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Have not got a marjorie rawlins 311766 from there investigations going back about this lady what's that no I imagine it was like the gas was just calcium normal inr 1 cranial a 113 a 130 baseline sodium normal alp a 146 from a 112 remainder of lfts normal crp 6 urea 13.8 oh that's upsetting you wanted to show off your pacemaker fine you able to sit forward have a listen to your back is that alright yes hit me k you can just sit back and relax me and get you so she's back okay and down that's lovely out that's lovely that's great thank you alright and any pain in the tummy or anything like that no not no we just had to have to have that injection this morning okay that's that's really good but it was really I I I was wrenching horrible and it was only like white fluffy stuff out horrible so I think this is covid causing symptoms as opposed to any problem with the heart but we'll investigate that as well lovely thank you we'll get an x-ray of your chest I'll have a blood test on to look for heart stretch or bnp and with that we can be guided that way that we need to do a jelly scan and get a heart and echocardiogram to see how well that's working we'll carry on on the dexamethasone I'll increase your insulin slightly yeah and then from there we might need to bring it up any every a little bit further depending on how the steroids go yeah so we'll keep an eye on your blood sugars at least 4 times a day yeah well once the oxygen's off we can stop the steroids which will be great so you feel better but in the meantime it'll be easy yeah okay well that's lovely thank you any questions anything else I've got for you no I've I've probably I've got these things good if you of think anything else I'm not sure what no nothing nothing nothing nothing nothing nothing nice to meet you see you later thank you so much thank you for calling so impression is covid-nineteen + or - element of heart failure plan add bmp chest x-ray continue dexamethasone no don't worry thank you 4 times a day blood sugars increase insulin by 10% to account for dexamethasone effect on bms wean oxygen is able once off oxygen stop dexamethasone and aim home social history this with husband active and fit nonsmoker non drinker no allergic history

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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.