patient_id stringlengths 6 6 | visit_id stringlengths 7 7 | total_visits int64 1 8 | visit_context stringclasses 38
values | clinical_note stringlengths 206 747 | clinical_findings stringclasses 345
values | risk_level stringclasses 3
values | symptom_duration stringclasses 4
values | summary_reference stringlengths 47 409 |
|---|---|---|---|---|---|---|---|---|
P10000 | V100001 | 4 | Gastroenterology outpatient | The patient presented with fatigue and pallor with haemoglobin of 99 g/L. No overt blood loss or melaena reported. No koilonychia or angular cheilitis seen. Per rectum examination was deferred today. Ferrous fumarate 210 mg twice daily was prescribed. | fatigue and pallor; melaena | Moderate | Recurrent | This was a first-visit assessment of melaena. Clinical signs included that per rectum examination was deferred today. |
P10000 | V100002 | 4 | Haematology outpatient | Follow-up encounter; fatigue and pallor with haemoglobin of 74 g/L persists at a similar level. Menstrual history was reviewed and considered relevant. No per rectum bleeding. Per rectum examination was deferred today. Abdomen was soft and non-tender. Conjunctival pallor was noted. No koilonychia or angular cheilitis s... | fatigue and pallor; conjunctival pallor | Moderate | Recurrent | This was a routine review and the picture remained similar to the previous visit, with conjunctival pallor again noted. Documented findings noted that per rectum examination was deferred today. Plan: dietary iron advice and vitamin C co-administration were discussed. |
P10000 | V100003 | 4 | GP consultation | This patient reported that symptoms had improved since the last review; today fatigue and pallor with haemoglobin of 89 g/L was less prominent. No overt blood loss or melaena reported. No koilonychia or angular cheilitis seen. Conjunctival pallor was noted. Abdomen was soft and non-tender. Per rectum examination was de... | fatigue and pallor; melaena; conjunctival pallor | Moderate | Recurrent | Improvement in fatigue and pallor was documented compared with the previous attendance. Clinical signs included that conjunctival pallor was noted. |
P10000 | V100004 | 4 | Haematology outpatient | A clear deterioration was reported compared with the previous visit; iron deficiency anaemia on routine bloods had worsened. No overt blood loss or melaena reported. No koilonychia or angular cheilitis seen. Conjunctival pallor was noted. Per rectum examination was deferred today. Two-week-wait colonoscopy referral was... | iron deficiency anaemia on routine bloods | High | Chronic | The trajectory had been downward since the last review, with previous visit; iron deficiency anaemia on routine bloods had worsened now more troublesome. On review, the clinician observed that conjunctival pallor was noted. As management, dietary iron advice and vitamin C co-administration were discussed. |
P10001 | V100005 | 1 | Pharmacy first consultation | Documented in the history of presenting complaint was viral upper respiratory symptoms over the past four days. No rash, neck stiffness or photophobia. Chest was clear to auscultation throughout. Temperature was 37.7 degrees Celsius. Safety-netting advice for worsening features was given. | viral upper respiratory symptoms; viral upper respiratory | Low | Short-term | This consultation marked the first formal review of presenting complaint was viral upper respiratory symptoms over the past four days. The note records that chest was clear to auscultation throughout. |
P10002 | V100006 | 3 | Practice nurse follow-up | On presentation, the focus was tightening band-like headache after long screen time. No nausea or visual disturbance reported. Neck range of movement was preserved without pain. Neurological examination was unremarkable. No focal deficit on cranial nerve testing. Blood pressure was 113/79 mmHg with regular pulse. Amitr... | tightening band-like headache | Low | Recurrent | This was a first-visit assessment of tightening band-like headache. The note records that blood pressure was 113/79 mmHg with regular pulse. At this attendance, headache diary was started to identify triggers. |
P10002 | V100007 | 3 | Telephone GP review | The patient attended for routine follow-up; current status remained consistent with prior reviews and tension-type headache occurring most evenings was again documented. Headache fully relieved by simple analgesia. Blood pressure was 111/74 mmHg with regular pulse. Neurological examination was unremarkable. Amitriptyli... | tension-type headache occurring most evenings; tension-type headache | Low | Recurrent | Since the last review, the patient's condition was unchanged with prior reviews and tension-type headache occurring most evenings was again documented continuing. Clinical signs included that blood pressure was 111/74 mmHg with regular pulse. |
P10002 | V100008 | 3 | GP consultation | She was reviewed under the long-term plan; intermittent tension headaches lasting a few hours remains the documented issue. No associated photophobia or phonophobia. Neck range of movement was preserved without pain. No focal deficit on cranial nerve testing. Neurological examination was unremarkable. Blood pressure wa... | intermittent tension headaches; tension headache | Low | Recurrent | On scheduled review tension headache remained at a comparable level to the last appointment. Findings on this visit included that blood pressure was 119/78 mmHg with regular pulse. |
P10003 | V100009 | 2 | Community physiotherapy | The history given was of L5 distribution radicular pain over four weeks. Numbness over the lateral foot reported. Ankle reflex was preserved. Straight leg raise was positive at 40 degrees on the right. Reduced sensation over the L5 dermatome was noted. Lumbar spine MRI was arranged through the MSK service. Naproxen 500... | L5 distribution radicular pain; radicular pain; L5 distribution | Moderate | Recurrent | The patient was newly assessed for l5 distribution at this attendance. Bedside review showed reduced sensation over the L5 dermatome was noted. |
P10003 | V100010 | 2 | Community physiotherapy | Today's review showed continuing improvement, with sciatica with pain radiating below the knee less troublesome. No red flag features for cauda equina present. Numbness over the lateral foot reported. Reduced sensation over the L5 dermatome was noted. Straight leg raise was positive at 40 degrees on the right. Ankle re... | sciatica | Moderate | Recurrent | Symptom burden from sciatica had reduced compared with the prior consultation. Documented findings noted that lumbar spine MRI was arranged through the MSK service. Today's plan involved A referral to community MSK physiotherapy was made. |
P10004 | V100011 | 2 | GP review appointment | She attended for assessment of dull frontal headache without aura or vomiting. No associated photophobia or phonophobia. Headache fully relieved by simple analgesia. Neurological examination was unremarkable. Neck range of movement was preserved without pain. A referral to community physiotherapy was made for posture w... | dull frontal headache without aura or vomiting; frontal headache | Low | Recurrent | Today's visit was the first documented review of dull frontal headache without aura or vomiting. On examination, neurological examination was unremarkable. |
P10004 | V100012 | 2 | Practice nurse follow-up | Today's appointment was for ongoing surveillance, with dull frontal headache without aura or vomiting unchanged from prior review. Trigger linked to poor sleep and screen use. No nausea or visual disturbance reported. Blood pressure was 122/80 mmHg with regular pulse. Trapezius tenderness was bilateral. Neck range of m... | dull frontal headache without aura or vomiting; frontal headache; trapezius tenderness | Low | Recurrent | Compared with the prior encounter the situation had not materially changed; dull frontal headache without aura or vomiting persists. Examination at this attendance found blood pressure was 122/80 mmHg with regular pulse. |
