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As it like the blaze and then we finished up in cape town lovely absolutely brilliant how wonderful and then unfortunately you've caught covid yeah he he he must have been on the plane hospital plane is your husband ill no good no he was poorly out there but there was a man who went on the october 1 who got on the coach it was a coach deal all the way down coffee and there were 30 people who were on military and 10 people had to go into hospital so I think he's the 1 who brought it on terrible yeah yeah and what are your symptoms what symptoms made you go to your gp well it was the leg swelling yeah my my legs because the the skin looked like it was gonna burst and I and I couldn't walk properly I was shuffling around and usually I'm I'm walking and then they thought it my heart mhmm so they did an ecg and then this morning I was gonna have a get an appointment to see a doctor but yesterday I I was I was so I I had sickness in my stomach so I couldn't breathe so all day yesterday I didn't drink and and I didn't eat have you got a sore throat or muscle aches no nothing like that no nothing at all any cough I've got a cough yes what are you bringing up nothing nothing at all dry but when doctor yeoman came and seen me last night well well this morning he gave me 2 files in 1 injection mhmm and put it into my arm to stop the sickness oh that's good and that's I I was just did that make you feel better oh yes because yeah so we can keep giving you that while you're in hospital if you like if you're feeling nauseated sorry we can keep giving you some anti sickness while you're in hospital if you're feeling nauseated yeah okay can I have a look at your legs oh yeah yeah have you noticed that there's nothing up on the side well when I got there they there was think things have gone down now well that's good yeah he that's really sore sorry I didn't mean to cause you pain less painful up here as well yeah sorry but it's it's it's not too bad up there no yeah yeah that's it sorry yeah it's okay you're very hard to have I just wanna see where the fluid is up to maybe a week or so sometimes mhmm and you had a recently had a your aortic valve replaced by about last year on the seventeenth my brother yeah on the eighteenth they gave me a bracelet uh-huh yeah 2 for 1 0 yeah that's good great and since then have you noticed your legs have been better or since what what was it that made you need to have the valve replaced were you breathless or did you have chest pain everything everything yeah the whole yeah and you had leg swelling with it as well no you didn't ever have leg swelling that time no they kept on testing my ankles like I know yeah they went for my ankles straight away I said to the 1 doctor why are you going for my ankles so he said you have to look for a little drop exactly yeah so it looks like you've bought a bit of a bit but at the same time you've been on a long flight and all that kind of stuff yeah and you is it particularly tender on 1 side more than the other I'm just wondering about dvt as well I guess oh how bad did you take before if I've pressed down towards that tender is it tender on either side no if you're on a blood thinner I'll give a glass first line for you that's fine thank you that's good shonal obviously you've got covid you're needing the oxygen and the weight you've been started on some steroids which we know works for covid but it's also gonna mess up your blood sugars so we need to keep a close eye it's a little bit better it has already it has right so we need to keep a close eye might need to bring your insulin a little bit how much insulin do you use I have 8 8 in the morning 6 of a night 8 in the morning 6 of a night and the novamix 30 yeah fine I'll bring that up ever so slightly giving you on the steroids and we'll keep it closed up please oh good thank you yeah and once this oxygen's off you're off and it's just that that needs to be sorted out so we can get you out of the hospital so that's what keeps you in oh right okay the more you move around the area that you're committed to move around so you don't infect anyone else yeah the more chance you have of being able to keep your lungs working well because we know resting in bed makes the lungs stick together and that can be another reason why people need oxygen oh right okay alright I'll have a blood test done to look for whether an element of the heart not working well yeah is leading to fluid on the legs and sometimes that could cause fluid on the lungs okay so I'll have a check whether that's causing things but I don't think it's likely that it's covid that's causing things yeah is that alright yeah that's fine any questions or anything no because when when the doctor came this morning he said the legs are a red hermit I think you're probably right yeah have a push this into your heart you don't to take anything off or anything like that no okay and now it sounds like it's working well and how did the pacemaker feel seems good yes was disappointed with when I went through customs it didn't go off no oh no

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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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Detect patient name and MRN locally, send placeholders externally, then re-apply them on the server.

Patient Name MRN

Mark extraction as reviewed.