Generate Note

Daniel scofield 1357548 investigations tsh normal bone profile normal magnesium normal crp normal urea 3.7 normal troponin 11 eosinase normal lfts alt 52 albumin 52 otherwise normal note that alt was 38 previously in march 2024 he's a 31 year old man medications list 2.5 mg of socolol as required so note to admission in march 2024 was admitted with palpitations and persistent af cardiaverted with dc cardioversion diagnosed with brugada syndrome rd and e november 2023 noted to attend in the emergency department in october 2025 with atrial fibrillation had cryoablation in exeter since being diagnosed with af has been discussed with the cardiologist of the week who advised 2.5 mg iv metoprolol was given with no improvement in radial symptoms no change in symptoms after taking 2.5 mg of bisoprolol onset of palpitations at 07:00 in the morning which felt like his irregular racing heartbeat yeah it's a good night I woke I woke up and asleep and I I looked over it yeah I can feel it it's because you've been in the office or I can see yes right and last time you were like this you were kind of invested weren't you yeah no last time I just I came in oh you did this went to the toilet I was out of bed mhmm like winning the time before I was quite a bit yeah but I had a correlation between the prior version and the last time okay so I'm back on a waiting list again for another correlation next to flush but yeah so I feel it doesn't feel intense okay I feel fine occasionally feel the palpitations but like compared to last 2 times really I don't I haven't really been hungry or anything and this time I feel fine to just yeah just over it I guess yeah I went down home of course you had a dose so they spoke to the cardiologist on call and they said give you a dose of platoprolol you had a shot back oh yeah and then it didn't really do anything and then I think they were thinking about giving you another bit of blood pressure no dropped I think by about 20 so you didn't really have had 2 lots of yeah 2 shots of the toxin yeah and then they were like oh we're not gonna do anything mhmm cardiac arrest of georgia l ward cardiac arrest georgia l ward

Choose a note service

Choose an assistant

Choose a template

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.