P10005 | V100013 | 6 | Resus room | The principal complaint at this attendance was ongoing chest pain at rest with associated breathlessness. No syncope but profound weakness. Patient appeared clammy and unwell on arrival. Blood pressure was 207/129 mmHg. ECG showed ST elevation in the anterior leads. Aspirin 300 mg, ticagrelor 180 mg and morphine were g... | ongoing chest pain at rest; ST elevation | High | Chronic | This was a first-visit assessment of sT elevation. The note records that blood pressure was 207/129 mmHg. Plan: ECG showed ST elevation in the anterior leads. |
P10005 | V100014 | 6 | Heart failure clinic | This was a planned review visit; the picture was unchanged with stable anginal symptoms relieved within five minutes by GTN continuing. Gtn spray used twice in the preceding month. Carotid examination was unremarkable. Blood pressure was 151/89 mmHg with regular pulse. Resting ECG showed sinus rhythm with no ischaemic ... | stable anginal symptoms relieved within five minutes by; stable angina | High | Chronic | There was no progression of stable anginal symptoms relieved within five minutes by between the previous and current consultations. The note records that resting ECG showed sinus rhythm with no ischaemic changes. |
P10005 | V100015 | 6 | Cardiology outpatient | He was reviewed in recovery from the recent acute episode; stable anginal symptoms relieved within five minutes by GTN continues to settle. No rest pain or change in symptom pattern. No signs of cardiac failure. Heart sounds were dual with a soft systolic flow murmur. Blood pressure was 165/94 mmHg with regular pulse. ... | stable anginal symptoms relieved within five minutes by | High | Chronic | The patient was seen in follow-up after the recent acute presentation, with stable anginal symptoms relieved within five minutes by resolving. Bedside review showed resting ECG showed sinus rhythm with no ischaemic changes. The agreed action was that he was reviewed in recovery from the recent acute episode; stable ang... |
P10005 | V100016 | 6 | Cardiology outpatient | The patient described worsening control since the last appointment; stable anginal symptoms relieved within five minutes by GTN was the dominant feature. No orthopnoea or paroxysmal nocturnal dyspnoea. Blood pressure was 167/93 mmHg with regular pulse. Carotid examination was unremarkable. No signs of cardiac failure. ... | stable anginal symptoms relieved within five minutes by; stable angina; systolic flow murmur | High | Chronic | The trajectory had been downward since the last review, with systolic flow murmur now more troublesome. Assessment today identified that carotid examination was unremarkable. As management, bisoprolol 5 mg once daily was continued. |
P10005 | V100017 | 6 | Heart failure clinic | Since the last encounter the picture had worsened, with predictable chest pain on climbing two flights of stairs now more pronounced. No orthopnoea or paroxysmal nocturnal dyspnoea. Gtn spray used twice in the preceding month. Heart sounds were dual with a soft systolic flow murmur. No signs of cardiac failure. Resting... | predictable chest pain on climbing two flights of; systolic flow murmur | High | Chronic | Compared with the previous visit, this patient's condition had deteriorated, with predictable chest pain on climbing two flights of stairs now more pronounced now more prominent. Examination at this attendance found resting ECG showed sinus rhythm with no ischaemic changes. |
P10005 | V100018 | 6 | GP chronic disease review | Recovery from the recent admission was on track; predictable chest pain on climbing two flights of stairs was less prominent today. Gtn spray used twice in the preceding month. Carotid examination was unremarkable. Heart sounds were dual with a soft systolic flow murmur. Blood pressure was 162/97 mmHg with regular puls... | predictable chest pain on climbing two flights of | High | Chronic | After the recent admission, this post-acute review showed continuing improvement of stairs was less prominent today. Assessment today identified that carotid examination was unremarkable. The agreed action was that recovery from the recent admission was on track; predictable chest pain on climbing two. |
P10006 | V100019 | 5 | Rheumatology nurse-led clinic | The patient was seen with a history of established seropositive RA on stable DMARD regimen. No infective symptoms in the past month. No synovitis on detailed joint count. DAS28 score was 2.9 indicating low disease activity. FBC, U&E, LFTs and CRP were sent for monitoring. Annual review with rheumatology nurse was arran... | established seropositive RA on stable DMARD regimen; low disease activity | Moderate | Chronic | Today's visit was the first documented review of history of established seropositive RA on stable DMARD regimen. Bedside review showed DAS28 score was 2.9 indicating low disease activity. |
P10006 | V100020 | 5 | Rheumatology nurse-led clinic | Today's appointment was for ongoing surveillance, with established seropositive RA on stable DMARD regimen unchanged from prior review. No infective symptoms in the past month. Good adherence to weekly methotrexate confirmed. No synovitis on detailed joint count. Metacarpophalangeal joints were non-tender on palpation ... | established seropositive RA on stable DMARD regimen; low disease activity; methotrexate | Moderate | Chronic | This patient returned for scheduled review of low disease activity, which continues at a similar level. The note records that DAS28 score was 2.7 indicating low disease activity. As management, annual review with rheumatology nurse was arranged. |
P10006 | V100021 | 5 | Rheumatology outpatient | Progression was evident from prior records; established seropositive RA on stable DMARD regimen dominated today's encounter. Good adherence to weekly methotrexate confirmed. No synovitis on detailed joint count. Metacarpophalangeal joints were non-tender on palpation today. DAS28 score was 3.1 indicating low disease ac... | established seropositive RA on stable DMARD regimen; low disease activity | Moderate | Chronic | Compared with the previous visit, the patient's condition had deteriorated, with established seropositive RA on stable DMARD regimen now more prominent. Findings on this visit included that DAS28 score was 3.1 indicating low disease activity. |
P10006 | V100022 | 5 | Rheumatology nurse-led clinic | The patient attended on schedule; documentation continues to focus on established seropositive RA on stable DMARD regimen. No extra-articular manifestations reported. DAS28 score was 2.7 indicating low disease activity. Metacarpophalangeal joints were non-tender on palpation today. FBC, U&E, LFTs and CRP were sent for ... | established seropositive RA on stable DMARD regimen; low disease activity; methotrexate | Moderate | Chronic | The patient was reviewed today with methotrexate unchanged from the previous encounter. The chart documents that DAS28 score was 2.7 indicating low disease activity. At this attendance, annual review with rheumatology nurse was arranged. Routine surveillance was reaffirmed. |
P10006 | V100023 | 5 | GP chronic disease review | Scheduled review took place; established seropositive RA on stable DMARD regimen continues unchanged. No extra-articular manifestations reported. No synovitis on detailed joint count. DAS28 score was 3.1 indicating low disease activity. Vaccinations including pneumococcal and influenza were confirmed up to date. | established seropositive RA on stable DMARD regimen; low disease activity | Moderate | Chronic | Compared with the prior encounter the situation had not materially changed; established seropositive RA on stable DMARD regimen persists. Examination at this attendance found DAS28 score was 3.1 indicating low disease activity. |
P10007 | V100024 | 2 | Minor injuries unit | Today's consultation centred on wrist soreness following a fall onto outstretched hand. Ottawa rules did not suggest a need for radiograph. Range of movement was preserved with discomfort at extremes. Neurovascular status was intact distally. Tenderness was localised over the affected area without bony point tenderness... | wrist soreness following a fall onto outstretched hand; wrist soreness | Low | Short-term | Initial workup of wrist soreness following a fall onto outstretched hand began at this attendance. Bedside review showed no imaging was indicated based on examination. The agreed step was that A tubigrip and graded loading exercises were advised. |
