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Have not got a marjorie rawlins 311766 it's main investigations going back about this lady what's that no I imagine it 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 hemoglobin a 111 from a 121 note has previously been anemic in april full blood count normal apart from a low red cell count okay thank you that's fine add to the plan chest x-ray medications list zalin night x a I l I n night ointment at night apixaban 2.5 mg twice a day indapamide 2.5 mg once a day doxazosin 2 mg once a day peptac as required up to 4 times a day paracetamol 1 g 4 times a day amlodipine 10 mg once a day amzoprazole 30 mg once a day levothyroxine 25 micrograms once in the morning levothyroxine 75 micrograms in total once in the morning to remove any other mention of levothyroxine novomix 30 flexpen as directed past medical history tavi 20 24 with pacemaker 2024 aortic stenosis 20 22 corrected with tavi tia 2019 dvt 2010 type 2 diabetes 1992 hysterectomy 1987 most recent h b 1 c june 2025 56 millimoles per mole most recent tsh 1.88 in june 2025 observations saturation 97% 236.6 degrees heart rate 60 respiratory rate 18 blood pressure 161 over 76 hello how are you you alright excellent I'm rob 1 of the medical doctors how are how are you feeling I feel very well good thanks I'm glad but it's just this nasty oxygen that you're in hospital yeah it it's it's it's monday today isn't it it is saturday I went to abbey's hospital mhmm with with my legs they've swollen up so much but I I think that was the flight okay because I've just come back from south africa what a good trip oh when did you go went we flew from heathrow to johannesburg mhmm and then I did the tour it's a garden route oh yeah but the garden route I'd I'd picked it wrong okay the the proteus was just starting to bud out but but my husband can't stand heat so must have been hot out there it it was only 30 okay but any any anything after that he he just passed much and that that wasn't out in the maze like blaze

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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.