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So next patient is terry charalambos 658290 85 year old lady so medications list melatonin modified release 2 mg at night the ical d 3 once per day clopidogrel 75 mg once a day dapagliflozin 10 mg once a ramipril 1.25 mg at night atorvastatin 20 mg a day furosemide 40 mg at breakfast and 40 mg at lunchtime lanzoprazole 30 mg once a day aspirin 75 mg once a day problems list so she's 85 year old lady I don't know if I said that so problems list copd small segmental pulmonary embolism november 2025 stroke 2023 housebound from 2021 heart failure with reduced ejection fraction after acute st elevation myocardial infarction anterolateral in 2021 underwent primary pci with 2 stents esophagitis it is hernia essential hypertension ck3 they can see from the gp record about involvement of rowcroft hospice with the patient and her daughter test maternal cardiac arrest team this is your test please respond to 412 so on the march 18 saw a paramedic practitioner at her gp practice with her daughter tracy recent home visit tap change for not for admission to hospital has capacity reduced oral intake over the approximately last week dark urine and some possible pain in her back currently on oral amoxicillin wants to go to hospice open not open to community blood tests and doesn't want intervention that time palliative care just in case medicine's discussed but don't feel appropriate at this. Review after antibiotics on friday possible package of care to help with adls and reduce pressure on daughter and care of burnout and then further involvement with our team at the hospice who discussed with her on the telephone 2 days ago spoke with her daughter as she as the patient was too unwell to get to the phone the daughter's moved in to live with the patient and solely caring for her mom which she's finding very difficult both had a chest infection over the last 2 weeks which hasn't helped patient's struggling to get onto the commode on her own daughter's lifting her mom they have no other help at home the daughter has 11 dogs and 5 cats both struggling with chest infections again the day a week later oh no a day after I should say has been using oxynorm liquid at night and they plan to visit her again on the march 30 and then it appears that subsequently they discussed with the hospital at home and frailty team because of shortness of breath on the back of 2 weeks of antibiotics for criglia respiratory tract infection obs were all fine but fluid overloaded + or - community acquired pneumonia daughter has care about her unable to manage her at home at all no carer support available so was admitted to hospital she's in the waiting room her lights for her yeah and where did they put you have you been in the in the chair all night no I think so yeah oh I'm so sorry it's horrid isn't it I'm rob I'm 1 of the medical registrars yeah I can see my colleague you there's been some discussions lately about a chest infection and feeling a bit poorly at home yes yeah and how are you feeling now with your chest fine fine good not needing any oxygen or anything like that be shoving me in a chair all night apart from that yeah fine any fevers or cough or anything like that no cough down again this night I was very short of oxygen last night feeling short of breath yeah but your oxygen levels were fine but you were feeling short of breath I was yes I'm I'm okay now yeah oh good fine alright and what makes you feel short of breath do you think a recent chest infection could do it have you noticed any swelling in your legs at all slightly on the left but I've got slight kidney problem yeah fine you stop only on the left yeah okay fine and I understand you live at home with your daughter is that right who helps look after you a bit well at the moment yes I'm hoping you won't be for much longer yeah of course and what's your plan moving forward then in terms of looking after and things like that yeah to go home and be by yourself at home yeah fine that sounds nice well I've got a little dog oh have you that's nice what kind of dog have you got okay yeah fine that's nice lovely can I have a little look at you do you mind look at your hands look at your nails mhmm do you do them yourself or does your daughter do them sorry did you do you do them yourself or does your daughter do them for you no no I do them you do them yourself me doing actually oh they look good do you mind if I just call these people back is that alright I know it's very rude cool no it's alright well I can't call them anyway their pain is breaking how is it listening to your front do some big breaths for me no doubt any chance I could get through this dressing gown could you loosen it at the front and I'll just pop my you don't have to peek through there that's lovely sorry my hands are a bit cold both sides sounds like there's a bit of fluid there a bit of crepitations on both sides but on the right it is a little bit coarse I'm like there may be a bit of infection there as well how are your legs can I can I poke and prop them is that okay that one's always sore that's the 1 with the kidney problems as you say you got some swelling on the left up to your knee and then on this side the same up to your knee as well does it go up any higher do you mind if I just press over here fine alright and allergic to anything fine and I understand there's a 5686 there's been some discussions about what what the best thing to do is in terms of looking after you and the discussion has been to get you to hospital for a little bit to to try try and and get get some some help at home and we'll kinda get a bit of fluid off your chest to stop to help you feel better does that sound alright hospital how long well it's difficult to say isn't it probably for the weekend I would think oh let's saturday today I don't think there's anything medically that needs to keep you in hospital we could increase your water tablets slightly and we could cover you for an infection in your chest at the same time and x-ray your chest while you're here given you're here think I can have a chest x-ray good I'll have a look at it lovely alright mhmm so I'll get all of those things sorted and then I'll go to all these people does that sound alright thank you yeah good I'm sorry you're back waiting around it's okay but once we can get you out of the waiting room to somewhere nice that'll be much better won't it here's where you're back sorry I can't walk very far don't worry that's really fine how do you get around at home I get alright okay fine just it's pretty young did you say yeah thank you it's okay so on examination pitting edema to the knees bilaterally bibasilar crepitations with right this is coarser than left heart sounds normal impression multifactorial perceived shortness of breath with no oxygen requirements secondary to resolving infection + or - element of overload + significant frailty plan chest x-ray increased furosemide further weaker oral antibiotics to cover for resolving chest infection to and cover atypicals with doxycycline medically fit for discharge ot review in light of care of burnout / jets review and aim home with pack acute package of care

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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?

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Patient Name MRN

Mark extraction as reviewed.