P10007 | V100025 | 2 | Community physiotherapy | The lady was reviewed under the long-term plan; wrist soreness following a fall onto outstretched hand remains the documented issue. Swelling was minimal and bruising was localised. Tenderness was localised over the affected area without bony point tenderness. No joint effusion was clinically detectable. A self-referra... | wrist soreness following a fall onto outstretched hand | Low | Short-term | The patient was reviewed today with wrist soreness following a fall onto outstretched hand unchanged from the previous encounter. Clinical signs included that tenderness was localised over the affected area without bony point tenderness. |
P10008 | V100026 | 2 | Practice nurse appointment | On arrival, he described low-grade fever, sore throat and rhinorrhoea. No shortness of breath or chest pain reported. Tympanic membranes were intact and pearly bilaterally. Throat was mildly erythematous without exudate. No investigations were required. No antibiotics were indicated for this viral illness. | low-grade fever, sore throat and rhinorrhoea; sore throat | Low | Short-term | The first clinic record concerning sore throat was made today. The agreed action was that no antibiotics were indicated for this viral illness. |
P10008 | V100027 | 2 | Practice nurse appointment | On planned review, no material change was identified; self-limiting coryza with sore throat and mild cough continues. Tolerating oral fluids and eating normally. No rash, neck stiffness or photophobia. Tympanic membranes were intact and pearly bilaterally. Temperature was 37.5 degrees Celsius. Chest was clear to auscul... | self-limiting coryza; coryza | Low | Short-term | Comparison with previous documentation showed continuity of self-limiting coryza. On examination, chest was clear to auscultation throughout. The clinician arranged that symptomatic management with paracetamol and fluids was advised. |
P10009 | V100028 | 1 | Walk-in centre | The history given was of atopic eczema flare with secondary impetiginisation. Low-grade systemic upset but no fever. Household contact had recent skin infection. Honey-coloured crust over excoriated eczema patches was noted. Regional lymphadenopathy was present in the right axilla. Flucloxacillin 500 mg four times dail... | atopic eczema flare; honey-coloured crust | Moderate | Short-term | This was a first-visit assessment of honey-coloured crust. Assessment today identified that honey-coloured crust over excoriated eczema patches was noted. The agreed action was that flucloxacillin 500 mg four times daily was prescribed for seven days. |
P10010 | V100029 | 5 | Practice nurse asthma review | The opening complaint at this encounter was partially controlled asthma with night symptoms twice weekly. Inhaler technique was reviewed and sub-optimal. No recent hospital admissions for asthma. No accessory muscle use at rest. Auscultation revealed scattered expiratory wheeze. FeNO measurement was arranged at the nex... | partially controlled asthma; expiratory wheeze; scattered expiratory wheeze | Moderate | Ongoing | The patient came for assessment of scattered expiratory wheeze for the first time. Clinical signs included that auscultation revealed scattered expiratory wheeze. The agreed action was that inhaler technique was reviewed and sub-optimal. |
P10010 | V100030 | 5 | GP chronic disease review | This was a planned review visit; the picture was unchanged with asthma review with peak flow diary below personal best continuing. Inhaler technique was reviewed and sub-optimal. No triggers identified beyond viral illness. Peak flow was 372 L/min, around 70 percent of best. No accessory muscle use at rest. Auscultatio... | asthma review | Moderate | Ongoing | Asthma review with peak flow diary below personal best continuing continued at its established baseline since the last documented review. The note records that auscultation revealed scattered expiratory wheeze. The clinician arranged that A written personalised asthma action plan was issued. |
P10010 | V100031 | 5 | Respiratory clinic | Scheduled review took place; partially controlled asthma with night symptoms twice weekly continues unchanged. No recent hospital admissions for asthma. Auscultation revealed scattered expiratory wheeze. Peak flow was 345 L/min, around 70 percent of best. A written personalised asthma action plan was issued. | partially controlled asthma | Moderate | Ongoing | Since the last review, the patient's condition was unchanged with partially controlled asthma continuing. Clinical signs included that auscultation revealed scattered expiratory wheeze. |
P10010 | V100032 | 5 | Practice nurse asthma review | Progression was evident from prior records; partially controlled asthma with night symptoms twice weekly dominated today's encounter. Inhaler technique was reviewed and sub-optimal. No recent hospital admissions for asthma. Peak flow was 311 L/min, around 70 percent of best. Respiratory rate was 21 breaths per minute. ... | partially controlled asthma | Moderate | Ongoing | The patient's partially controlled asthma had become more pronounced since the last appointment. The note records that respiratory rate was 21 breaths per minute. The agreed action was that inhaler technique was reviewed and sub-optimal. |
P10010 | V100033 | 5 | GP chronic disease review | Compared with the prior visit there was clear improvement; partially controlled asthma with night symptoms twice weekly was now milder. No triggers identified beyond viral illness. Inhaler technique was reviewed and sub-optimal. No accessory muscle use at rest. Respiratory rate was 22 breaths per minute. Auscultation r... | partially controlled asthma; expiratory wheeze | Moderate | Ongoing | Partially controlled asthma had partially resolved between visits, easing the previous concern. The note records that auscultation revealed scattered expiratory wheeze. Plan: spirometry was requested through the community respiratory team. |
P10011 | V100034 | 2 | Same-day urgent GP appointment | Today's encounter was prompted by community-acquired chest infection with green sputum. Low-grade fever and reduced oral intake. Able to speak in full sentences. Focal coarse crackles at the right base were heard. Oxygen saturation was 95% on room air. Chest X-ray was requested through the community pathway. Safety-net... | community-acquired chest infection; focal coarse crackles | Moderate | Short-term | This consultation marked the first formal review of focal coarse crackles. The chart documents that chest X-ray was requested through the community pathway. The clinician arranged that chest X-ray was requested through the community pathway. |
P10011 | V100035 | 2 | Walk-in centre | Improvement was reported at this attendance; lower respiratory tract infection with productive cough for ten days had eased considerably. Able to speak in full sentences. No haemoptysis or pleuritic pain. Respiratory rate was 22 breaths per minute. Oxygen saturation was 96% on room air. Amoxicillin 500 mg three times d... | lower respiratory tract infection; productive cough | Moderate | Short-term | Since the previous review, the patient had improved and lower respiratory tract infection was less prominent today. Assessment today identified that oxygen saturation was 96% on room air. Management included that doxycycline 100 mg twice daily was prescribed in penicillin allergy. |
P10012 | V100036 | 2 | GP consultation | The patient presented with calf strain during a long run. Swelling was minimal and bruising was localised. Tenderness was localised over the affected area without bony point tenderness. Neurovascular status was intact distally. A self-referral to community physiotherapy was offered. | calf strain; tenderness | Low | Short-term | The patient was seen for new symptoms relating to calf strain. Bedside review showed tenderness was localised over the affected area without bony point tenderness. |
