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So next patient nicola larder 143401 68 year old lady presented complaint exertional chest pain and palpitations history of recent complaint 1 week ago presents to the hospital with left sided chest pain associated with palpitations and diagnosed with paroxysmal atrial fibrillation full stop started on direct acting oral anticoagulant and bisoprolol full stop <\n\n> Yesterday, feeling woozy in the morning and feeling like she might have a low blood pressure which affects her quite commonly stop visit the pharmacy who advised cessation of bisoprolol or titration of dose to symptoms full stop attended a and e who advised could consider stopping bisoprolol full stop this was actually 2 days ago <\n\n> Then yesterday stopped taking had not taken the bisoprolol that morning then in the evening when walking her dog I'd noticed some slight left sided chest pain on exertion full stop was able to walk through the pain and did not stop her full stop however pain resolved on stopping walking full stop <\n\n> Then, at home, when watching tv onset of left chest pain radiating to the jaw with associated palpitations no shortness of breath paragraph ambulance full stop chest pain has now resolved however lasted for many hours overnight full stop <\n\n> Past medical history paroxysmal atrial fibrillation medication history apixaban 5 mg twice a day bisoprolol 1.25 mg orally once a day social history let alone but with family close full stop retired bank it worker full stop independent and active nonsmoker no alcohol patients chest x-ray clear lung fields ecg sinus rhythm at 80 beats per minute approximately blood tests troponin t 6 using his normal lfts normal crp 9 from 1 inr 1 amylase 57 full blood count normal impression symptoms of chest pain is the evening attributable to paroxysmal atrial fibrillation however additional symptoms of exertional chest pain are concerning for stable angina stop grace score grade score 95 3% probability of death for admission to 6 months examination no peripheral edema normal heart sounds no crepitations on chest good regular peripheral pulses warm and well perfused looks well and not appear in pain at the moment full stop plan number 1 add on cholesterol and glucose number 2 referral to rapid access chest pain clinic number 3 discharged home with safety netting advice to return if symptoms persist or worsen number 4 stop bisoprolol there's no evidence of fast rate number 5 may benefit from rhythm control strategy with flecainide if coronary artery disease or exertional symptoms on treadmill test <\n\n> And then referral to replex chest pain clinic dear cardiologist I'd be grateful for your review of this lady in your replex chest pain clinic who presented to the medical take on the 2025 with mild left sided exertional shortness of breath work source and external chest pain which radiated to the jaw however had resolved at the. Of assessment full stop she's recently been diagnosed with paroxysmal atrial fibrillation and started on doac and bisoprolol however symptoms had symptom and symptoms were similar to episodes of af full stop on exam on investigation on the take up rhythm was sinus on an ecg full stop I'd be grateful for your assessment as to whether there may be coronary artery disease concomitant with her arrhythmia and what whether she may benefit from an alternative rhythm control strategy for her atrial fibrillation okay sorry

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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

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