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Hello hi it's rob you're in hello good afternoon my name is anita jermann I'm 1 of the specialty doctors calling from simpson ward hi I would like to discuss a patient regarding ogd we have a 96 year old gentleman that is was treated with cap and aki that has been treated and that's improving but this gentleman developed melena yesterday okay he's 96 but he lives with his wife he's independent self caring independent with washing dressing and walking but has got some mild cognitive impairment according to his family for the last 2 years he was on apixaban for pasc he has pacemaker got and ckd his age because so yesterday he had a couple of episodes of melena he had further 4 episodes of melena today he's hemodynamically stable and apiracial his glasgow bloodscore is eleventhirteen I can't see any obvious evidence of heart failure in this gentleman but he may have underlying heart failure because he has got some peripheral edema so the question is are unsure whether because we feel that obviously he's 96 ideally we don't want to subject him you know we don't want to do any investigation but he's in good 96 mhmm we are just wondering so he's repeat so he had 2 hbs today this morning was 97 repeat 1 this afternoon he's 89 mhmm he's really 21 which evidently has gone up we haven't given him any apics about this since yesterday morning so the last dose he received was yesterday morning we are still waiting for cog screen we have sent cog screen this afternoon fine but we just wanted what what observations is blood pressure okay and stuff blood pressure is okay yeah blood pressure is between yeah it's 1 3 5 49 he looks quite well to be honest he wasn't even taking himself to the toilet when having malnited right this discouraged me to do that maybe and walk on the ward where he's having acute malina but he is very much he would base his management on what we feel is appropriate for him I understand he does have evidence of short term memory loss so he does remember that I had a chat with him about tomgd this morning he remembers he's having black stools but he doesn't remember you know our you know in-depth chat same I had a chat with his next of kin that has got poa for health his son has got his other brother and they all feel that they would follow what we think as a medical team is appropriate and for what's his name sorry his name is frederick young how ironic cool he's a very good he doesn't love lucky's age really okay fine so I mean I guess there's lots of ways we can do this so yeah you know in in these in these patients there's gonna be a role for endoscopy from a diagnostic. Of view but also potentially in a therapeutic. Of view yes however you know if there's you know that often the thing that does the treatment is the omeprazole not the camera yes is he on omeprazole already yes he was started yesterday on I d 40 40 b d so I think he has received 3 2 or 3 doses by now of I d 40 b d fair so we're managing a peptic ulcer actively obviously if we go in and do an endoscopy and give treatment that's great but what's most likely to happen I would think is that we'll go and do an endoscopy subjecting to some risk but only from a diagnostic. Of view and obviously that's not optimal for him yeah I think I should come and see him and see I'm sure he is a very good 96 year old but I should just get I know you get a bit of vibe when you see someone so I'll just come and see him and then oh thank you so much and then we can make a plan so I guess first I kept him just so you know I kept him nearby mouth thank you just in case so he did have breakfast then I kept him on just sips of water but for the last couple of hours he's completely nearby mouth I want iv fluids I guess that's helpful if you think that he might go to endoscopy in the middle of the night but it's probably not gonna happen today at this. Because we don't have a god list today yes okay perfect but but yeah I'll come and see him and come up with a plan I think it's think what I'm likely to recommend is just carrying on the ppi holding fast and if he develops significant normally if he rebleeds or his hemoglobin drops despite all of that treatment over the next few days then we ogd him because there may be something to treat but I think the worst situation I think for him is to subject him to the risk of an invasive test and aspiration and perforation and all that for and not actually deliver any therapy I understand yeah but yeah I'll I'll go write some notes what to avoid of course and he's you know if he was very fair 19 years old I would be very happy to say you know he wants to talk about but no exactly actually seem pretty good but perhaps no complete has been failing yeah and it's it's a bit of a trick to and these are the challenging cases where probably they're gonna get better with the ppi but we all feel better having had a look at it with our camera but actually we probably subject them to reasonable amount of aspiration risk just by shutting it down so yeah anyway yeah I'll come and see him work it out great thank you so much pleasure to talk to you thanks so much thank you bye bye bye bye bye

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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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Patient Name MRN

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