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Welcome why not it kinda cut her thigh so I'm sorry about that is it helpful for you for these issues yeah yeah absolutely okay cool yeah because I will just put the results on our system where to I don't know where our hole punch is in here but yeah I would probably suggest you bring it after a week or so we have to bring it in can put that in discharge room sure because often with stuff like that it's often quite poorly communicated to our primary care visit care team so if we can put that in a discharge room then we can appreciate that they've had a proper talk yeah yeah and that's and patients often just often they sometimes relapse very quickly so that's why at the end of hospital admission is the best time to do this so that's great fine just gonna screw it down yep if I can if I get chance we'll screw it up no problem thanks signed cd copy that's not an aunt's of ours john no it's not okay cool sorry to be a pain I'm not gonna say anything so it's miss weber can she just have a couple of units if she has any okay any other injections she's the decon cirrhotic test no no just yeah just 2 units 2 units so 40 pounds 20 pills and reabsorb okay sorry do we have it again next time yes I'll do it and then I'll tell some I'll have it to do so oh you don't need to chase anything you just need to I sure you guys need to be clear yeah yeah yeah as in if you want them reassess afterwards overnight no I'm not so no it's the nurses can call them if there's any problem and the and the symptoms are he looks unwell less alert okay okay what would be driving that yeah okay mhmm alright nice to see you yeah you're cool so just yeah very hca and general ed so it's not that much hca normal fine I have okay so general ed alright you listened to his chest what is it the live well wards though or is it sound they're different wards here different are there some that live well that health care is lovely or no I think they're all in like gold that's a different roaster isn't it yeah yeah so this is like medical I don't know yeah yeah it's fine but I'm usually day job with hepatology but for whatever reason we don't always get to cover our own wards so it's just a bunch of patients I don't know so yeah his chest sounds okay he's needing a bit of oxygen but it's not dramatically increased what are moving to now he's big he's got some increased work he's social training oh beautiful where is he wow yeah it's a bit far yeah I wanted to stay downstairs but I got a job in kingston there too so I just move anywhere for peak surgery off I go I'm gonna so you had any chest you had a ctpa when was that yesterday you said well I'm not an irish so I'm just gonna be like normal weather you know it's cold anyway and yeah yeah it's your help today alright his abdomen but the ct didn't show any surgical cause for that fecal loading oh fecal loading in even oh no fecal position of the contents of the terminal ileum fecalization of the contents of the t lino so he's very constipated and there's atelectasis fine constipation yeah but the bmp's in all even in the context of acute illness when it would be very sensitive overly sensitive in fact yeah fine and he's got some sort of cardiac history because he's on dual antiplatelets tia fine cardiologist has been here yeah no fair enough okay I'll pop by on my way up and have a little look at him listen to his chest and see what I think but I suggest he's probably constipated isn't he that's the only thing we've got to fix he's on apiates he's having a bit of laxido which is good but he could have some as well to try and combat that sort of a of a prokinetic to try and combat the sluggishness from morphine and then if you could have the sun auricular now we can auricular then I'll pop and see you and see what we think it's alright cool talk to soon cheers bye

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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.