P10012 | V100037 | 2 | GP consultation | Since the last encounter the picture had worsened, with calf strain during a long run now more pronounced. Ottawa rules did not suggest a need for radiograph. Swelling was minimal and bruising was localised. No joint effusion was clinically detectable. Range of movement was preserved with discomfort at extremes. Neurov... | calf strain | Moderate | Short-term | This patient's calf strain had become more pronounced since the last appointment. Documented findings noted that tenderness was localised over the affected area without bony point tenderness. |
P10013 | V100038 | 5 | Practice nurse asthma review | The patient presented with asthma review with peak flow diary below personal best. No triggers identified beyond viral illness. No recent hospital admissions for asthma. Auscultation revealed scattered expiratory wheeze. Peak flow was 281 L/min, around 70 percent of best. Oxygen saturation was 93% on room air. Respirat... | asthma review | Moderate | Ongoing | The first clinic record concerning asthma review was made today. Bedside review showed respiratory rate was 19 breaths per minute. The agreed step was that A written personalised asthma action plan was issued. |
P10013 | V100039 | 5 | High dependency unit | Emergency attendance with acute severe asthma with inability to complete sentences was triaged today. Salbutamol used over twenty puffs in the preceding hour. Patient was anxious and exhausted. Respiratory rate was 32 breaths per minute with accessory muscle use. Heart rate was 140 beats per minute. Peak flow was 128 L... | acute severe asthma | High | Ongoing | An acute deterioration prompted this urgent attendance, with acute severe asthma the principal concern. The chart documents that heart rate was 140 beats per minute. The clinician arranged that the medical registrar was contacted and ITU outreach reviewed the patient. |
P10013 | V100040 | 5 | Respiratory clinic | The patient attended for follow-up after the recent acute presentation, with asthma review with peak flow diary below personal best largely settled. Inhaler technique was reviewed and sub-optimal. Oxygen saturation was 95% on room air. Respiratory rate was 22 breaths per minute. No accessory muscle use at rest. Auscult... | asthma review; expiratory wheeze | High | Ongoing | The post-acute trajectory was favourable; asthma review continued to improve at this visit. Examination at this attendance found oxygen saturation was 95% on room air. Plan: A written personalised asthma action plan was issued. |
P10013 | V100041 | 5 | Practice nurse asthma review | The gentleman returned for post-event review; asthma review with peak flow diary below personal best had continued to resolve. Inhaler technique was reviewed and sub-optimal. No triggers identified beyond viral illness. Peak flow was 347 L/min, around 70 percent of best. Oxygen saturation was 93% on room air. Respirato... | asthma review | High | Ongoing | Recovery from the recent event was on track at this review; peak flow diary below personal best had continued to resolve was no longer dominant. On examination, respiratory rate was 18 breaths per minute. Management included that fostair 100/6 was up-titrated to two puffs twice daily. |
P10013 | V100042 | 5 | GP chronic disease review | Recovery from the recent admission was on track; asthma review with peak flow diary below personal best was less prominent today. No recent hospital admissions for asthma. No triggers identified beyond viral illness. No accessory muscle use at rest. Respiratory rate was 19 breaths per minute. Peak flow was 371 L/min, a... | asthma review | High | Ongoing | The post-acute trajectory was favourable; asthma review continued to improve at this visit. Assessment today identified that respiratory rate was 19 breaths per minute. Treatment at this visit comprised no recent hospital admissions for asthma. Onward review was scheduled per the care plan. |
P10014 | V100043 | 2 | Resus room | The patient came forward with bilateral leg weakness with perianal numbness. No preceding trauma. Saddle anaesthesia was confirmed on examination. Perianal tone was reduced on per rectum examination. Post-void bladder volume was 600 ml on bedside scan. Bilateral lower limb power was 4/5 with reduced reflexes. An urgent... | bilateral leg weakness; saddle anaesthesia | High | Recurrent | This was a first-visit assessment of saddle anaesthesia. The note records that an urgent MRI lumbosacral spine was arranged within the four-hour pathway. Today's plan involved an urgent MRI lumbosacral spine was arranged within the four-hour pathway. |
P10014 | V100044 | 2 | Community physiotherapy | Recovery from the recent admission was on track; lumbar pain with radicular symptoms down the right leg was less prominent today. Numbness over the lateral foot reported. No bladder or bowel disturbance. Ankle reflex was preserved. No saddle anaesthesia and intact perianal sensation. Reduced sensation over the L5 derma... | lumbar pain | High | Recurrent | After the acute event, this review confirmed ongoing recovery of lumbar pain. Clinical signs included that reduced sensation over the L5 dermatome was noted. |
P10015 | V100045 | 7 | Acute medical unit | The patient came forward with diabetic ketoacidosis with capillary glucose of 24.6 mmol/L. Drowsy but rousable on arrival. Preceding intercurrent illness. Respiratory rate was 31 breaths per minute, deep and laboured. GCS was 12 on triage. Ketones were 5.8 mmol/L on capillary testing. Venous gas, FBC, U&E, glucose, ket... | diabetic ketoacidosis | High | Ongoing | An initial review was conducted today, focused on diabetic ketoacidosis. On examination, respiratory rate was 31 breaths per minute, deep and laboured. |
P10015 | V100046 | 7 | Diabetes outpatient clinic | The patient was reviewed in recovery from the recent acute episode; suboptimal glycaemic control with reported polyuria continues to settle. Polyuria and increased thirst noted over six weeks. No peripheral oedema and clear chest on auscultation. Foot examination showed intact pulses and protective sensation. Blood pre... | suboptimal glycaemic control | High | Ongoing | The patient was seen in follow-up after the recent acute presentation, with reported polyuria continues to settle resolving. The chart documents that foot examination showed intact pulses and protective sensation. |
P10015 | V100047 | 7 | Diabetes outpatient clinic | Progression was evident from prior records; suboptimal glycaemic control with reported polyuria dominated today's encounter. Polyuria and increased thirst noted over six weeks. No peripheral oedema and clear chest on auscultation. Foot examination showed intact pulses and protective sensation. Empagliflozin 10 mg once ... | suboptimal glycaemic control; polyuria | High | Ongoing | Compared with the previous visit, the patient's condition had deteriorated, with reported polyuria dominated today's encounter now more prominent. The note records that polyuria and increased thirst noted over six weeks. |
P10015 | V100048 | 7 | Practice nurse diabetic review | Convalescence after the acute episode was reviewed; type 2 diabetes with HbA1c rising to 80 mmol/mol was clearly improving. Polyuria and increased thirst noted over six weeks. BMI was recorded at 33.9. Foot examination showed intact pulses and protective sensation. Blood pressure was 164/100 mmHg. No peripheral oedema ... | type 2 diabetes | High | Ongoing | After the acute event, this review confirmed ongoing recovery of type 2 diabetes. Assessment today identified that blood pressure was 164/100 mmHg. Management included that convalescence after the acute episode was reviewed; type 2 diabetes with HbA1c rising to. |
P10015 | V100049 | 7 | Practice nurse diabetic review | This patient was reviewed in recovery from the recent acute episode; suboptimal glycaemic control with reported polyuria continues to settle. Polyuria and increased thirst noted over six weeks. Weight had increased by four kilograms over the year. No peripheral oedema and clear chest on auscultation. Foot examination s... | suboptimal glycaemic control; polyuria | High | Ongoing | The post-acute trajectory was favourable; suboptimal glycaemic control continued to improve at this visit. On review, the clinician observed that polyuria and increased thirst noted over six weeks. Treatment at this visit comprised empagliflozin 10 mg once daily was added as second agent. Continued specialist input was... |
