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Mesian lake then 153341 okay the negative flow ecg high voltages neutral fibrillation rate of a 104 hi doctor I'm rob 1 of the doctors it's nice to meet you how are you how are you feeling sorry tired very little bit tired how's your breathing feeling it is a little better little better good I'm glad have you got any other symptoms any pain in your chest no I didn't no pain any headache or anything like that sorry any headache no visual changes no any weakness or numbness in any part of your body nothing right now no have you noticed any fevers or feeling shivering shaky or hot and cold did have that 2 or 3 days ago mhmm but it was just sort of like 24 hour thing okay and then it's resolved okay and when did your symptoms with the shortness of breath start oh 3 days quite badly about 3 days ago but mhmm at least a week before that really fine so you've been a week at increasing shortness of breath but then particularly bad 3 days ago yeah mhmm in what way was it deteriorating over the weeks really fine can you tell me about your life more generally who lives at home with you yes who lives at home with you nobody nobody you buy yourself do have any pets or anything like that no no what did you do for a living I was I bred horses quite few years bred horses mhmm cool round here yes mhmm I haven't got any horses now yeah okay cool good and I did office work as well mhmm alright do you drink or smoke no you've been like that have you ever smoked before yes when how long did you smoke for I haven't smoked since I was about 30 so fine so a while ago years yeah and how old are you now 75 75 yep yep yep you haven't smoked for a long time no no and how long did you smoke for probably 5 started on hours fine I'm 17 I think yeah fine mhmm right I'm fine with that 23 years or so sorry 13 years I say and how how much do you smoke for that time what 20 a day yeah okay okay that's fine that's good can I have a quick look you you need to sit forward and have a listen to your back is that alright oh you're so sweaty do you feel hot no big breath sounds having a good unique I think that's it my blood pressure is a 110 can we have a bit of nausea now I think that's a good 1 has anyone told you about a heart murmur before yeah oh that 1 yes okay I've got a long time what did they tell you what kind of heart murmur it was I'll take it that's it sorry for squeezing me so hard just wanna see how high the cord goes straight into your knees okay so I'll just lift your head up and down that's great and have a look at this vein of your neck can you just hold it to the opposite side of the knee for me that's great and try and relax your head as best you can thank you very much can I see you at home thank you that's great alright and what's your understanding of what's going on why you're in hospital and what's been done for you so tricky breathing really yeah yeah you're struggling to breathe because you've got lots of fluid on your chest you need to get that fluid off we do that in lots of ways but probably with a a medicine to try and open up the vessels to allow your to breathe better if you could so you're starting a little bit fat mhmm your blood pressure is quite high that can cause you to have these kind of symptoms right do you take anything for your blood pressure I take magnesium that's okay I can look you up on the computer did you take your medicines today 3 months no don't think I've had them tonight it's fine take 2 question it really is is it tablet it was that yes and how about yesterday do you have a new day recently you did it yesterday if you can drive it poorly you can lift it that's great have you gone for a wee wee recently yeah have you been for a wee wee recently yeah so far not for a long time good that's great brilliant well you're out of bed for your children it's nice to meet you you know inr 1.1 full blood count hemoglobin a 114 platelets a 180 red cells low 3.99 but no what's no raised white cells bone profile normal creatinine a 144 from baseline 97 potassium and sodium normal liver function test normal crp 29 previously 8 urea 14.2 from 8 ast 17 phosphate 1.48 venous blood gas not acidotic arterial blood gas was type 2 respiratory failure but without acidosis nt probnp from february 8352 so on examination crepitations to the midsaid bilaterally chest x-ray upper lobe diversion with hazy opacification in the right apex small bilateral pleural effusions larger on the left than the right prominent vasculature in keeping with pulmonary edema did not take antihypertensives today

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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.