesterday like a crushing or tightness or a sharp pain right no and can you describe it you use any descriptive words I'm not that's okay don't worry shortness of breath going along with it it's better than it was you'd feel short of breath yesterday yeah mhmm right over the last few weeks how have you been feeling well I'm good have you been getting any chest pain over the last few weeks I don't think so no for example do you walk up the stairs or go for a walk anywhere you're in the your care home yeah that's walk around in the care home not really you spend most of your time in your room sorry you spend most of the time in your room yeah how do you get around the room walk around with a frame with a stick on the furniture you don't know how you get around your room I know but my memory is terrible that's okay don't worry absolutely terrible do you drink or smoke no have you smoked in the past no good fine great and has anyone explained what's gone on since you've been in hospital the tests we've done and things like that no not really not really sorry to hear that sorry I would have done but I forgot that's okay you've had a chest x-ray it doesn't show any sign of a big chest infection good I can see you recently had some urine samples sent have you got any symptoms with your urine at all I don't think so none of them show any infection no your markers of infection are slightly raised though which makes us think there might be an infection somewhere but we're not sure where yeah your blood tests show raised markers of damage to the heart and so it may be that he's had a heart attack alright that's causing his chest pain alright what we really need to do is get this pain under control yeah we need to make you completely pain free that's the most important thing because when you're in pain we know that your heart's not happy so you must tell us if you have chest pain yeah that's your job in the hospital are you in chest pain at the moment have but I'm not going to be okay no pain no good excellent so we've we've done it then that's good if you do get any pain please tell us gonna have a listen to your chest is that alright yeah thank you say again best way to tell that is that's fine listen to your lungs I won't ask you to sit forward I'll just listen around your back like this is that okay yeah just do some big breaths for me okay too much and then let's do on this other side no just sneak under there big breaths for me maybe you got a few little sounds on this left side it may be that you've got a chest infection going along with it let's have a look at your legs thank you have you noticed any swelling in your legs very badly very badly over how long last 2 weeks fine so you've got edema up to your knees you've got swelling up to your knees yeah yeah fine and can I touch your tummy do you mind yeah any pain in your tummy no are your bladder and bowel's working okay no wonderful great I thought I'd be really good oh should I ask someone to help you give you a hand with going for a wee yeah of course but like I say your blood test show you had a the possibility of a heart attack and listening to your chest it sounds like you've got a chest infection and maybe that you've had both at the same time unfortunately oh we'll give you some antibiotics for the chest infection we'll give you some medicine for the heart attack to help break down any clot that's in the heart okay the cardio I've had that say again how long have I had that the heart attack yeah yeah probably started when you had the chest pain yesterday oh right and now remember that if you have pain please tell us yeah are you allergic to anything by yourself very good and do you take any regular medicines no nothing you're fit and healthy nothing that's good I don't see no I don't think you do either it doesn't look like on your gp record that you do no so that's good great I'll get 1 of those things sorted for you it was nice to meet you can I turn the lights off so you can get some sleep it's 5 in the morning now uh-huh I've got a lot of work I'm trying to get you to sleep yeah fine that's okay you can keep trying I can turn this off if you like how's that that's better good see you later nice to you heart rate 82 sat's 96% respiratory rate 17 blood pressure 142 over 65 impression myocardial infarction number 2 left community acquired pneumonia plan antibiotics for pneumonia curb 65 score 1 oral amoxicillin number 2 medical management of non st elevation myocardial infarction and that should be the impression in non st elevation myocardial infarction ecg t wave inversion v 3 sinus rhythm dual antiplatelet therapy cardiology review and post op ward round paranux ep dnar and then on examination heart sounds normal chest left basal crepitations abdomen soft and tender pitting edema to the knees bilaterally tongue moist slightly confused however 05:00 in the morning

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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?

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Patient Name MRN

Mark extraction as reviewed.