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Next patient deborah daymond 4 1 1 8 3 0 93 from a 110 neutrophils nought 0.46 from 2.01 108 from 270 eosinophils naught. Naught 1 lymphocytes naught 0.21 from 1.63 al normal creatinine 55 at baseline but potassium 3.32 hundred and 78 from 1 in july 3.2 inr 1.1 venous blood gas 1.3 past medical history left grade 3 idc breast cancer being treated with neoadjuvant chemotherapy with 4 cycles of weekly paclitaxel and carboplatin and continuing on 3 weekly pembrolizumab breast cancer left sided grade 3 22 mm idc clinically and radiologically note negative triple negative breast cancer chest x-ray as part of the indications autocad on the right chest hazy left lower zone opacification at previous medication history citalopram 10 mg once a day only up to the past medical history depression months I've got to think about that I'm just surprised are you how are you feeling I'm feeling I'm feeling good I'm good I'm good really that's good and you might feel a little better no I don't recall really that was the main thing go up but then it came down again before okay what have it got to 1. I had I had 1 it was 377 1 was 38 okay so you just 4 but I was okay then yeah but by wednesday I did spend wednesday bone children and they're a little bit snotty so yeah and obviously you're having treatment for breast cancer mhmm and the pembrolizumab at the moment and you had a couple of side effects not last week last week on the tuesday I started the new doing pembrolizumab yeah and I wish I could write for the tv for you okay and then pause and see can get back to us here sure no you're not gonna pass me a doctor no it's like a bit of danielle's steel you're welcome I'm sure I would okay okay thank you that's great that's what I had at the start how much do you know about your tests and things like what you found they told me that the neutrophils were very low very low and that I've got to have some injections yes to bring the neutrophil levels up k which will help you fight the infection my x-ray was clear clear your your x-ray x-ray shows shows you've got a chest infection on this side okay that's a good idea it's the early stages it's not a significant assuring is that you don't need any oxygen and the numbers from the nurse is a good thing that you haven't had a fever since you've been here as far as I can tell and your heart rate and blood pressure are infection or very high in the blood you're wacky you're your legs you're both up at home do you drink or smoke no all that and what do you do for a living work here yeah in eye surgery okay yeah cool yeah great I mean I I know I did put off you need a ring mhmm okay but I didn't feel I didn't feel well and would the outcome be different that's you need 1 and then you're quite happy that you're able to fight infections do do you make any any sputum if you cough anything up with that that nothing's coming up you expectorate if you feel like it's stuck there and you want to get it out great to get a sample to see what bug it is to make sure we that's all practice manager practice manager okay nice flattering bowels same with that alright not sure fairly b what about the fluffy blanket you've got it's like emo blanket I got this free from here oh that's it they'll and they let you use it the morning as soon as mhmm very dry oh yeah I've never ordered actually that's been happening great and then you've got the spree and if you haven't forgotten anything you say you on I'll let them know that's fine everyone's just going and stuff okay well I don't think you should be anywhere apart from a side at getting them getting patients who are on chemotherapy right sorry I can't give you a concrete that's especially if on a computer so on examination heart sounds normal on chest auscultation decreased breath sounds in the left lower zone with crepitations in the left mid zone abdomen soft and nontender no rashes no peripheral edema moist mucous membranes impression left community acquired pneumonia plan treat for neutropenic sepsis with sepsis protocol antibiotics number 2 gastrin number 3 oncology ward number 4 iv fluids number 5 surgery

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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.