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That's me hello just be careful because you got these cameras in I'm sorry sorry can I give you a hand she's trapped in there oh my goodness you okay alright oh there you are we lost you for a minute there the hearing aid out on the monitor no no public bathroom thought you'd stick it up because I was doing his temperature oh sorry this 1 thing called a therapy talk is fine to 1 of the video what you're saying yeah I've been hearing this really I'm rob I'm 1 of the medical doctors it's nice to meet you how are you no you carry on talking it's okay I'm not a scratch hearing aid I've got it in your ear now sorry very good you turn it on can you hear me okay yeah good I'm rob I'm 1 of the medical registrars nice to meet you the a and e doctor tells me tells me that you fell over what the a and e doctor tells me you fell over yeah how did you fall little tiny step of putting that on mhmm and what were you in my daughter's in that way alright I tripped I hit the wall oh you poor chap drop down and then just straight on me back oh you poor thing and did you hit your chest not not as deep as you that was there before yeah tell me about that I've been for about 3 weeks mhmm just got tight tight feeling in your chest yeah and is it worse since falling or no no no no not it's not same as it has been good fair enough and any pain in your chest I have but it's not so bad as it was to give me some antibiotics past where balances the pain whereabouts is the pain in your chest on my back there was nothing on me nothing on your front a bit on the back of your chest okay and on the right hand side that's why you give me the antibiotics and tell me about you more generally you're going to see your daughter how did you get there drive you dried good man I didn't drive okay I can't I sun dried you sun dried but you still drive yeah you normally do fine I don't drive in the dark fair enough you can't drive very often at the moment because it's so dark all the time oh good not every day mhmm I'm doing nothing else yeah fine alright and how often do you drive then once a day once a day great fine brilliant you just I used to walk and get me paper mhmm I thought I'd gone on to walk too far so I'd rather not get me paper right I think walking is good for you isn't it yeah yeah bit of a walkway okay and do you live in a house or a flat bungler do you live with anyone else yeah my son your son okay fine and you look after each other does he help you with anything around the house oh yeah yeah yeah what does he help you with I have a cleaner coming okay how many times a week does your cleaner come in once oh 5 not too many weeks 5 for too old okay once a week for 2 hours and what does your son do for you we have shopping mhmm you do the shopping together or does he do that no he does 1 but I don't do another lot okay so you share it you're fine alright and how about washing dressing all that stuff I wouldn't do that you do all that yourself alright you're very robust there that's good so yeah and I'll do the washing mhmm and I'm on me lovely sounds good sounds really good fine and then I hear from the a and e doctor that your chest has been not good for the last couple of weeks can you tell me about that I don't want to bore I was I had a jersey that was a bit tight it's too small a shirt no jersey a jersey mhmm a jersey yep and then that was a lot of her neck and then tied her neck it's when I took off okay fine so I bought some bigger ones and you're having problems with your breathing for a couple of weeks not not so much no no no no they're like okay so no real problem with your breathing for a few weeks right I hear you were gonna see a gp today because of problems with your breathing was that not true no I rang up the gp yeah and well I rang up a receptionist she had 1 with the doc and they said I had a report to after your fall a and e after you had your fall no before before for what your chest what about your chest I was complaining about the tightness of my chest okay and he didn't see me and he suggests I go the a and e and here you are and here I am not intentionally but but you're here I was here so on the right hand side of your chest you're pointing to the right and your right upper tummy a bit as well can you describe it to me no he's warm like a dull ache a dull ache when did it start oh like I said about like 2 days 2 weeks ago 2 weeks ago a dull ache in your chest there the whole time oh no I don't know if it's that when does it come on when I put the jersey on only when you put the jersey on when you take the jersey off it's alright when you walk up a hill I don't walk uphill fine fair enough normal flat where the bungalow is fair enough when do you do much exercise at all no when you walk from the bungalow to your car yeah that's about 20 pages and does your chest get bad when you walk 20 pages no do you get short of breath no no okay fair enough it doesn't sound like you're having problems with your breathing at all then does it no not really that's fine love just the tightness chest up and forward yeah the intermittent as well I know can see you take a few you're on a blood thinning medicine called a doxplan oh yeah and we need to just stop that for a bit do you know the result of your scan and your blood tests has anyone told you no idea okay your blood tests show your blood tests are fine your kidney function's fine your liver function's fine your full blood count is fine you've got slightly raised white cells that possibly might suggest an infection but the other tests looking for infection are normal so I doubt that very much your ct scan of your whole body body shows a collection of fluid in your chest the fluid looks a bit like blood you haven't broken any ribs or anything like that I had 1 must be about 3 months ago now mhmm a scan yeah I'll have a look at that they said there was something there but not to worry about it okay fine I'll have a look at that and compare it to this 1 but there's nothing else to worry about in your scan which is obviously no no so there's a bit maybe a bit of blood in your chest for that I think you should see my surgical colleagues who are the experts in managing people with possible blood in their chest and I'll ask them to see if they don't want to look after you then I'll keep looking after you but it may be that they want to look after you given the blood in your chest alright good I'll have a look at your medicines and like I say I'll stop your edoxaban for now and I'll compare it with your previous scan that sound alright yeah last thing can I have a listen to your chest yeah I'm taking things off oh that sounds normal when I touch your chest is it painful and how about around your back that's sore sore on that right hand side I'm sorry alright and how about this side is that painful as well no just be alright next time okay thank you I'll see you soon alright 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.]

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.