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Hi hi hi everyone I'm rob I'm 1 of the medical registrars nice to meet you how's it all going what's happened a it's long time thanks so basically I I don't I can't remember exactly when it was but when I said july during july july august I collapsed at home mhmm so I got up to let the dog out and then I just felt this real sharp pain in my head and I turned to my wife and I just clapped that was that I got brought in to the hospital this was in lancaster yes yeah a ct scan the specialist come back after the scan and said they'd found back that something something related to that they wanted me to stay in I didn't I left mhmm I've been fine since and I've had like nearly same niggly headaches and sore to touch on the face but nothing as bad as yesterday yesterday's been really what time yesterday about lunchtime and it's a headache that you've got it's it's I wouldn't I wouldn't say it's a headache it's like a pain so it felt like you were hit yeah like it feels like I was got a belt of something into the side of the head it's that like sharp instant pain and then sore to touch oh my left side goes weak feels like my face is drooping but it's not I don't know if it is or not I don't know it is when you and just can't process my words and stuff if that makes sense yeah pretty much it and the weakness is that there now or is that yeah it's it's not as bad as yesterday was really bad I really struggled yesterday but I was in the pain and I woke up at 04:00 this morning for a week got up and got back to bed I felt okay and I turned I turned over in the bed and that sharp pain hit me again like fucking hell it was it's like it's I just get really like disoriented mhmm and then I went to sleep and I woke up I was fine this morning then and when did the weakness go like about about 11:00 11:00 last night no this morning this morning okay so I've picked my in laws up from I was working in london yesterday picked my in laws up from there but I just got back from bangkok mhmm and then I've got to the. Where I couldn't drive so I'd have to have to go over and and it's just the left side of weakness is getting worse yeah tingling and it's just so it's just not right you know and what can't you do with the left hand side what is it that you can't do just feels it feels strong this I just mhmm just feels weak tired and I know how to explain it it just feels tired yeah it feels it feels like I can't mhmm I don't have the oomph on that side of my body yeah okay so it's fine alright and then when when it collapsed that time mhmm my wife said to me it looked like I was having a stroke right because everything she couldn't lift she couldn't I couldn't feel anything in the left side mhmm and everything gets like kind of drooping my speech was yeah my mother-in-law was up there and she she on the time that I collapsed the first time yeah she can tell you how I sounded because she used to do a ball mhmm and it sounded like I was drunk but I don't drink so I wasn't drunk but that's how it sounded okay fine alright but you're any speech disturbance today it's it's it's it's some I can't get my words out and I'm a bit stuttery here and there but it's not like it was yesterday yesterday was really bad so this is my strength that's yeah you guys are good you can strength no whole team we looked at we all come in this is all the strength team so let's see hello we'll come and say hello hello hello is your doctor calling again say again so you're on again it's nonstop isn't it hi how are you you alright there you are we were just having a chat and I was just about to do an ana hss but what time one's at 11 some with with a headache primarily that's been over the last couple of days since yesterday since yesterday and some left sided heaviness it's just tingling on the side of your face it's really sore to touch really sore to touch and it's it's just it's just because usually I'm like bang on it's just a bit stuffy at times and yeah you know I'm just a bit slower than I usually and then previously in lancaster had a similar episode you had a ct scan which showed something in your brain something to do with a blood vessel retracting or something I don't know my wife knows more I was completely out of it this is longer he's stretched well I wanted to arrange this task do you have headaches not no no migraines no nothing like that nothing like that we checked all of that in lancaster and it's like as I said it's not really a headache it's like I've it feels I don't know what it's like to be hit with something across the board but that's what it feels like have a constant pain me do to take look is that okay I would love that is that alright yeah you're busy sweet thanks guys bye cheers guys

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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.