P10015 | V100050 | 7 | Practice nurse diabetic review | On planned review, no material change was identified; suboptimal glycaemic control with reported polyuria continues. Weight had increased by four kilograms over the year. BMI was recorded at 30.2. Foot examination showed intact pulses and protective sensation. Blood pressure was 147/93 mmHg. No peripheral oedema and cl... | suboptimal glycaemic control; polyuria | High | Ongoing | A stable picture of reported polyuria continues was found at this routine attendance. Examination at this attendance found blood pressure was 147/93 mmHg. |
P10015 | V100051 | 7 | Endocrinology outpatient | She was reviewed in recovery from the recent acute episode; suboptimal glycaemic control with reported polyuria continues to settle. Polyuria and increased thirst noted over six weeks. Blood pressure was 166/95 mmHg. No peripheral oedema and clear chest on auscultation. BMI was recorded at 34.8. Structured dietary advi... | suboptimal glycaemic control; polyuria | High | Ongoing | This patient was seen in follow-up after the recent acute presentation, with reported polyuria continues to settle resolving. Documented findings noted that no peripheral oedema and clear chest on auscultation. |
P10016 | V100052 | 2 | Telephone GP review | On presentation, the focus was post-prandial bloating with mucus per rectum. No per rectum bleeding or unintentional weight loss. Diet diary suggested high fodmap triggers. No palpable masses and no organomegaly. Per rectum examination was deferred today. Bowel sounds were normal on auscultation. Abdomen was soft with ... | post-prandial bloating; bloating; mild generalised tenderness | Low | Recurrent | First contact for post-prandial bloating was documented at this visit. On review, the clinician observed that abdomen was soft with mild generalised tenderness. |
P10016 | V100053 | 2 | GP review appointment | This patient returned for scheduled review with continuation of post-prandial bloating with mucus per rectum. Diet diary suggested high fodmap triggers. No nocturnal symptoms or family history of bowel cancer. Abdomen was soft with mild generalised tenderness. No palpable masses and no organomegaly. Lifestyle and stres... | post-prandial bloating; bloating; mild generalised tenderness | Low | Recurrent | Mild generalised tenderness continued at its established baseline since the last documented review. On examination, abdomen was soft with mild generalised tenderness. The agreed action was that A low-FODMAP dietary trial was discussed. |
P10017 | V100054 | 2 | GP consultation | Documented in the history of presenting complaint was wrist soreness following a fall onto outstretched hand. Swelling was minimal and bruising was localised. Ottawa rules did not suggest a need for radiograph. No joint effusion was clinically detectable. Range of movement was preserved with discomfort at extremes. Ten... | wrist soreness following a fall onto outstretched hand | Low | Recurrent | This consultation marked the first formal review of presenting complaint was wrist soreness following a fall onto outstretched hand. Bedside review showed no imaging was indicated based on examination. |
P10017 | V100055 | 2 | GP consultation | Since the last consultation, the patient has improved and left shoulder strain after gardening is now better controlled. No inability to weight bear at the time of injury. Tenderness was localised over the affected area without bony point tenderness. No joint effusion was clinically detectable. No imaging was indicated... | left shoulder strain | Low | Short-term | Today's review showed clear progress; left shoulder strain was less troublesome than before. On examination, tenderness was localised over the affected area without bony point tenderness. Plan: naproxen 250 mg twice daily was prescribed for ten days. |
P10018 | V100056 | 2 | Walk-in centre | The patient was seen with a history of left shoulder strain after gardening. Ottawa rules did not suggest a need for radiograph. Range of movement was preserved with discomfort at extremes. No joint effusion was clinically detectable. A tubigrip and graded loading exercises were advised. | left shoulder strain | Low | Short-term | The patient was newly assessed for left shoulder strain at this attendance. |
P10018 | V100057 | 2 | Walk-in centre | On planned review, no material change was identified; calf strain during a long run continues. Ottawa rules did not suggest a need for radiograph. No joint effusion was clinically detectable. Neurovascular status was intact distally. A tubigrip and graded loading exercises were advised. A self-referral to community phy... | calf strain | Low | Short-term | Since the last review, this patient's condition was unchanged with calf strain continuing. At this attendance, A tubigrip and graded loading exercises were advised. |
P10019 | V100058 | 1 | Walk-in centre | On presentation, the focus was atopic eczema flare with secondary impetiginisation. Household contact had recent skin infection. Low-grade systemic upset but no fever. Regional lymphadenopathy was present in the right axilla. Honey-coloured crust over excoriated eczema patches was noted. Temperature was 38.1 degrees Ce... | atopic eczema flare; honey-coloured crust; impetiginisation | Moderate | Short-term | The patient came for assessment of secondary impetiginisation for the first time. Documented findings noted that honey-coloured crust over excoriated eczema patches was noted. At this attendance, flucloxacillin 500 mg four times daily was prescribed for seven days. |
P10020 | V100059 | 2 | GP consultation | The principal complaint at this attendance was lower respiratory tract infection with productive cough for ten days. No haemoptysis or pleuritic pain. Able to speak in full sentences. CRB-65 score was 1 placing the patient in low-risk group. No accessory muscle use. Focal coarse crackles at the right base were heard. C... | lower respiratory tract infection; productive cough | Moderate | Short-term | Lower respiratory tract infection was the reason for this initial attendance. Assessment today identified that chest X-ray was requested through the community pathway. |
P10020 | V100060 | 2 | Same-day urgent GP appointment | Today's review identified deterioration; lower respiratory tract infection with productive cough for ten days had become more prominent. Low-grade fever and reduced oral intake. Oxygen saturation was 94% on room air. Focal coarse crackles at the right base were heard. Chest X-ray was requested through the community pat... | lower respiratory tract infection; productive cough | Moderate | Short-term | Today's review revealed deterioration; productive cough had increased in severity. The chart documents that oxygen saturation was 94% on room air. The clinician arranged that chest X-ray was requested through the community pathway. |
P10021 | V100061 | 1 | Dermatology outpatient | Documented in the history of presenting complaint was atopic eczema flare with secondary impetiginisation. Household contact had recent skin infection. Increased itch and disturbed sleep. Temperature was 38.1 degrees Celsius. No signs of cellulitis spreading beyond the affected area. Potent topical steroid was added on... | atopic eczema flare; impetiginisation; atopic eczema | Moderate | Short-term | This patient presented for the first time with atopic eczema flare. Examination at this attendance found temperature was 38.1 degrees Celsius. |
P10022 | V100062 | 3 | MSK clinic | The lady was reviewed for L5 distribution radicular pain over four weeks. No bladder or bowel disturbance. Ankle reflex was preserved. Reduced sensation over the L5 dermatome was noted. Straight leg raise was positive at 40 degrees on the right. No saddle anaesthesia and intact perianal sensation. Lumbar spine MRI was ... | L5 distribution radicular pain; radicular pain | Moderate | Recurrent | Today's visit was the first documented review of l5 distribution radicular pain. Bedside review showed lumbar spine MRI was arranged through the MSK service. The agreed action was that the lady was reviewed for L5 distribution radicular pain over four weeks. |
