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Next patient robin stancombe s t a n c o m b e 441681 investigations inr 1.1 full blood count white cells 30.4 with neutrophils 27.47 monocytes 1.23 chest x-ray today bilateral pleural effusions on the right peripheral interstitial thickening suggestive of an element of interstitial edema calcium normal albumin normal renal function at baseline potassium and sodium normal liver function test bittery been 25 from 13 previously but no other lft derangement noted crp 49 from previous 19 phosphate naught 0.7 ast normal venous blood gas reassuring blood cultures from today negative so far saturation is 90% on 3 l of oxygen pulse 99 blood pressure 136 over 62 temperature 37.1 news score 3 missus duncan how are you do you alright yeah I'm rob 1 of the medical registrars nice to meet you how are you yeah hi paul good good rob with you I'm fine what I'm fine sorry to see you in the hospital I understand the orthopedic team have come down to see you already concerned about the recurrence of this lasting sounding necrotizing I just think you had was it 2011 2010 2010 yeah so a while ago now so that's good okay fine and how have you been over the last few weeks I've I've been alright I mean mhmm it's just you're aware of this infection which came in last night from like 30 01:30 mhmm it was 1 night and what were what did you feel at 01:30 I don't I just went to I sort of woke up and I was shivering uncomfortable feeling freezing all the time really cold yeah fine mhmm and that kept me awake and have you had any other symptoms other than feeling shivery and shaky and breathless breathless yeah mhmm that's that's pretty much it I've got pain any pain anywhere pain pain on the top of the right foot and the right foot mhmm back in the back the the no that's the worst day and any change to your medicines recently or anything like that no nothing like that good to find out I've got all the good numbers and medicines on your gp rep yeah yes because they wanted to change it they wanted to get me on to warfarin okay what do you take instead of warfarin bedoxaban yeah but warfarin yeah they wanna be on warfarin already with all the monitoring it's so expensive because you have to have an inr taken all the time yeah it's a nightmare it is a nightmare well I'm glad you're not on it that makes my job all the time no hurts to be fair our doctor is pretty good sort of listens to you what's good said we'll stick with the the the the the 8 9 years yeah can you hear all can you and you had a what what caused you to be on the edoxaban it was atrial yeah when you had your neck fascia and this before I after was that after I was done yeah of course yeah alright do you mind if I examine you you don't have wash my hands yeah no worries at all yeah great I'm rob I'm a medical resident I'm so relieved yeah fine I mean have you think it's right for setting up think you can have any issues at all this is nasty isn't it I feel just I get cold in the past a 100% I mean he was breathing so hard back at your house wasn't he yeah yeah I think it was the concern issue about anything except it it's not really bad isn't it yeah once you've got sleep gentle ice and then tears the sim and your breathing it all started around the same time or was your breathing getting bad before that I mean he's not best at breathing anyway he's had a respiratory team he's a profusion not as bad as that in sitting in the yeah yeah thank you thank big breath for the new lady 02:00 right that's that's o'clock lovely 2 zones on both sides I can hear those 2 other fusions they sound like they've got a a bit bit bigger bigger it's fine and this is a wound from your previous tracheostomy is it mhmm when you had when you're in intensive care I'll get a little bit fat and how your tongue any pain in your tongue or anything like that or can press somewhere on my nose I'll try not to do that do you wanna have look is that okay yeah and tell me about your life more generally do you live at home together yeah yeah and what kind of things do you do at home in a day I don't smoke don't smoke smoke I mhmm wouldn't be aware of that I should scared bed much yeah no yeah get out of bed every morning yeah and then what kind of things do you do what's your telly mhmm play games take your own computer mhmm occasionally go to the grand children's road mhmm occasionally you go to the drive mhmm that's about it beautiful and how do you find getting into the car is that difficult or it's quite fine okay and would you walk distance distance like how far can you walk a day yeah but not far and now you're obviously in hospital with this nasty infection which you've had some strong antibiotics for looking at the rest of your numbers in terms of your blood tests your kidneys are doing fine your liver's doing fine your markers of infection are obviously up and keeping with this infection in your leg your chest x-ray looks like there's lots of fluid in the wrong places which can happen when you've got a nasty infection the blood vessels can become leaky and can leak fluid into your chest on top of the collection of fluid that you've got on both sides you've got swelling in the lung because of fluid in the lung and that makes is making your breathing worse and makes you need this oxygen your blood pressure's pretty good a 152 over 77 so you could have some medicine to get that fluid off some furosemide have you had anything like that before I do get a little bit a you have furosemide at home yeah fine so I'll get you an intravenous shot of some furosemide to try and get that fluid off your chest if you like when's the last time you had a gem scan of your heart an echocardiogram you've never find the money no yeah a baby scan exactly yeah long time long time might get the machine and and pop it next to you and we can have a quick look at your heart together if that's alright that'll help us look at what's going on how much of that fluid in the chest is related to the heart and how much is related to infection and get a bit of an idea about how your heart's working alright cool drugs I'll come back with that thing in minute alright but other than that you'll be staying in yeah no worries it's this that keeps you in this time you need less oxygen to breathe okay I'll come back with a machine in a sec alright alright alright great come back in thank you so on examination heart sounds normal chest dial to percussion to the midsones bilaterally with fine crepitations to the midsones bilaterally peripheral edema to the knees with chronic venous changes and evidence of previous necrotizing fasciitis surgery and debridement and scarring to the right leg on the right leg there's an area of erythema spreading to the knee and down to the foot he's got regular pulses peripherally ecg looks like sinus rhythm with sinus arrhythmia so her impression is right leg cellulitis pulmonary edema secondary to underlying cardiomyopathy, hypertension, diabetes, obesity and infection ecg actually shows atrial fibrillation at a rate of 95 blood pressure 150 over 77 respiratory rate 20

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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.]

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Patient Name MRN

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