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Hey it's rob you okay okay what's his name oh yeah I think I've heard of him yeah poor man yeah I haven't heard about him but I can see that he have a look at his notes 1 sec how do I get onto that did we dfm last time 778688 outcome from 20 fifth functional dyspepsia well sinus reflux and dyspepsia with pericardial episodes of regurgitation recent normal hd and barium ibs c diff gone prior episode of dysfunctional breathing vertebral artery aging authorsic very receptive happy to be discharged yeah fine and has a planned outpatient appointment with gastroenterology team tomorrow and that was on the 20 fifth so then he would have seen the gastroenterologist what friday yesterday in theory not sure whether it happened but let's have a look and see if we can see anything on that actually happened but now he's come back with the same symptoms or I assume fine weird isn't it I don't know what the communications be I'm guessing none of your doctors have seen him he's just come to triage down down yeah what does he want cyclizine what does he ask for iv okay alright appointment yep gastro he was seen on the 20 sixth the letter isn't done yet obviously but hold on maybe preview the letter don't really know how to do it can't be too mr boling mr boling I'll be great for your help he's struggling with regurgitation we've seen refluxes was an input helped for him have ph monitoring he sees this as auditory motility when he's coming in hospital frequently must be on the urging good and there's a letter to the gp fine so he saw us and they planned to refer multiple different gi symptoms celiac disease beef with calpro oh no this was back in december fine yeah so what does he want us to do now give him some antiemetics and send him home or what yeah okay difficult then isn't it I mean I guess he can wait mean what can we do we can't unless we kick him out yeah given he's well known to us and he comes in with the same symptoms I guess it's sensible to just I mean are there any doctors going to add anything they're gonna see them a lot quicker than we are let's have a look okay yeah we have a 30 the longest wait was 13 hours and 18 minutes cool man maybe they'll succeed I'm more than happy to talk to them because obviously I'm a gastro reg so I'm happy to help them with the reassurance if I can yeah cool no worries nice to talk to you as always bye bye that was 778688 troy ibarka telephone device

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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.