P10022 | V100063 | 3 | GP consultation | On planned review, no material change was identified; L5 distribution radicular pain over four weeks continues. No bladder or bowel disturbance. Numbness over the lateral foot reported. No saddle anaesthesia and intact perianal sensation. Straight leg raise was positive at 40 degrees on the right. Ankle reflex was pres... | L5 distribution radicular pain; radicular pain; L5 distribution | Moderate | Recurrent | Today's encounter showed no meaningful change in l5 distribution since the prior visit. Documented findings noted that MRI lumbar spine was requested via the spinal pathway. |
P10022 | V100064 | 3 | GP consultation | The patient was reviewed under the long-term plan; sciatica with pain radiating below the knee remains the documented issue. Numbness over the lateral foot reported. Reduced sensation over the L5 dermatome was noted. Straight leg raise was positive at 40 degrees on the right. MRI lumbar spine was requested via the spin... | sciatica | Moderate | Recurrent | Since the last review, the patient's condition was unchanged with sciatica continuing. The chart documents that MRI lumbar spine was requested via the spinal pathway. |
P10023 | V100065 | 4 | GP consultation | Today's consultation centred on microcytic anaemia with low ferritin. Exercise tolerance was reduced over six weeks. No overt blood loss or melaena reported. Conjunctival pallor was noted. Per rectum examination was deferred today. Coeliac serology and faecal calprotectin were requested. Two-week-wait colonoscopy refer... | microcytic anaemia; low ferritin | Moderate | Recurrent | The patient came for assessment of low ferritin for the first time. Clinical signs included that conjunctival pallor was noted. |
P10023 | V100066 | 4 | Haematology outpatient | Scheduled review took place; microcytic anaemia with low ferritin continues unchanged. Menstrual history was reviewed and considered relevant. Abdomen was soft and non-tender. Per rectum examination was deferred today. Conjunctival pallor was noted. No koilonychia or angular cheilitis seen. Coeliac serology and faecal ... | microcytic anaemia | Moderate | Recurrent | Compared with the prior encounter the situation had not materially changed; microcytic anaemia persists. On examination, conjunctival pallor was noted. |
P10023 | V100067 | 4 | GP consultation | Since the last consultation, the patient has improved and microcytic anaemia with low ferritin is now better controlled. Exercise tolerance was reduced over six weeks. No per rectum bleeding. Per rectum examination was deferred today. Abdomen was soft and non-tender. No koilonychia or angular cheilitis seen. Dietary ir... | microcytic anaemia; low ferritin | Low | Recurrent | Recovery since the previous visit was clear, with low ferritin now better controlled. Assessment today identified that per rectum examination was deferred today. Today's plan involved dietary iron advice and vitamin C co-administration were discussed. |
P10023 | V100068 | 4 | GP consultation | A clear deterioration was reported compared with the previous visit; microcytic anaemia with low ferritin had worsened. Exercise tolerance was reduced over six weeks. Per rectum examination was deferred today. Conjunctival pallor was noted. No koilonychia or angular cheilitis seen. FBC, ferritin, B12, folate and TFTs w... | microcytic anaemia; low ferritin | Moderate | Recurrent | An adverse change in microcytic anaemia was the principal observation since the last visit. Bedside review showed conjunctival pallor was noted. As management, A referral for upper and lower GI investigation was made via two-week-wait. |
P10024 | V100069 | 1 | GP consultation | The history given was of productive cough with chest discomfort and breathlessness on exertion. No haemoptysis or pleuritic pain. Respiratory rate was 21 breaths per minute. No accessory muscle use. Focal coarse crackles at the right base were heard. Chest X-ray was requested through the community pathway. | productive cough; focal coarse crackles | Moderate | Short-term | An initial review was conducted today, focused on focal coarse crackles. Clinical signs included that respiratory rate was 21 breaths per minute. |
P10025 | V100070 | 1 | GP consultation | The patient came forward with calf strain during a long run. Swelling was minimal and bruising was localised. Tenderness was localised over the affected area without bony point tenderness. Neurovascular status was intact distally. No joint effusion was clinically detectable. Range of movement was preserved with discomf... | calf strain; tenderness | Low | Short-term | The patient sought assessment of calf strain, with no prior encounters recorded. The chart documents that tenderness was localised over the affected area without bony point tenderness. The agreed action was that A tubigrip and graded loading exercises were advised. |
P10026 | V100071 | 3 | GP consultation | The principal complaint at this attendance was L5 distribution radicular pain over four weeks. No red flag features for cauda equina present. Ankle reflex was preserved. Reduced sensation over the L5 dermatome was noted. Naproxen 500 mg twice daily with PPI cover was prescribed. A referral to community MSK physiotherap... | L5 distribution radicular pain | Moderate | Recurrent | An index assessment of l5 distribution radicular pain took place at this visit. The note records that reduced sensation over the L5 dermatome was noted. |
P10026 | V100072 | 3 | Resus room | An unscheduled acute attendance took place; back pain with new bowel and bladder dysfunction was the precipitating concern. Lower back pain for two weeks preceding new neurology. Saddle anaesthesia was confirmed on examination. Post-void bladder volume was 600 ml on bedside scan. Perianal tone was reduced on per rectum... | back pain | High | Recurrent | This patient presented urgently after a sudden change; back pain dominated the picture. Documented findings noted that perianal tone was reduced on per rectum examination. The agreed action was that an urgent MRI lumbosacral spine was arranged within the four-hour pathway. |
P10026 | V100073 | 3 | GP consultation | Following the recent acute event, the lady was reviewed; L5 distribution radicular pain over four weeks was no longer the dominant feature. No red flag features for cauda equina present. No bladder or bowel disturbance. Ankle reflex was preserved. Reduced sensation over the L5 dermatome was noted. Straight leg raise wa... | L5 distribution radicular pain; radicular pain | High | Recurrent | After the recent admission, this post-acute review showed continuing improvement of l5 distribution radicular pain. Bedside review showed reduced sensation over the L5 dermatome was noted. The agreed action was that MRI lumbar spine was requested via the spinal pathway. |
P10027 | V100074 | 2 | GP consultation | On arrival, this patient described post-prandial bloating with mucus per rectum. No per rectum bleeding or unintentional weight loss. Bowel sounds were normal on auscultation. No palpable masses and no organomegaly. Per rectum examination was deferred today. Abdomen was soft with mild generalised tenderness. A low-FODM... | post-prandial bloating; bloating | Low | Recurrent | An index assessment of mucus per rectum took place at this visit. Findings on this visit included that abdomen was soft with mild generalised tenderness. |
P10027 | V100075 | 2 | GP review appointment | He attended for routine follow-up; current status remained consistent with prior reviews and lower abdominal cramping relieved by defaecation was again documented. No nocturnal symptoms or family history of bowel cancer. Bowel sounds were normal on auscultation. Abdomen was soft with mild generalised tenderness. Per re... | lower abdominal cramping relieved by defaecation; mild generalised tenderness | Low | Recurrent | A stable picture of prior reviews and lower abdominal cramping relieved by defaecation was again documented was found at this routine attendance. Assessment today identified that bowel sounds were normal on auscultation. |
