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Robin baker 10 9 9 02 75 year old man current medication edoxaban 60 mg once a day ramipril 2.5 mg once a day spironolactone 25 75 mg once a day amlodipine 10 mg once a day busoprolol 1.25 mg once a ibuprofen gel amiodarone 100 mg once a day sucupril / valsartan 49 / 51 mg tablets twice 1 to be taken twice per day fluticasone nasal spray 1 or 2 sprays once a day omeprazole 20 mg twice a day amitriptyline 10 mg to 20 mg a night selzalexin 1 g to be taken twice a day methotrexate 15 mg to be taken as once per week folic acid 5 mg once per day paracetamol 1 g as required 4 times a day atorvastatin 20 mg once a day past medical issues age related macular degeneration af heart failure with reduced ejection fraction atrial fibrillation with rapid ventricular response nonalcoholic fatty liver disease inflammatory arthritis seronegative left knee osteoarthritis central hypertension investigations full blood count normal liver function test normal coagulation screen eosinase normal crp 2 urea normal ast normal mister robin baker please robin baker please what was maybe it has a different effect on mine no I just felt you never met good yeah alright uh-huh that's cool I will give it home I've asked you when you come up with my name and you're like oh you can't believe it hello is that mister robin baker hi I'm rob as well I'm I'm 1 of the medical registrars here at torbay hospital I'm sorry that there's such been such a big wait I I don't know if you're still around the ed or whether you've gone home oh I'm sorry mister baker it's very tough sorry it's a nightmare yeah of course and and tell me all about what happened do you mind no not at all no will it be possible to come in tomorrow I you were welcome to come in tomorrow but I don't know whether it'll be any better that's my problem if only I could have had a maybe better mondays are often bad but it may not be it's very difficult to know what happened was on saturday I just got up saturday morning to make my wife a cup of tea to take into her and I collapsed in the kitchen and fell back and hit my head on the worktops yes and then yesterday morning I woke up and my heart was going into palpitations and 1 side of my face was kind of needles impingified and when I collapsed in the kitchen I got this noise like the only way I can describe it is like electrical short it's like through my head and then I was awake again it only happened for a second I guess but that's the kind of thing I heard but I've had this before because a couple of years ago my heart went into ecg went into af and I collapsed in the kitchen then and they took me over to albay hospital and the same kind of thing happened so I didn't know whether there was anything to that going on yeah course I'm on quite a lot of art tablets I'm under the art squad there at your place and I didn't know whether it was anything going on with that of course it's difficult isn't it to know whether it was anything going on with your heart or whether you maybe something going on in your head after you hit your head obviously you're on blood thinners yes yes so yes blood pressure yeah maybe blood pressure or something although my blood pressure again I'm on quite a few tablets for blood pressure yeah I'm on a beta blocker and some other different things and it seems to be okay I don't seem to get any problems with that and I only seen them at the art squad about a month ago may not be as long as that and they would debug you with me they said you're doing well yeah that's good fine you I don't know what's going on my wife keeps saying I've had this virus coughing virus that's been going around before christmas and I keep coughing and every time I'm coughing I'm having to hold my chest because it's making me cough so much yeah of course I don't know whether that's there's like maybe a couple of things going on feel sounds like we some tests are in order to work out what's going on doesn't it yeah I seen my doctor a a few weeks ago and asked them for something for this coughing business and they said well we can't give you antibiotics because you're on so much other stuff all right is that you the know I'm sure there must be something I could take surely yeah it sounds like an x-ray of your chest and a scan of your head would be nice things to do yes in order to make sure that you haven't bled and see what the cause of this cough is and this collapse is and then try and go from there yeah I phoned my doctor up first thing this morning and my doctor said being you've you're getting this with your heart palpitations and your head aching I've had horrendous headaches they said you better get to torbay and she said I'll phone the head and tell the medical team just go into a and e and get seen to but that's not happened no I'm sorry unfortunately the medical team I run the medical take and we have a huge wait unfortunately and we often rely on the fact that patients have been seen by other teams usually the a and e team we've seen them who usually do the initial things so strangely although in for both of gps they feel like it expedites things calling ahead often it means the a and e team don't see you and then the wait for to see us is so significant and so because we tend to do a thorough job which takes more time yes yeah and that can obviously be mean that people wait a very long time I'm very sorry that that was you I I feel as though there's something not right obviously there's something not right yeah so I I need to come in and and perhaps I could come in again tomorrow yeah well how about instead of coming into the a and e waiting room tomorrow you come into our acute medical unit where you're right in front of us and we'll be able to see you a lot more expeditiously I would think in that environment as opposed to being in the a and e waiting room where we kind of assume that people have been seen by the a and e team before but I've just looked at your notes and found that they hadn't seen you which is reasonable because you've been referred to us but yeah but often they will see people before when they've been waiting a long time but yeah anyway so why don't why don't I book you in to come to our acute medical unit tomorrow morning yeah you can turn up anytime from yeah half past 8 in the morning and yeah and how how do I find you so that is it's not in a and e it's in a separate part of the hospital so do you know where the heart and lung unit is you would have gone there for your chest yeah yeah that's my second home exactly so just next to you we're the neighbors of your second home so as you're looking at heart and lung left of heart and lung you'll see there's like a drive which goes up past pharmacy and at the end and opposite so next to heart and lung is the acute medical unit it's a big grey blocky building and there's a waiting room there we can see there we can scan your head do a chest x-ray I'll get all those requests on the computer system for you so I hope they'll happen rapidly when you arrive and then we can take it from there does that sound alright that sounds good thank you okay I'm sorry that you've had to come home and I can't promise that it'll be I can promise it'll be quicker but I can't promise it won't be an all day affair no that's fine okay so I guess preparing for that is is important as well I'll bring a bit of lunch with me yeah that sounds good okay sir thank you very much it's a pleasure I'm sorry that you had to go home I was okay acute medical center acute medical unit exactly medical unit anytime tomorrow morning just come on in the earlier the better it gives us more time to sort you out the sooner you get in the sooner you get out probably yeah thank you very much when did you fall and hit your head again on saturday before lunch saturday yeah fine yeah saturday morning sorry yeah lovely alright I've put the request in for the scan of your head as well as the chest x-ray and we can have a good look at you when you come in to see us is that alright yeah good thank you very much pleasure it was nice to talk to you thank you bye mister baker bye bye bye thank you so that was a telephone consultation with mister baker who unfortunately went home prior to being seen but he's gonna come back into the acute medical unit tomorrow and we will see you there

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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.