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So next patient mini browning 119429 investigations inr 1.1 calcium normal alp 137 remainder of liver function test normal alt hemolyzed ast hemolyzed sodium 131 previously has been mildly low 130 back in august creatinine 58 at baseline tsh 1.32 crp 6 25 at the september hemoglobin 104 previously been as low as 68 back in august and 87 on the september 5 platelets 145 mildly low venous blood gas reassuring recent urine mcns 09/13/2025 positive for e coli susceptible to amoxicillin fosfomycin and nitrofurantoin iron studies recently transferrin saturation 10% so admitted 20 ninth to the eighth 20 25 and discharged 2025 it's now the 2025 following a right tibial plateau fracture discharged from teen ward slipped and fell on a mat no loss of consciousness isolated injury low hemoglobin during admission followed up in nursing or in in community hospital also treated for uti during this admission new abbott hospital add to the plan add on magnesium to blood tests well we'll line up you know and then we all start on you back to back it's non stop I like to interrupt of course I try to explain as well what's the benefits of the air mattress she doesn't want to go on really you would of course you would explain I wouldn't wanna spend any yeah because I'm inflating 1 for her thank you this is like a bed you're talking about like a bed yeah bed with a bed lovely that would be so nice yeah hello I'm doctor miller I'm 1 of the medical registrars it's nice to meet you yeah how do you do how are you feeling I'm well I don't feel too bad myself good that's what I'm saying but the knee part would take a little while to feel that had a break in your knee didn't you easy when you fell over oh and you're in this horrid priest 3 blazers oh you poor thing are they gonna do anything about it think francis look you poor thing looks sore I'll tell you what 94 and a and I'll you you say your right knee is a bit bruised isn't it do you know what 94 year old and I really thought I was so happy coming out from burn fat and I thought well I'm 94 now so I really enjoy it are you scottish where are you from where did you grow up where am I from where did you grow up no I don't even grow up mummy I'm not taking you anywhere where did you grow up when I grew up I mean I'm 94 now yeah where did you grow up I was in north north devon fine do you know it whereabouts they've opened me up in skye skye isle of skye can I see your hands is that alright thank you are you taking my have I so your heart's going quite fast and you've just started on some treatment to make it go a bit slower it can happen where the heart goes fast like this I'll tell you something I know it's bad but I've always been like this all my life so nervous oh so frightened oh I'm sorry I'll wait you a bit better again don't worry everything's fine yeah I do your lovely nurse that's looking after you was hoping to put you on a bed that's not a trolley you're on a trolley at the moment oh is it because you're staying in hospital to manage this heart rate she's gonna put you onto a bed is that okay you see you've gotta get me off this 1 yeah to go on the bed yeah I'll get they'll get lots of people to help you can't stay on this forever I don't want to I want I asked somebody if I can buy me on time and tell you I think I want to move now we'll get you onto a bed is that okay is that okay we'll get you onto a bed because this thing is very uncomfortable and you'll get pressure sore well just about but not quite we'll be fine don't worry I told him I'd ask him when I'm ready alright how are you and I said me too darling she's loving yeah oh my god no how are you gonna get how are you gonna get this lovely lady onto a bed what's your plan we're going to pass light and she doesn't I have to be on the know but she needs to be on the bed we've already got an air mattress blowing up lovely okay I'm not very big no you're not no but I'm heavy you're dense ghosts don't twelve's dame that's fine we can leave you don't worry have you seen me I'm so strong listen you gotta meet you are you allergic to anything at all I don't I don't know how to deal with this 1 I got pain what are you giving up anything good got it's got I'm just giving her oral it's gonna take ages to act just give me pain young man you can give her his pain enough may go some pain yeah I'm giving her pain can we give her iv dig instead because she will never break control if we do is that okay yes you I'll switch it just had an oral before but you alright great can I no no can I listen to your chest do you mind yeah not with me yeah yeah you're right you're right I didn't do that but hi she's rolling her eyes she just can't get the staff these days can you she's a proper character isn't she she is she's a proper character oh yeah we're not gonna have an easy time with you are we well yes and you knew me if we move you like you said you didn't wanna be moved oh you did you did can I listen to your back billy is that alright what a lovely name that is is it short for anything minnie no I don't is your name short for anything minnie not me is your name short for anything or is it just minnie minnie that's a lovely name minnie francis minnie francis yeah can I have quick listen back there do some big breaths for me go on big breaths and can I have a listen on this side you bye got respiratory creps then can I touch your tummy how's your bladder and bowels pain on any pain in the tummy have you got a catheter do you have a catheter you do that's fine no I don't need that's alright I don't need to see it it's okay she'll go and take me to and see that that's fine don't need to it's alright just touch your tummy touch your v I mean no peripheral edema that's good and your leg is looking a little bruised but not erythematous and not hot to touch excellent great you've had an ecg so atrial fibrillation with a fast ventricular response I haven't seen you before doctor no we've not met before not so young anymore naughty with that mhmm and then naughty with it oh dear better be like that no stuff just is that alright is it irritating you or is it okay yeah just leave it alone we'll just use it to give you some medicine to make you feel better I shouldn't like to have this roller jacket tablet in that I'd suggest starting that again while you're in hospital is it I'd suggest starting that again now you're in hospital is that okay you do what's up I got my foot mhmm oh you were injecting sorry I thought you was gonna be kind to me no not me alright I really was a little bit kind it's a 140 I think what what did you think 140 let me have some peace from you from me yeah goodbye man see you later so impression is atrial fibrillation with a fast ventricular rate with no clear underlying trigger apart from immobility and recent hospitalization plan now ag magnesium to bloods + or - replace add to the allergic history diclofenac and aspirin and then number 2 in the plan iv digoxin for second loading dose as the rate still not controlled followed by 125 mg of digoxin tomorrow once rate controlled chest x-ray tenth form already present not for escalation amu followed by discharge back to community hospital once rate controlled on examination very hard of hearing + or - slightly confused no hearing aids in situ and challenging history secondary to this may be related to acute illness being in recess and it being the middle of the night so suggest further informed discussion regarding risk benefit of anticoagulation for atrial fibrillation undertaken marley

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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

Mark extraction as reviewed.