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Yeah I had af okay never heard of af no that's not fair and so and what happened after the af did you start doing some blood thinners and things like that yeah and it would be blood thinners yes okay and other than that apart from that you're generally fit and well because there's this concern about cardiomyopathy but you you don't have don't need to know this I'm sure but I suffer from depression depressed it's more to know isn't it it stresses me of course so that might have an effect I don't know no doubt up and down just in the last couple of weeks I lost my brother oh goodness I'm so sorry I still haven't processed that properly yet what a magic there any family member left I'm I'm just saying that's what's been going on the last couple of weeks and over the last couple of weeks have you been looking after yourself have you been eating and drinking and things no don't encounter myself very well I've been hanging on friends to feed me when's the last time you had something to eat last night what did you have rice and something I can't remember what she could you had something yeah right and some and you have anything to drink today just water and tea I drink a lot of tea fine so you've had you've had a good amount of intake yes have you been having fevers or anything like that no no and not feeling not good no cough or cold or pain passing water no fever no cough alright no just feeling very low oh no sorry not quite well we can have a look at a few things and yeah check a few blood tests when we go to toilet okay thank you sorry so I'm sorry sorry I'm no thanks for helping me out I'm sorry it's fine yeah thanks for talking to me sam okay yeah we'll just take him out to you check his thyroid and everything so he did sort of say that I'm gonna go to home and sort of thing so I think we'll see if that that if happening that's in the short end right okay so you just think you should leave me as long as you know I can get him to the er to understand okay so then I need to get back to you real quick you think you'll be able to sit up off the bed and then lie on our trolley in a brief moment you don't have to meet just yet please yeah that's fine thank you we'll just meet you very quickly yes yeah that's fine no I never know it's sort of flat it's all right it's not no yeah exactly we'll tell when we thought alright so like pop your leggies down how do you feel with your legs down okay yeah okay do you wanna try swinging the brain into the chin up in the hand if you need it okay excellent and this is what I'm telling you to do if I want to hi do you want me to hop over if that's alright just here it's easier good okay can you put that back up prior will you do it again yeah please yeah no let me know when no that's fine yeah I'm gonna take this you know I'll I'll do it again there you go alright alright but it's just these things there can give yours you're gonna put that on your feet is that right yep yep okay thank thanks very much for your help appreciate that you take care david alright thanks how are you feeling suck up a bit more it's quite rough skin here so feel fine you actually close it out yeah okay okay another feeling of stuff that you're helping yeah okay able it for I'm be able do gonna for I'm be able do it for I'm gonna be able to do it gonna go in and do 1 of that coordinate and train there as we go so yeah yeah david jelfs j e l f s +1 41792 71 year old man weighing 53 kg heart rate 53 beats per minute during test feeling low thin on examination heart sounds normal chest clear no peripheral edema adrenaline soft and nontender but thin and cachectic impression is hypotension of uncertain cause but in the context of low mood and bradycardia hypothyroidism should be part of differential however wide at this. Plan move to ed for further assessment iv access blood tests including thyroid function so investigations tsh bone profile normal eosinase normal lfts crp 5 urea normal full blood count normal no anemia venous blood gas normal ph 7.4 recently tested for pancreatic fecal elastase in august and september which was normal and a normal fit test because of weight loss ttg was also normal at that time so let's go hi good how are you feeling how you feeling I'm not good yeah feeling any better or not really no no I'm feeling much better good yeah good luck yeah your blood tests are all plum normal that's your thyroid's fine and the rest of the blood tests are all totally fine okay there's nothing to worry about there which is good I suspect that it was all much of a muchness with the wrong size cup and we all backed around about okay about nothing probably okay but I think it's good to make sure and you've had your blood pressure checked yeah while you've been here and that's good consistently good alright just good so shall we see how you are on your feet yeah we could try and get you out of here couldn't we yes sure does that sound alright yeah I'm so we're we're I don't know how we're gonna get back because I had to you know of course you had someone to drive drive a taxi to bring me here and he he he's been sent on his way of course and and then come back or do you think we should if it's a volunteer service I see but I'm stuck we can find a way to get you back on sure if I take my sheets off you we'll hang over and let you wander and see how you feel how do you feel on your feet yeah I'm looking at you you okay feel normal I do good I'm glad I didn't pull my head in a pisine no it's really scary good I'm really glad so am I good thank you why don't you wander back in there then and rest rest up and we'll work out how we're gonna get you out of here I'll check my computer I'm sorry I live in frankfurt frankfurt frankfurt you know I'm a fairly busy fair yeah yeah fine I'll work it out thank you welcome okay yeah yeah good you're welcome yeah it's nice in jackfruit have you got hot bones what the fuck's that look at jackford it's a idea where that is I'll go to the chat with him I was gonna go home yeah he's he got here with some volunteer transport service brought him for his appointment and now they've gone and they're not gonna come back we'll have a chat k is that alright yeah no

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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.