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It's sort of like a slight pain 1 type 2 and then it just goes gets worse and worse and then it comes up like around this part and then it goes all the way around and it goes up around my back it's really really painful so it's a colicky so it comes on and then gets gets better again yeah are you ever without pain or is it bad all the time no never it's not there all the time it comes and goes and how about your bowels how are they no they're bad tell me about that I get weak I have diarrhea every day for how long now it's been going on for years for years yeah I'm sorry how many times a day do you go oh my god I can't cut you and tell you and it's just getting me down you bet it's exhausting they're horrible sometimes bit I just feel like taking all my supplements and just stopping it all I'm sorry it's horrible feeling it is getting me done and do you have pain like this more than today or is it just today that you've had the pain no I got it old before this pain yeah mhmm yeah well I'm sorry and when's the last time you're up for a pee yeah so how many times so well it's been hours of this morning I mean it's been this morning yeah so it's been a while since going to the same thingy vows yeah and you've got this bowl have you been vomiting yeah mhmm what was coming up just like watery fluid really because I've got nothing in my stomach I'm eating since sunday mhmm why not I just because every time I eat I get I need toilet every time you eat you rush to the toilet well I can't rush I gotta come over which I use at home mhmm exhausting and I don't sleep at night or anything I've gone downstairs and my dining room was cranked up the stairs I can't manage it washing the synagis I don't really have mhmm so it's hard really hot really hot I'm sorry okay and any weight loss lately I don't know you might be a bit interested who lives with you at home you're by yourself no my daughter your daughter hence the mom really well that was my mom's oh really fine yeah yeah she does try and help as much as she can how do you get around your house is it a house or a flat a house a house I've got use my frame use your frame yeah what makes you use the frame because my blood pressure as soon as I sit up and drink up I get really dizzy mhmm and disoriented and whenever you sit up and how long has that been going on for oh it's just been going on for a few years as well I'm on blood pressure tablets right because it fluctuates my blood pressure all the time uh-huh but as soon as I got up gotta hold on to the frame or safety of coming out of me yeah so I can't move around the house I haven't been outside of the house for years years that's the cool thing I mean that doesn't help you move does it no no exactly inside yeah no these are really debilitating symptoms aren't they yeah and what makes you not go outside is the frame and also the urgent bowels is that right yeah yeah yeah the disorientation and and do you have do you use anything for the pain no because I was on gabapentin mhmm but then I don't know it took me off everything somebody at the hospital took me off it so you're not on gabapentin anymore are you on codeine or or anything else no that's what I need see just to help me through it all I'm sorry it's painful can I touch your tummy do you mind yeah there's gas in there isn't there must feel uncomfortable yeah it is you had an x-ray of your tummy yeah yeah you haven't yeah alright I'll have a look at it just a minute yeah I'll go and have a look at your x-ray of your tummy I'll come back in a second alright okay and I'll give us a bit more info on what's going on is it alright to move you around yeah oh it is can you ask 1 of the nurses course on this so it's not that we've got more of the other questions mhmm yeah so I brought you lovely call clarence yeah a quick read rather than me sort I'm doing a test just something so quick noticed I've seen him have seen him okay well he's just request me to see a doctor luke's gonna come and see him he's written him up so I've got him in your colleague and some stuff I've got this '21 no he's there okay so basically investigations for leslie broad 59 year old lady 762255 double x-ray challenging interpretation due to very poor quality film no evidence of stool in the rectum impression of thickened colonic wall on the left hand side with some evidence of fecal loading to my eye as well as right sided gas and feces unable to see the transverse: on this very difficult to interpret chest x-ray small left basal pleural effusion otherwise clear lung fields possibly some bilateral hazy opacification most likely to be atelectasis the combination of abdominal impression the combination of abdominal pain with chronic loose and urgent stools makes me consider whether overflow constipation due to her poor mobility I need a print an abs to not blood thinners trial of laxatives iv fluids psych review given low mood and stated suicidal ideation yes you can nerve does obstruction on this seed on this abdominal x-ray however if symptoms persist despite treatment then cross sectional imaging could be helpful

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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.]

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Patient Name MRN

Mark extraction as reviewed.