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It's an email about ian bt 1441497 44 year old man dear doctor neil, <\n\n> Thanks for your advice regarding mister bt open brackets 1 4 4 1 4 9 7 close brackets full stop this is the 44 year old gentleman currently being treated with pembrolizumab for metastatic melanoma who has developed immunotherapy related colitis full stop <\n\n> I can see in the notes and printouts from some emails between doctor poles and the oncology team full stop before coming into hospital he was opening his bowels 7 times per day with urgency and blood full stop he hasn't had any features of systemic stop <\n\n> I went to see him on the acute medical unit after our discussion about methylprednisolone and found that he actually hadn't opened his bowels for 3 days passing passing nothing and no flatus full stop <\n\n> His abdomen is generally tender and mildly distended although he does have bowel sounds full stop <\n\n> Paragraph at this moment it doesn't sound like he clearly has an exacerbation of his immunotherapy colitis however the possibility of an ileus, perforation or collection is a strong possibility in this immunocompromised man who has had long standing colitis symptoms full stop <\n\n> Therefore, I hope it's okay, that I have arranged a ct thorax abdomen and pelvis both for repeat staging as requested by the oncologist in their recent emails as well as to exclude ileus or complication full stop I've handed over to the amu team to give him 1 to 2 mg/kg of methylprednisolone in 2 divided doses if there is signs of ileus on the scan full stop if there's a complication like perforation or collection then I've suggested they speak to the surgical team in the first instance and stop his steroids full stop <\n\n> I hope that you're happy with this plan please let me know if there's anything else you'd like me to do and I can make sure it's action full stop <\n\n> I hope that your endoscopy goes well this evening many thanks of note doctor the consultant and his name is spelled n e a l e and the patient's name is ian viti and that is is spelled spelled b b e a t t I e and ian is spelled I a n thank you

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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

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Patient Name MRN

Mark extraction as reviewed.