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Christopher sheriff 175933 72 year old man past medical history t 3 n 0 m 0 emvi positive mid rectal tumor completed neoadjuvant radiotherapy to the rectum 25 gray and 5 fractions started 3 months of neoadjuvant xelox chemotherapy in on november 14 this is oxaplatin and capecitabine full blood count awaited crp awaited bone profile normal electrolytes normal creatinine at baseline bilirubin 22 when previously 11 however remainder of lft is normal magnesium normal glucose normal previous full blood count of platelets a 104 on the november 14 but awaited today c o past medical history copd social history 30 20 a day smoking history stopped smoking in 2006 hypertension joint liver replacement 2023 parambolycal repair 2018 independent medications list salbutamol ramipril statins sildenafil treligine inhaler and caractin note recent anesthetic assessment va 2 66% of predicted barometry confirming copd colonoscopy june 2025 rectal cancer in the middle third right lateral wall 13 centimeters from the anal margin indication was positive fit through the bowel cancer screening program ct tap june 2025 no evidence of metastases moderate coronary artery calcification heavy calcification of the aortic valve moderate central lobular and paraseptal emphysematous changes in the lungs observations respiratory rate that's 99% on air pulse 88 blood pressure 99 over 65 alert temperature 37.3 note was blood pressure was 85 systolic with ambulance crew is it mister sheriff no oh what's your name sir mister sheriff oh it is I'm 1 of the medical registrars it's nice to meet you how are you freeze freeze and cold I'm sorry quite warm but well just warm good maybe just a few how are things how are you feeling it's a it's just kind of moved out and crap sorry yeah I'm not surprised mhmm I don't know that's true I didn't finish you started on the chemotherapy the capsaicin based and obviously platinum based chemotherapy early mid november is that is that right a couple of weeks ago possibly possibly do you go in for the infusions or do you take it at home oh it's an infusion do do you go in to the to ricky grant and have a drip of this chemotherapy or do you take it by tablet at home tablet you take it by tablet every day at home fine then over the last few days I understand you've been having loose stools is that right I'm on cough and dry food though you really I'm sorry so we've been taking flu and cool thing and how many times a day were you going twice twice a day tired so bupno it's coming out like a slime did you say oh yeah yeah really wet like completely water yeah yeah yeah yeah okay twice a day any blood in it or any mucus no no good no no blood no no no and any other symptoms at all any fevers cough and cold trouble with your breathing no anyone else ill at home no nothing like that only any yesterday oh there you go then that would be impossible no 1 no 1 you hang out with that's been ill lately just wondering if you might have gastroenteritis or something like that I don't know I'd like be that or you live by yourself at home yep do you drink or smoke nope you smoked in the past I understand but you don't now no I don't have are you allergic to anything can't see what happens if you have penicillin can't remember fine just thinking you might be allergic well they told me I was you told me very you look incredibly uncomfortable do you understand that can I try and make you more comfortable the bed is very upright you could either sit like this or if you wanted to lay down I could lay the back of the bed down you you look forward well I just want to make you more comfortable I hate to see a man in discomfort if you slide up the bed now there's a pillow behind you if you see over there good good good good good so we'll get that in between alright good so 1 more there we go a bit of bang if you bang your knees 1 out for you're happy with that yeah yeah and you can just pee right off the end of bed nope sure is that better more comfortable in your hands brilliant yeah it is I'm happy I'm I'm I'm happy can I have a quick listen to your chest is that alright no no okay we don't have take anything off I just listened to your heart so just breathe away normally I do need not at all and I think it is unfortunate to be quiet that's not good and now you can decompress if you wouldn't mind okay that's helpful any chance you could sit forward and I could have a listen to your back sorry in no way I'm pushing you not after yeah what want do what you want doctor you shouldn't say things like that please I'm just joking I'd go home honey that's my wife a little more please feel some lymph nodes in your tummy my neck alright that's lovely can I open your legs you can go around and do it you're having a drip of some fluid to rehydrate you do you feel dehydrated feels what the fuck I'm sorry it's probably chemotherapy induced diarrhoea which does sometimes happen probably yes but you know but you're poorly with it give you a drip of some fluid we'll check your stool cultures a couple of times to see if there's any infection there if there is we can treat you for it if you don't have an infection we can use a medicine to try and slow your bowels up a bit to try and get you feeling better the rectal tumour that you've got the cancer in the last part of the bowel is breaking down with this chemotherapy and it's going to make you you're very at risk of chemotherapy related diarrhea if that makes sense unfortunately alright so lots of fluid feel better lots of good paracetamol stop leaking fluids or anything like that we'll check your stool cultures and take it from there okay I'll also arrange your chest x-ray just because you're slightly wheezy just to make sure you haven't got chest infections going along with it okay I don't think I need to have a cough no think it's simple to get into the hospital now the cough is selling it no it's just cough is you're laying it on too thick I'd already decided oh I've done that there's loads of bleeding I'll drink you're not gonna have an operation alright we're not gonna do an operation you can drink I'm gonna ask you to get him some do you wanna sit up a bit or I'll wait and come back and get him some nice to meet you see you later bathroom I'm go bathroom well I'm gonna try and get a bath and I'm go to bathroom and I'm go to the bathroom hi sorry I'm talking to a lawyer say again hi you take some medicines at home I understand regular tablets do you take any at home I don't do 1 the chemo you don't take a statin or anything like that oh yeah statin yeah oh you I do like catch you out yeah what's the other 1 called what statin do you take I can't get on your gt record someone asked me oh you've got a list oh yeah sure no don't worry happy with that and dovastatin fourteenth 1 good job 1 of the internal statins in the correct and yeah your blood pressure's a bit low isn't it say again no because you're dehydrated okay I'm the inhaler in the morning am I why not you are a little bit wheezy listening to your chest you can probably do with it okay I'm sure it'll even be better make me feel better if it doesn't make you feel the prolactin sr 10 mg twice per day your folic acid 5 mg once a day ramipril 5 mg once in the morning but I've held that the trelegy ellipta 92 by 55 by 22 1 inhaled inhaler as required you've got some painkillers some anti sickness it does constipate you a little the anti sickness it could be a good 1 I don't see much seen that I've had problem how much do you weigh roughly do you think oh god I'm still do you think that's I'm not this 1 anymore no you're not that big are you we'll weigh you and make sure we're giving you the right dose to get you the right medicines I want to Google what coractin is coractin you know I'm at 14 41 fetipine should we hold that do you get chest pain no good put me on a minute just because you're on a medicine which we sometimes use for chest pain could the caractin and the nifedipine we're probably using it for blood pressure for you I take caractin at home what for just for fun no it's on the list I believe it is on your list I've put it on your chart but I've suspended it for a few days because your blood pressure's quite low alright oh that's the antibiotic actually I wanted something to correct the noise there it's a dofetiline it's a calcium channel blocker medicine it works to reduce the blood pressure oblique can I change any of these say again left right mouth sorry right mouth okay what's your mic sorry I'm not sure okay what's phone number you'd like to see you later yeah

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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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