Generate Note

Next patient is angela parfit alpha 1 8 0 9 8 1 the diagnosis eyelid crohn's disease diagnosed 1997 ileocecal resection '19 '90 '7 dilated cbd on mrcp 20 17 normal dexa scan 20 12 bile acid malabsorption colonoscopy 20 21 june patchy erythema in the neoterminal ileum with 1 large ulcer and several aplethis ulcerations anastamotic recurrence other medical diagnoses hypertension b 12 deficiency thyrotoxicosis tonsillitis current medications I'll add those to the additional notes past medical history admission under colorectal surgery january 20 24 with right sided abdominal pain ct demonstrating edema around the first and second part of the duodenum epi initiated to treat duodenitis a past medical history cholecystitis and appendicectomy as well investigations mri small bowel may 20 23 single segment of acute inflammatory crohn's disease affecting the neoterminal ileum with luminal narrowing and mild proximal dilatation similar to the previous study from 2021 gallstones in the gallbladder most recent colonoscopy june 20 21 post ic resection changes ic anastomosis fibrotic stricture but not inflamed unable to intubate cre balloon dilatation 12 to 15 millimeters small mucosal tear at 12:00 allowing intubation patchy erythema in the neoterminal ileum 1 large ulcer and several aphthous ulcers biopsies taken histology demonstrating unremarkable fragments of ileal mucosa with no active inflammation ulceration or granul omatta and unremarkable fragments of colonic mucosa in other medical problems plan number 1 blood's including vitamin d vitamin b 12 and thyroid function number 2 colonoscopy 3 points + or - dilatation of t and terminal ileal stricture number 3 consider mri small bowel number 4 colesevelam to treat bile acid malabsorption and number 5 follow-up 3 months I had the pleasure of speaking on the telephone to miss parfitt on behalf of doctor hayward in inflammatory bowel disease clinic today full stop I'm sorry to hear about the significant burden of symptoms which she's experiencing as well as her challenging social circumstances lately full stop <\n\n> She describes challenges with her bowels which are quote constant end quote full stop she describes that eating makes her symptoms much worse and she'll rush to the toilet immediately after a meal full stop she's decreased her oral intake and feels like she's lost some weight because of this full stop she'll open her bowels with significant urgency up to 10 times per day passing yellowy loose stools full stop <\n\n> In addition to loose stools, she describes right sided abdominal pain which is colicky and they're constantly full stop she describes the pain makes her quite tired and she was previously on b 12 injections although these now stopped since her b 12 has normalized full stop <\n\n> In terms of her social history, she stopped smoking 2 years ago after discussions with doctor hayward and I've congrat congratulated her on this today full stop she works as a customer service representative in a shop and works long days with this full stop I was very sorry to hear that she's recently lost her brother to pancreatic cancer and she's now a solo carer for her elderly parents which is understandably very challenging full stop <\n\n> In terms of extraintestinal manifestations of inflammatory bowel disease, she has stiff hands throughout the day which she finds locks full stop I note her recent hand x rays demonstrating signs of osteoarthritis but without evidence of inflammatory arthropathy full stop she doesn't have buttock pain and she does not have any eye symptoms full stop <\n\n> I think that her loose stools are due to bile acid malabsorption following her ileocecal resection and I've suggested that she start some colesevelam for this which she's keen to try full stop she's aware that she needs to space it around her other medicines and she can increase the dose as required for her symptoms as above full stop <\n\n> We had a discussion about how to manage her pain and her which is due to her neoterminal artery stricture full stop we discussed options of mri small bowel and further discussion, colonoscopy with biopsies + or - - dilatation at that time or consideration of surgical options full stop she'd like to pursue a colonoscopy with biopsies + or - dilatation so I'll request this for her urgently as 3 points full stop <\n\n> To investigate her fatigue, I would suggest some blood tests including vitamin d vitamin b 12 and thyroid function which I'll request and which she can have performed at windsor house 8 till 4 weekdays full stop <\n\n> I'll see her back in clinic in 3 months time to discuss the results of her investigations and other next steps full stop yours sincerely

Choose a note service

Choose an assistant

Choose a template

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.