Generate Note

I'm julian gibson 937621 hi hi hello I'm 1 of the medical registrars in manitoba nice to meet you how are you good yeah I'm sorry to hear that in what way aren't you good pain. All the way your tummy yeah constant yeah yeah right and I understand you have regular paracentesis where you drain the fluid every time when was the last 1 3 0 it was monday monday monday okay okay so 8 and obviously you've recumulated a little since then yeah quite a lot that's the quickest it's come back this time but I couldn't do it till next time yeah quite a lot and then I've got my first few months of it mhmm rotten yeah that's I'm describing okay so it might make it feel like it's daylight but we don't if it's the same no no matter what time of the day it is around yeah so you obviously come into hospital had a few tests has anyone explained the results of them or anything like that no no fine your blood markers show various markers of infection and inflammation yeah you've been started on some antibiotics to cover for an infection in the fluid in the tummy that can happen after we've instrumented it it also happen spontaneously because bacteria can move out of the gut into the fluid so you've started with strong antibiotics think you had a bit of intravenous fluid and somehow when I bring your blood pressure up and your blood pressure is quite low at the start it looks like the only tumour may be a lot better with the treatment that they've given you yeah I'm sorry to hear they haven't made you feel much better what can I do to make you feel better 90 sickness yeah so I think probably your nausea and pain is probably because of the of this fluid isn't it it is she's had several I think have you touched her yeah I've had 2 sickness haven't you thank you that would be the biggest sort yeah I mean I can do that for you that's absolutely fine if you want me to please yeah obviously you know pain is just getting her face she's just having more pain mhmm yeah you know about the benefits and risks of it because you've talked you've had it many times yeah yeah yeah and when we I'll have a look with the ultrasound machine and make sure there's lots of fluid there we can take a little bit off and see if there's an infection in the fluid we tend to not to try to take it off but obviously it's about what you want and what's important for you if we take fluid off when there's a concomitant infection it raises the risk of damage to the kidneys and kidney impairment because we know that taking all the fluid off decompresses the kidneys and dries them out a little bit so when you've got infection on board at the same time it can increase the risk of a kidney injury and that can be quite dangerous for you on the 1 side on the other side you're unhappy because you've got pain and and so you have to balance those 2 things together probably and decide what the most important thing for you is so can you drag this to yeah exactly that's what I was gonna say a nice compromise might be to take say 4 litres off or something like that I don't know how much you get off normally what comes off normally to the first 1 was 4.7 so you don't have a fusion there 9 and this last 1 was 3 yeah 4? You could take 1 or 2 l off even to get you feeling better I think yeah take a sample if I was going to drain that lady yeah would where would that go I would end up going to miu sorry that's okay there might be 1 knocking about but it will be somewhere obscure in a drawer that no one's ever touched yeah it would take as well to find no it's okay I'll have a look at the pictures I'll next time I'll you next time next time yeah that'd be awesome I can get a little heart failure crp 84 urea 9.3 creatinine 62 albumin 6 hemoglobin a 101 white cells 20.4 neutrophils 18.2 ph 7.29 on a venous gas lipase 11 impression worsened abdominal pain and raised inflammatory markers possibly secondary bacterial peritonitis need to balance risks and benefits of low volume paracentesis in the context of a patient with a limited prognosis who is in dis profound discomfort secondary to tense ascites on examination grade 3 ascites but low volume generally tender abdomen just to take chest do you mind so I should have gone to the abdomen thank you yeah thank you alright that's a nice little bit of a nice little p p yeah it's a bit of a clear sense of entropyl going down yeah when you build up here it can swell up there yeah water certainly fine bro I'm gonna go look for the equipment because I haven't got it here okay pain's really bad again at the minute oh that's fine she just say the pain's really bad again yeah I don't know don't think that's that fine I lost the tears I'm yeah and your bowels working okay everywhere are you very constipated because that can cause pain no I take I've been taking she did have a barisoprost great yeah his doctor any cough or cold or anything like that no have you had a chest x-ray since you've been here yeah good I'll have look at that alright yeah that's it he came in when he said oh yeah yeah yeah I'll go look at the look at the investigations okay I'm interested in that so plan number 1 would likely benefit from limited paracentesis number 2 continue antibiotics number 3 septic screening number 4 chest x-ray number 5 ecg number 6 will not need albumin for paracentesis number 7 iv fluids

Choose a note service

Choose an assistant

Choose a template

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.