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Been sitting up here no I don't mind I'm gonna hang it on I might go pop yourself back into that room I'll take little bit of it hello hello hi and a straightforward home yeah her abdomen pain still feeling quite low yeah she's feeling so well weight she's just getting over colitis this last couple of days she said didn't you no medications to worry about no other alerts not allergic to anything I don't know why I think your gp has something yeah alright okay he's got some okay but you've lost weight yeah do you please not record it nicely called name it is william good so you're alright how are you I'm alright good I'm bit nervous but you know it's not not had 1 of these before I've not had 1 down there I've had it the other way yeah fine it's a lot quicker this 1 yeah and a lot simpler a lot less prep exactly then you're not supposed to yeah and tell me about your symptoms oh I've been it's been awful like I was taking myself to a and e a couple of months ago it was just the it says it starts at heartburn yeah then it goes around your back then it goes up to my jaw then it's just it's like wanna die well the pain is so bad it's like yeah it's like I need this pain to stop it can't it can't do anything about it I'm it's just it just feels like I've got a lead balloon in my stomach you lost leg cancer yeah and it just hit to your left leg yeah and then it's and you said the pain goes up to your jaw it go yeah just radiates up to my jaw but it all starts off like if I let myself go too hungry too long okay if I have to smoke too fizzy it will start the bubbling in my in my tummy and then it will just it will I'm like to my partner it's coming and I know it's coming and then it just goes throughout my whole body and there's nothing that eases it even rocking on fours mhmm do get your symptoms when you move when you walk up a hill or anything like that anything my job is sitting down I do sit down quite an awful lot at at the office but I tend to try and move as as much as I can in a day because I everyone else at work eats 3 4 meals a day I don't I'll eat little bits and bobs because you're sat down for 12 hours it's not going anywhere mhmm but like the pain is honestly I feel like the lining of my stomach is coming away oh right that's how bad it feels right yeah and I am I'm not intentionally trying to lose weight but some days I can't eat mhmm what's sign that you're so I don't I tend not to eat to avoid pain but then that causes me a vicious circle of if I get that hunger pang and then you get that fizziness of because you're hungry that will then cause this to start even more so eating makes it better eating makes it better mhmm yeah right and how much weight do you think you've lost I was 100 well in july I was 115 mhmm and now I'm 104 right so yeah but that's not I was I mean I was a and you said it's like heartburn so I'm just thinking about it yeah it's and it's like a yeah and I think because it's in the middle behind your breastbone or is it because it's a burning feeling it's because it's a burning feeling then sometimes I'm like oh shit is it my heart yeah you know because it is going up that way mhmm so but I'm obviously not inside but I've read lots and lots of different things I don't want to read too much of being wrong because I'm not going be for you I think we can have a look I don't think we're particularly clever we can have a look with our camera and see what we can see if there's abnormal we can take some samples from it if it still has to be like the pain blockages as such it felt like it got here and then it was stuck a couple of months ago I had a roast dinner on a sunday at work on a tuesday I felt sick all weekend and then at work I had to make myself sick because I was I was feeling so sick I brought up the potato ad on sunday fine okay it was still not digested so and then since then I've been very cautious of like hard vegetables make sure I don't eat cooked vegetables and make sure they're very very soft no skin on anything are you getting a lot of vomiting after eating or is that just the 1 time no I am vomiting after eating because I feel like I'm just getting blocked then mhmm every time big meals mhmm that's why I tend not to eat too many big meals now like maybe 3 or 4 times a week mhmm but yeah if I eat anything starchy meat I can't digest red meat no more mhmm chicken's fine you feel like you get stuck and then you have to vomit your back all yeah the way possibly we'll have a little look shall we the procedure's called an upper gi endoscopy the benefits of the diagnosis are the cause of your gastrointestinal symptoms frequently occurring risks of the test sore throat is very common for the days after the test okay but it's not necessarily a serious risk the serious risks of the test are very rare but they're of bleeding so sometimes we deliberately or accidentally make something bleed with our camera the good thing is we can usually fix it with our camera it may not be at that moment in time it may be with a different team later that day or something like that the other serious risk of perforation that's making a hole or a tear in the wrong place if that were to happen you might just stay in hospital might need to have an operation to fix that the good news about those risks is they're incredibly incredibly uncommon they happen in less than 1 in 9000 diagnostic gastrostrophies I've luck by the way I've got really good luck so we say balanced out it's the best test we've got and it is a really good test to look at the upper gi tract there's always a chance of not getting to where you want to get to that's a failure either because of my technique equipment my team your ability to tolerate the test or food in your stomach or whatever or missed lesion so that's if something's hiding behind a bolt or under a pool of fluid we might not see it there's a chance of missing something does that make sense any questions about tests or anything like that no are you gonna have local or are gonna have some sedation I'm sedated some sedation yes you got someone to look after you yeah my colleagues will take home my son who's 23 is at home and then my partner's home at 6 that's fine 23 year old son should be able to look after you for a hit I'm at 23 years he won't go away I see he's just that right perfect thank you cheers yeah but my 16 year old's just gone off to college in brighton mhmm living my best life my 22 year old's not even planning on going on dating my god that's gets me but me too but I think he's gonna I think he's gonna end up monday like taking my skin off on my own ear if you if you stop through to appointments we'll know that happens okay thank you that'll be alright that's it that's true yeah I feel bad when you're scared I'm all good he likes coming looking like he's going that's true yeah yeah and then he'll see you okay we'll rush over to the next 1 and you pop it up on a second stool and that's hi my name is charlotte I'm a student at claire's and we're just gonna be working on her today okay so I'm behind the cath capsule right you guys got the cath plan good because I didn't have any my name's mike hi mike I wanted to know steve I'm working with you in dallas I'm working with my wife important do you have any of these before no only the other way I don't know so yeah can we no that's good yeah I'm being pumped I okay can you see them they send you a I'm all done yeah exactly exactly don't you see my calendar then well done you're very fluent in here I'm listening to the left and the right there okay great ready to do a check and then I do quick in or whatever once you've got a sunday lunch mhmm can you shout out your full name and date of birth for us amber taste it eating well first of all wonderful hospital number 658847 yes and do you come back by any chest yes no yep pulmonary yeah ibs thank you you've got a wee thank antibiotics required no course no are of the patient oh fine fine any allergies no no medication abdominal pain thank you thank you do you guys do you guys wanna put a tripping or shall I I don't that's fine oh wait oh my cat picked you up last night oh I'm happy to give it a go legend could give it a fudge stabbing thank you I'll talk about that chairman I'll give it a okay cat thought we'd have a little goat here

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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.