P10028 | V100076 | 3 | Rheumatology nurse-led clinic | On arrival, the patient described RA disease activity flare with morning stiffness over two hours. Function had declined with difficulty gripping. DAS28 score was 4.9 indicating moderate to high disease activity. Synovitis was palpable over the second and third MCPs bilaterally. Wrists were warm and tender to passive m... | RA disease activity flare with morning stiffness; synovitis | Moderate | Recurrent | Initial workup of synovitis began at this attendance. The chart documents that DAS28 score was 4.9 indicating moderate to high disease activity. Plan: intramuscular methylprednisolone 80 mg was administered today. |
P10028 | V100077 | 3 | Rheumatology outpatient | He described feeling better since the previous appointment; RA disease activity flare with morning stiffness over two hours was reduced today. No infective symptoms preceding the flare. Function had declined with difficulty gripping. Wrists were warm and tender to passive movement. DAS28 score was 6.2 indicating modera... | RA disease activity flare with morning stiffness; synovitis; high disease activity | Moderate | Recurrent | Recovery since the previous visit was clear, with morning stiffness over two hours was reduced today now better controlled. Examination at this attendance found DAS28 score was 6.2 indicating moderate to high disease activity. Plan: biologic escalation was discussed at MDT. |
P10028 | V100078 | 3 | Urgent rheumatology review | Routine review today; RA disease activity flare with morning stiffness over two hours remains the active issue. No infective symptoms preceding the flare. Synovitis was palpable over the second and third MCPs bilaterally. DAS28 score was 5.9 indicating moderate to high disease activity. Methotrexate dose was reviewed f... | RA disease activity flare with morning stiffness | Moderate | Recurrent | A stable picture of morning stiffness over two hours remains the active issue was found at this routine attendance. The chart documents that DAS28 score was 5.9 indicating moderate to high disease activity. |
P10029 | V100079 | 1 | Dermatology outpatient | The gentleman was reviewed for infected eczema with weeping and crusting on the forearms. Household contact had recent skin infection. Low-grade systemic upset but no fever. Temperature was 37.5 degrees Celsius. Regional lymphadenopathy was present in the right axilla. Potent topical steroid was added once infection se... | infected eczema | Moderate | Short-term | The first clinic record concerning weeping and crusting on the forearms was made today. Bedside review showed temperature was 37.5 degrees Celsius. Management included that potent topical steroid was added once infection settles. |
P10030 | V100080 | 6 | Acute medical unit | The chief complaint documented was life-threatening asthma exacerbation with silent chest. No recent steroid course. Salbutamol used over twenty puffs in the preceding hour. Oxygen saturation was 88% on room air. Peak flow was 131 L/min, below 33 percent predicted. Wheeze was reduced bilaterally on auscultation. Respir... | life-threatening asthma exacerbation; life-threatening asthma | High | Ongoing | The patient was newly assessed for life-threatening asthma exacerbation at this attendance. The note records that respiratory rate was 33 breaths per minute with accessory muscle use. The clinician arranged that chest X-ray was requested to exclude pneumothorax. |
P10030 | V100081 | 6 | Respiratory clinic | Adverse change since the last appointment was reported, with asthma review with peak flow diary below personal best foremost. Inhaler technique was reviewed and sub-optimal. No accessory muscle use at rest. Oxygen saturation was 96% on room air. Respiratory rate was 19 breaths per minute. FeNO measurement was arranged ... | asthma review | High | Chronic | The condition had moved in the wrong direction; asthma review with peak flow diary below personal best foremost was less well controlled today. Documented findings noted that oxygen saturation was 96% on room air. |
P10030 | V100082 | 6 | GP chronic disease review | This was a planned review visit; the picture was unchanged with asthma review with peak flow diary below personal best continuing. No recent hospital admissions for asthma. Oxygen saturation was 93% on room air. No accessory muscle use at rest. Respiratory rate was 20 breaths per minute. FeNO measurement was arranged a... | asthma review | High | Chronic | This patient was reviewed today with asthma review unchanged from the previous encounter. The note records that respiratory rate was 20 breaths per minute. Plan: montelukast 10 mg once nightly was added as add-on therapy. |
P10030 | V100083 | 6 | GP chronic disease review | Symptoms had progressed since the last review; today the patient described asthma with increasing salbutamol use over six weeks. Inhaler technique was reviewed and sub-optimal. No triggers identified beyond viral illness. Auscultation revealed scattered expiratory wheeze. Oxygen saturation was 93% on room air. Peak flo... | asthma with increasing salbutamol use; expiratory wheeze | High | Ongoing | There was a clear decline since the last review; asthma with increasing salbutamol use had worsened. Examination at this attendance found auscultation revealed scattered expiratory wheeze. The agreed step was that spirometry was requested through the community respiratory team. |
P10030 | V100084 | 6 | GP chronic disease review | Today's review identified deterioration; partially controlled asthma with night symptoms twice weekly had become more prominent. Inhaler technique was reviewed and sub-optimal. No triggers identified beyond viral illness. Respiratory rate was 22 breaths per minute. Oxygen saturation was 96% on room air. Spirometry was ... | partially controlled asthma | High | Ongoing | Worsening of night symptoms twice weekly had become more prominent between visits prompted reassessment of management. Findings on this visit included that oxygen saturation was 96% on room air. Management included that montelukast 10 mg once nightly was added as add-on therapy. |
P10030 | V100085 | 6 | Practice nurse asthma review | The patient was reviewed in recovery from the recent acute episode; asthma review with peak flow diary below personal best continues to settle. Inhaler technique was reviewed and sub-optimal. Auscultation revealed scattered expiratory wheeze. No accessory muscle use at rest. Peak flow was 338 L/min, around 70 percent o... | asthma review; expiratory wheeze | High | Ongoing | After the acute event, this review confirmed ongoing recovery of asthma review. On review, the clinician observed that auscultation revealed scattered expiratory wheeze. The clinician arranged that A referral to the respiratory specialist was made for further assessment. |
P10031 | V100086 | 2 | Walk-in centre | Today's encounter was prompted by productive cough with chest discomfort and breathlessness on exertion. Able to speak in full sentences. No haemoptysis or pleuritic pain. CRB-65 score was 1 placing the patient in low-risk group. Oxygen saturation was 93% on room air. Focal coarse crackles at the right base were heard.... | productive cough; focal coarse crackles | Moderate | Short-term | The patient was newly assessed for focal coarse crackles at this attendance. Documented findings noted that oxygen saturation was 93% on room air. At this attendance, doxycycline 100 mg twice daily was prescribed in penicillin allergy. |
P10031 | V100087 | 2 | GP consultation | On planned review, no material change was identified; productive cough with chest discomfort and breathlessness on exertion continues. No haemoptysis or pleuritic pain. Low-grade fever and reduced oral intake. Focal coarse crackles at the right base were heard. No accessory muscle use. Chest X-ray was requested through... | productive cough; focal coarse crackles | Moderate | Short-term | This patient was reviewed today with focal coarse crackles unchanged from the previous encounter. On examination, chest X-ray was requested through the community pathway. The agreed step was that chest X-ray was requested through the community pathway. |
