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Hello alright thank you I just wondered if I could quickly discuss someone with you of course your girl how's it going it's a lady her name is ina leach oh yeah I think I recognize that name I recognize the name yeah so she's it it looks like she's been an inpatient for a while but essentially originally admitted second for a traumatic brain injury yeah and then was found to have a subarachnoid hemorrhage and also a subdural hemorrhage and then the last few days has developed these seizures oh yeah that's why I saw her for seizures and she was on brivaracetam we loaded on keppra and put it through the scanner yeah yeah so that's all been done they did like an I don't know if you've seen her since but she said they did like an eeg and stuff and it it just says subclinical epileptiform activity okay so basically her seizure so it was discussed with urology they recommended some medications they recommend added adding 1 on if her seizures weren't controlled which they aren't at the moment they're happening about the nurse is saying it's every 10 minutes okay and they've kind of just been increasing in frequency but they're 30 seconds long they're self terminating mhmm so I've just added on this other medication that you're what is it called recommended it is disinterested it's something beginning with l I didn't recognize it lamotrigine or no okay let me just get you to send me drug shots lacosamide lacosamide yeah yeah very trendy now I don't really know anything about it but I see it more on drug charts I think the I think it's a recent favorite of the neurologist okay yeah so I've added that on this evening great that's what they recommended but just to kind of check with you so she's had a few low grade fever spikes so it's going up to like 37.5 yeah her crp is 19 but her white cell count is just kind of staying around for the last 2 days and like 13 and then it's 12.7 today right and when I'm so the nurse has also raised me she's got like quite a distended abdomen okay and I agree it looks very distended I've examined it she's kind of she's not verbalizing to me but when I'm examining it it's very tender in the center and she's grimacing and and it is it is soft but she's kind of you know voluntary guarding when I'm pressing on the center of her abdomen mhmm she had her bowels open okay today and yesterday alright fine and she's not retaining any urine they've done a bladder scan she's got a catheter in which is draining I'm just wondering if there's some sort of underlying infection here or that's driving the oespecially to increase in frequency agreed so she's not on any antibiotics currently and she's got high inflammatory markers yeah I'll look at them weird isn't it 67 and what's our and before all of this was she good or was she not good my impression was that she's good yeah she's 4 cpr fine yeah yeah she I think she was well before all of this happened yeah mine I seem to remember that as well yeah abdominal distension strange isn't it and then let's have a look at her oh no I'm looking at the wrong patient I'll leave 660781 cool oh I have a cup of tea in a minute I'm getting tired now you're making me yawn sorry that's okay so new frontal lobe infarct this morning on clear cause so when did I saw her on the last set of nights I think she's having seizures and we put her through the scanner then on the 20 second which showed complete resolution of previously seen small right subdural collection a small shadow residual collection no new integrated rehydrocephalus small focal swellings of the scalp or the vertex noted as before and then then she then on the 20 sixth new right facial droop and right sided weakness wedge shaped area of hypoattenuation in the left frontal lobe which we've been keeping with an acute infarct wow well how unlucky is that yeah I know but she got af or something is that is she just at risk of stroking out I forgot anyway in front of me which is sinus sinus yeah fine intracranial vascular chair with no venous sinus thrombosis okay and she had a chest x-ray lungs are clear ng tube appropriately cited mhmm and talks about focus of infection the alt is uptrending but she's and she's not on any antibiotics no no and she's got some tummy discomfort crp is 19 not exactly thrilling is it no potassium 3.1 are we gonna correct that yeah but it looks like someone's already described some sound okay for her ng okay yeah fine ast phosphate's low is she gonna have some phosphate replacement yeah she could have it down the ng as well great thank you and then tough isn't it lymphopenic but neutrophilic with raised white cells it all sort of fits with her having some sort of underlying infection but the chest x-ray doesn't seem to go for it the blood cultures are negative we haven't looked at a urine like by the looks of it so maybe doing that is a sensible thing to do yeah any other microbiology she's had a urine on the 20 first she had eco is she an enterococcus yeah receptible like she was treated with much phyrintoin which is now stopped a couple of days ago okay yeah fine maybe we're sending that is she she's not old is she 67 she could even we could even just dip her urine couldn't we and if she's got a positive dip then I would be have a low threshold to treat her and send off a a midstream or catheter sample urine to see whether there's any infection growing in the lab just to cover her for the potential of a uti driving a bit of this mhmm and then I guess with this abdominal distension and abdominal pain I mean it's so hard when they won't give you a history isn't it yeah there's nothing shouting in the blood saying this is where her infection is but she has got a slightly uptrend or she has had an uptrending alt and her bilirubin's usually 5 and now it's 8 I guess I don't know I just wonder about scanning her and just making sure that she doesn't have something in her tum tum but yeah it's it's very difficult when she won't give you a history but I think I think it would be worth doing okay because if she had a big intra abdominal infection then that would change what we did if she had an abdominal collection for example that that can easily be driving her infect her seizures and her border and her you know grumbling inflammatory markers that don't seem to respond very much to the antibiotics that she had before and things like that so I think should we do should we ask for a ct abdomen and say and say we can't get history she's got abdominal distension she's got abdominal pain she's seizing all the time and we'd like wanna find out why if there's anything in her tummy that makes us that's lowering her seizure threshold yep is that okay then radiologists may say this is a bit weird in which case I'm happy to talk to them okay yeah any and if they want to is that alright yep that's fine that makes sense thank you no no worries I think yeah trust your clinical acumen if you feel like there's something going on then investigate it you know yep why not yep cool thank you nice to talk to you see you later you too bye yes that was ina leach 06/1981 67 year old lady on george elle ward so in history of the upsetting complaint patient became unresponsive with reduced level of consciousness on arrival of the ambulance crew sat up on bed opens eyes to voice pale lethargic increased work of breathing weak radial pulse has been worsening over 2 days no food or fluid intake not able to take her medications gcs 12 on on initial assessment with low blood pressure borderline pyrexia heart rate 130 irregularly irregular and sats of 85% on air manage with iv fluid oxygen current medications mst 10 mg twice per day 12 hourly paracetamol 1 g 4 times a day celecoxib a hundred milligrams twice per day oramorph 2.5 to 5 mg 4 to 6 hourly lanzoprazole 30 mg in the morning atorvastatin 40 mg at night levothyroxine 200 mg in the morning clonazepam 4 tablets at nighttime for tremor sulfasalazine 500 mg in the morning and the evening it's actually 1 g in the morning and 1 g in the evening primidone unclear dose in the morning theacardy 3 in the morning escitalopram 20 mg in the morning amoxicillin and prednisolone rescue medications presenting complaint is decreased responsiveness generally unwell and increased work of breathing

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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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