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So next patient margaret pierce 174154 79 year old lady presenting complaint incopy history of the presenting complaint admitted in late 20 24 with atrial fibrillation with a fast ventricular response initially managed with rate control strategy with beta blockade and digoxin however echo showed ejection fraction 21% with mild mitral regurgitation and so decision made to the rhythm control strategy full stop started on amiodarone during admission in late 20 24 and digoxin stopped at that time full stop underwent elective dc cardioversion in july 2025 with post cardioversion echocardiogram demonstrating impaired left ventricular systolic function in the presence of lv dyssynchrony dilated left ventricular internal dimensions and normal wall thickness biatrial enlargement mild mitral tricuspid and pulmonary regurgitation unclear whether she was in atrial fibrillation at that time ed ejection fraction at that time 39 full stop <\n\n> Then, today, felt palpitations and was concerned that she was in atrial fibrillation and so took her took some digoxin that she had at home open brackets gp record most recent dose a hundred and 25 micrograms close brackets when she'd already taken amiodarone and bisoprolol that day full stop <\n\n> Then around lunchtime had a syncopal episode since then has been presyncopal no chest pain no shortness of breath no fevers <\n\n> Has had a cough over the last few days productive of white sputum but feels well well otherwise full stop <\n\n> At the time of ambulance arrival heart rate 20 with complete heart block in ed recess heart rate 20 with fusion beats and short runs of ventricular tachycardia on ecg atropine attempted however no response unrecordable blood pressure however patient was alert at that time full stop started on isoprenaline infusion which improved heart rate to forties thirties to forties and patient alert arterial line in situ with invasive blood pressure monitoring demonstrating current blood pressure a 150 systolic ask medical history atrial fibrillation osteoarthritis osteoporosis medication history rivaroxaban 15 mg once a day ramipril 2.5 mg once at night amiodarone 200 mg once a day rheola 60 mg in 1 mil subcut 6 monthly bisoprol 5 mg once a day furosemide 40 mg once a day famotidine 20 mg twice a day teriparatide subcutaneous daily laxita 1 sachet once twice a day cholecalciferol 400 units / calcium carbonate 1.5 g take 1 twice a day cocodamol 30 / 500 tablets 1 or 2 tablets 4 times a day as required and add to the past medical history total abdominal hysterectomy and bilateral salpingo oophorectomy december 2002 allergic history atorvastatin leading to constipation and headaches investigations hemoglobin 108 neutrophilia 11.81 raised white cells of 13.2 previously 5 earlier in the day likely dilutional troponin 70 creatinine a 133 from 92 potassium 5.5 on formal bloods and sodium a 128 previously a 132 all but remainder of lfts normal crp 7 urea 12.7 clear of blood gas 7.33 however otherwise reassuring psa on examination good pulses for bradycardic heart rate of 35 on monitor with blood pressure a 115 over 90 respiratory rate 14 saturations 98% on air febrile heart sounds normal chest possible left lower zone repetations abdomen soft and nontender no significant peripheral edema and no peripheral rashes dry mucous membranes impression complete heart block secondary to taking own dose of digoxin with concurrent amiodarone and beta blockade use plan number 1 discuss with cardiology consultant on call then <\n> Discussed with on call cardiology consultant he was happy with management so far no role for digibind to continue isoprenaline maintaining current heart rate not aiming to increase further as they precipitate fast atrial fibrillation again needs to come to ccu number 2 add calcium and magnesium to blood + or - replace number 3 chest x-ray number 4 suspend diuretics and ace inhibitor in aki you could add aki to the impression aki 1 if evidence of and then next in the plan if evidence of chest infection on chest x-ray to treat with antibiotics move to the coronary care unit when able to continue amiodarone but hold bisoprolol for the morning dip support are only overnight as may require pacing with anesthetic support

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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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