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Patient horrible way to wake up are you okay you okay yeah it's sorry it doesn't fit oh sorry it's a horrible way to wake up are you alright can you hear me okay do you want your hearing aid battery in please sorry can you hear me okay I'm in a load today oh you want another sorry just sorted I was very painful ribs after you fell over pull again saturday morning now 07:00 in the morning I tried to let you sleep as long as I could I hope that's okay I've done all the paperwork but I let you sleep as long as I could and the consultant will be in an hour so I just thought I'd come and say hi to you I'm rob I'm 1 of the medical records yes what's the night is busy I don't every night is busy it was it was yes yeah yeah alright nothing we can't handle got really good it not really a bed is it trolley we would call it the chair it's 1 way I'm looking at it you're a positive person you're glass half full of cake yes when did you fall over again it's saturday today wednesday yeah you fell on your right hand side and hurt your right hand side is what I understand and did you come into hospital or did you go straight home no didn't I I didn't come into all that's fine alright the first day it was painful mhmm but after 2 days it was this right hand side it was on my and your back as well I thought it was your chest that you'd hurt no no your back at the back mhmm at the bottom right fine but it was the way I felt as though I was getting a bit swept mhmm drunk you know my head mhmm and I just go home up so mhmm and then you end up here yes only only around like done and how's your breathing feeling it's good yep not not worse than normal any worse than normal I know you've got yeah it is a bit worse not good but I asked because your inflammatory markers are quite high your crp is 157 back in july when you left hospital hospital being treated for that you were being seen in hospital with the colonisation with the pseudomonas tobramycin nebulizers are you still on those tobramycin medications I'm 1 month on 1 month off 1 month off and then off you're in the cough I see fine fair enough has your cough changed at all or anything like that I I don't cough no you don't cough an awful lot fine okay but your chest feels a little bit different you said your breathing feels a little bit worse in what way does it feel worse if I just talked you into it it's okay if I've talked you into it just say got very good very good historian what they say it's okay I understand that's fine I see fine have sorry that you've hurt yourself it's horrid isn't it x-ray your back and see make sure you haven't broken any bones or anything like that but if I have I you can't do anything like you'd be unlikely to have an operation to fix it but mhmm we could do something to strengthen your bones does that make sense so if you or you had a fracture there that might would give us some medicine which strengthens your bones up alright there would be some goal in doing that any rashes anywhere or anything like that any other signs of infection pain passing the water see it but I can't it's a big guy because of you because of your oh you can't see because it's a wet back yeah of course try to look in the mirror to see if I was bruised or normal could would it be possible for me to have a look would it be of course I don't know how you'll do it will you are you able to sit up would that be very painful for you oh yeah oh doctor happy to help put that there on your oh jeez nearly new phone territory you got away with that no no you're good to help what about you I didn't get my jaw stroking me enough that's okay you you pointed to your right hand side is that right yeah I just my coccyx is is it tender when I when I'm touching it's good feel like I'm just fine you're playing up here listen at the back mom is that more yes yes thank you trust me that you're ready sorry I'm also digging in quite a bit normal breath head up or should I just rest you back you have us lie down I think I'll let that's okay that's true can I have a good listen in the front yeah yeah good mhmm okay so we've done the list yeah oh yeah it's a long old list we never reached the bottom but that's okay you're bored means we're never bored no never no can I touch your tummy do you mind any tenderness or pain in there at all no no pain possible can I look at your legs I I oh go urine been really really yeah because I've really struggled to drink and now yeah yeah no worries that's all that's a bit of a throat I didn't mean to help you no worries you know to make sure I drink enough because I was just topping up my glass and because you don't really know how much you want but 2 l is impossible yeah it's hard to reach that mhmm I mean it's hard you're only little aren't you as well you're a small lady yeah so it'd it'd be good wouldn't it to keep flushing things through yeah keep your secretions moist because you're able to expectorate them and things I've looked through all of your previous cultures and I can see you have grown sooner I know we've got some sputum oh how lovely we would love to have some anyone in a pot yes I've got pot because the doctor arranged it yeah that's great in this orange bag can just write it it's just yes it's challenging you're ever so good how did you know you were onto something how did you know well I doctor wrote it and they always said what's this for me I'll leave it on the side because I'll put a sticker on it I don't wanna get it lost yeah yeah get someone to come first to place it till later I could bring it up only come yesterday that's good it's a later in the day yeah that's I've looked at your previous ones and the medicine that that will work for the infection that you've got you've got a couple of options but I suggest we put you on an intravenous medicine initially because your marker of infection is high and give you a few doses while you're here with us yeah before I switch you on to a tablet is that okay yeah it may be that this raised inflammatory marker is because of an injury to your bones which can happen yeah but if you're if you feel like this we'll see what this grows and we'll see yeah whether you've got a nasty infection or not do just think I'm they probably want to see they to see that and they may come see you in hospital they might be on the weekend they will do they will be around yeah the respiratory team will be around hopefully they'll come to see you it should be nice once we see all markers of infection and inflammation coming down with the antibiotics then we can be quite to try to get you out to that that will be monday you never know okay yep that's fine any questions anything else you've got no I am under that reward yeah I'll let them know that's good to know thank you great you no problem thanks take care so for that no problem we'll see see you next time alright hi yes yes how is he doing good I might not have I could I could easily not have heard that's fine I've probably not written 1 henry I'm sorry if you've been looking around for it for a while I'm I'm sure sure I I just just couldn't if you leave me with another side I'll come and go in a minute thanks henry I appreciate it cheers bye

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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.