P10032 | V100088 | 1 | Minor injuries unit | The principal complaint at this attendance was left shoulder strain after gardening. Ottawa rules did not suggest a need for radiograph. No inability to weight bear at the time of injury. Tenderness was localised over the affected area without bony point tenderness. No joint effusion was clinically detectable. No imagi... | left shoulder strain; shoulder strain | Low | Short-term | First contact for left shoulder strain was documented at this visit. On examination, tenderness was localised over the affected area without bony point tenderness. The clinician arranged that naproxen 250 mg twice daily was prescribed for ten days. |
P10033 | V100089 | 4 | Gastroenterology outpatient | A history was taken of fatigue and pallor with haemoglobin of 97 g/L. No overt blood loss or melaena reported. Exercise tolerance was reduced over six weeks. Abdomen was soft and non-tender. Per rectum examination was deferred today. No koilonychia or angular cheilitis seen. Conjunctival pallor was noted. Coeliac serol... | fatigue and pallor; melaena | Moderate | Recurrent | Today's visit was the first documented review of melaena. Examination at this attendance found conjunctival pallor was noted. |
P10033 | V100090 | 4 | GP consultation | Acute decompensation brought she to immediate attention with fatigue and pallor with haemoglobin of 89 g/L. Exercise tolerance was reduced over six weeks. No per rectum bleeding. Conjunctival pallor was noted. Abdomen was soft and non-tender. Per rectum examination was deferred today. No koilonychia or angular cheiliti... | fatigue and pallor; conjunctival pallor | High | Recurrent | An acute deterioration prompted this urgent attendance, with conjunctival pallor the principal concern. On examination, per rectum examination was deferred today. Today's plan involved ferrous fumarate 210 mg twice daily was prescribed. |
P10033 | V100091 | 4 | GP consultation | The patient attended for routine follow-up; current status remained consistent with prior reviews and fatigue and pallor with haemoglobin of 88 g/L was again documented. Exercise tolerance was reduced over six weeks. No koilonychia or angular cheilitis seen. Conjunctival pallor was noted. Per rectum examination was def... | fatigue and pallor; conjunctival pallor | Moderate | Recurrent | On scheduled review fatigue and pallor remained at a comparable level to the last appointment. Examination at this attendance found conjunctival pallor was noted. Treatment at this visit comprised dietary iron advice and vitamin C co-administration were discussed. |
P10033 | V100092 | 4 | Gastroenterology outpatient | Follow-up encounter; iron deficiency anaemia on routine bloods persists at a similar level. No per rectum bleeding. Menstrual history was reviewed and considered relevant. Conjunctival pallor was noted. Per rectum examination was deferred today. Abdomen was soft and non-tender. Coeliac serology and faecal calprotectin ... | iron deficiency anaemia on routine bloods; iron deficiency anaemia; conjunctival pallor | Moderate | Recurrent | Conjunctival pallor had not progressed since last review, and the management plan was unchanged. Examination at this attendance found per rectum examination was deferred today. Treatment at this visit comprised dietary iron advice and vitamin C co-administration were discussed. |
P10034 | V100093 | 1 | Minor injuries unit | Today's consultation centred on right ankle inversion injury during recreational sport. No inability to weight bear at the time of injury. Tenderness was localised over the affected area without bony point tenderness. Range of movement was preserved with discomfort at extremes. No joint effusion was clinically detectab... | right ankle inversion injury | Low | Short-term | The patient was newly assessed for right ankle inversion injury at this attendance. Assessment today identified that no imaging was indicated based on examination. Plan: A tubigrip and graded loading exercises were advised. |
P10035 | V100094 | 1 | Walk-in centre | The patient was seen with a history of low-grade fever, sore throat and rhinorrhoea. No shortness of breath or chest pain reported. Throat was mildly erythematous without exudate. Tympanic membranes were intact and pearly bilaterally. Temperature was 37.5 degrees Celsius. Respiratory rate was 16 breaths per minute. Saf... | low-grade fever, sore throat and rhinorrhoea | Low | Short-term | The first clinic record concerning low-grade fever, sore throat and rhinorrhoea was made today. The chart documents that respiratory rate was 16 breaths per minute. |
P10036 | V100095 | 3 | Gastroenterology outpatient | Reason for attendance was microcytic anaemia with low ferritin. No per rectum bleeding. No overt blood loss or melaena reported. Abdomen was soft and non-tender. Per rectum examination was deferred today. Conjunctival pallor was noted. Coeliac serology and faecal calprotectin were requested. Two-week-wait colonoscopy r... | microcytic anaemia; low ferritin | Moderate | Recurrent | The patient came for assessment of low ferritin for the first time. On examination, conjunctival pallor was noted. |
P10036 | V100096 | 3 | Gastroenterology outpatient | Today's appointment was for ongoing surveillance, with microcytic anaemia with low ferritin unchanged from prior review. Menstrual history was reviewed and considered relevant. Abdomen was soft and non-tender. Per rectum examination was deferred today. Conjunctival pallor was noted. A referral for upper and lower GI in... | microcytic anaemia; low ferritin; conjunctival pallor | Moderate | Recurrent | There was no progression of microcytic anaemia with low ferritin unchanged from prior review between the previous and current consultations. The chart documents that per rectum examination was deferred today. |
P10036 | V100097 | 3 | Haematology outpatient | Today's appointment was for ongoing surveillance, with fatigue and pallor with haemoglobin of 87 g/L unchanged from prior review. No overt blood loss or melaena reported. No koilonychia or angular cheilitis seen. Conjunctival pallor was noted. Abdomen was soft and non-tender. Per rectum examination was deferred today. ... | fatigue and pallor | Moderate | Recurrent | The condition remained controlled; fatigue and pallor was again the focus of review. Assessment today identified that per rectum examination was deferred today. At this attendance, A referral for upper and lower GI investigation was made via two-week-wait. |
P10037 | V100098 | 2 | Walk-in centre | The gentleman was reviewed for infected eczema with weeping and crusting on the forearms. Increased itch and disturbed sleep. No signs of cellulitis spreading beyond the affected area. Honey-coloured crust over excoriated eczema patches was noted. Regional lymphadenopathy was present in the right axilla. Temperature wa... | infected eczema; honey-coloured crust | Moderate | Short-term | Weeping and crusting on the forearms was the reason for this initial attendance. The chart documents that temperature was 37.7 degrees Celsius. |
P10037 | V100099 | 2 | Walk-in centre | On planned review, no material change was identified; infected eczema with weeping and crusting on the forearms continues. Low-grade systemic upset but no fever. Regional lymphadenopathy was present in the right axilla. Honey-coloured crust over excoriated eczema patches was noted. No signs of cellulitis spreading beyo... | infected eczema; honey-coloured crust | Moderate | Short-term | This was a routine review and the picture remained similar to the previous visit, with honey-coloured crust again noted. The chart documents that honey-coloured crust over excoriated eczema patches was noted. |
P10038 | V100100 | 7 | GP chronic disease review | Reason for attendance was suboptimal glycaemic control with reported polyuria. Adherence to metformin was good but exercise had reduced. No diabetic foot symptoms or visual changes reported. BMI was recorded at 34.8. Foot examination showed intact pulses and protective sensation. Blood pressure was 168/95 mmHg. HbA1c, ... | suboptimal glycaemic control; polyuria | Moderate | Ongoing | Reported polyuria was the reason for this initial attendance. On review, the clinician observed that foot examination showed intact pulses and protective sensation. The clinician arranged that metformin was continued at 1 gram twice daily. |
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