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084017 charles mullen hello hi you're fine good nice to meet you I'm doctor miller I'm 1 of our medical registrars nice to meet you how do you do fine how are you feeling alright thank you good I'm glad the aed doctor told me all about you I was asking to come and see you just because you were needing a bit of oxygen oh yeah I can see you're needing a bit less oxygen now which is really good yeah how are you feeling tired tired I bet I mean it was 3 in the morning half 3 in the morning yeah mhmm his face looks the same whether it's day or night we forget sometimes yeah and you I I just think the a and e team have told you what's going on you've got a nasty chest infection yes how long have you been feeling poorly for well I've been having chemotherapy mhmm since christmas I think you are what have you been treated for with the chemotherapy I'm fine okay fair enough and the idea with this chemotherapy is it to cure the cancer well they said to cure it they're hoping to shrink it shrink it and they shrunk it great and now they've they put me on maintaining chemo or something so keep it small okay great brilliant I've come in here today the doctor said there's a mass in me to test for him I think it looks like there's a big infection there on your chest x-ray certainly it looks the same whether there's something sinister there or whether the infection there just looks the same correct on your chest x-ray so that's probably what we're talking about and then have you been coughing or anything like that uh-huh no when did when did these symptoms start you walking you've been walking into breath today just today yeah so so you became short of breath quite quickly is that fair to say yes very quickly mhmm okay and cough or cold not no chest pain no no no that's fine okay good fine when did you have your last chemotherapy 3 weeks back mhmm and is that the end of a course or is that or are you still on the course I'm still on the course it's still on the yeah scheme and what chemotherapy are you on do you know what it's called no I'll look at letters the and tell you wean things about it in couple days do you mind if I have a quick look at you listen to your hands and look at listen to your chest and look at your hands no thanks downfall yeah your friend just where you are white yeah lovely and you're from the north yes where'd you grow up yeah this place called south beach to maine okay well okay alright then and when did you move down to the south moved down went to the holiday remember welcome to connecticut holidays it's sad to see you lovely we've seen you in right spot from the hospital yeah it's been raining for 2 days oh shame I mean after I got this infection from the wet tree probably well he's been it it's always regular in the summery is it yeah you know why always seems to be they should have told you that before you came along last manchester yeah that's the rain exactly similar quick listen to your heart unconditions like copd or asthma smoked in the past yeah tell me about that how long do you smoke for I wonder if smoke I took it 1998 mhmm '98 to 9061 mhmm and when did you start since and I started when I was about 14 okay I'm not going to 1 next month okay so you're 18 hours enough time how many cigarettes are you made half a week at least 5 yeah and then I was a whole 3 mechanic that's a knitwear mechanic yeah the machine came in sorry cool yeah but there was a lot of stuff coming off the gown idea any asbestos exposure or anything like that nothing like that like if it's found farming any contact with hay or anything like that yeah lots of wet hay yeah alright a lot of it every day no not a lot of it I used to very part time that's it okay and how about pets do have any pets at home not now you're ddr dog dogs but no birds no no just to have it great well thanks for having me doctor and where's your lovely wife she's abandoning you I actually in lug it I flew in and got her lug there for a week fine okay so she's carrying on oh does she know you're here yes as I say chest looks very good you've got a nasty chest once an antibiotic is to treat that your oxygen levels are coming down which is a really good sign I had on a few tests to look for we haven't got an atypical infection because that can happen I mentioned immunotherapy are you on you're on chemotherapy not immunotherapy is that right I'm on chemo and look it up on the computer I might struggle because of the whole rip or do you have a tablet every 3 weeks okay so I feel I'm on the check it fine I'll see how you no and on top of the chemotherapy I'm on diabetes I'm a diabetic you got type 2 diabetes yeah okay what 500 mg have you got a list of reserves a day is that a is that a little tupperware tablets I see in there or is that the lunch can I have a look at them do you want no no ah no a list that would be perfect novomix 30 flexpen yeah how much how many units of that do you use and when I use 6 46 in the morning I think 46 in the morning this is partly at daytime and let me do it now you think I can remember that yeah you're up there you've written 48 and 40 I'm done fine so you now take 44 in the morning yeah and then now you take the dolamide eye drops yeah 1 drop twice tylenol tablets 50 micrograms so it's been done every morning how blood was that yeah that was good fine it was confirmed that you had a blood clot on your lungs alright alright good and have you felt then now do you when you had your blood clot oh it was the hospital pretty sure can I go off but this is what keeps you in hospital because you have this you're in with us at the moment we get off and get you out the next day or about today I mean improvements today and we can be optimistic on trying to get you out on thursday or friday yeah and saturday you go back to nottingham no no sorry fine we'll try and get you out on monday aw thank you happy nice meeting you bye see you later

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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.