Denies allergy.
No pregnancy or breast feeding
No pregnancy or breast feeding
Unable to contact in person
Mobile: Unable to leave message / Message left
Landline: Nill / Unable to leave message / Message left
Call back as required GP surgery / ooh 111 /
Walk in centre
Acute deterioration 999/ A+E
Mobile: Unable to leave message / Message left
Landline: Nill / Unable to leave message / Message left
Call back as required GP surgery / ooh 111 /
Walk in centre
Acute deterioration 999/ A+E
PROGRESSION / OTHER
No new or worsening symptoms or signs
No other acute concern's symptoms or signs
No new or worsening symptoms or signs
No other acute concern's symptoms or signs
BLOOD PRESSURE ( needs machine)
BP check, monitoring required.
1. Advised to get own machine/ Has own machine
2. Check twice, twice daily. Send in 7 days readings.
3. Check during any headaches
4. Urgent attention if above 180/90
or any new or worsening headaches.
Here / ooh 111/ a+e
5. Otherwise check by chemist
or Reception Appointment
Practice HCA or Nurse
BP check, monitoring required.
1. Advised to get own machine/ Has own machine
2. Check twice, twice daily. Send in 7 days readings.
3. Check during any headaches
4. Urgent attention if above 180/90
or any new or worsening headaches.
Here / ooh 111/ a+e
5. Otherwise check by chemist
or Reception Appointment
Practice HCA or Nurse
NEUROLOGY
No new or progressive neurological symptoms face arms legs,
No disturbance to cognition, vision, speech.
No new or progressive neurological symptoms face,
No disturbance to cognition, vision, speech
No new or progressive neurological symptoms lower limbs or perineum,
No urinary or perianal neurological symptoms
No new functional loss
No new or progressive neurological symptoms face arms legs,
No disturbance to cognition, vision, speech.
No new or progressive neurological symptoms face,
No disturbance to cognition, vision, speech
No new or progressive neurological symptoms lower limbs or perineum,
No urinary or perianal neurological symptoms
No new functional loss
Meningitis check
Fever: Nill
Headache: Nill
Photophobia: Nill
Ok with light
Nausea/Vomiting:Nill
No neck stiffness or pains
No none blanching rashes
Sore throat: Nill / Some
Ears: nill
Fever: Nill
Headache: Nill
Photophobia: Nill
Ok with light
Nausea/Vomiting:Nill
No neck stiffness or pains
No none blanching rashes
Sore throat: Nill / Some
Ears: nill
Phone Exam
Sounds stable no distress.
Sounds stable no distress.
FACE 2 FACE
GM Notes: seen
TPP: Nill / seen
Seen with
GM Notes: seen
TPP: Nill / seen
Seen with
PHONE ADVICE: URGENT A+E
Advised urgent A+E
Ambulance as required
Otherwise taxi or transport by other
States will arrange as quickly as possible
Advised urgent A+E
Ambulance as required
Otherwise taxi or transport by other
States will arrange as quickly as possible
Neuro exam / Ankles
PERLA / EOM full rom
Opthalmoscopy: nad
CNS PNS intact symmetrical
Ataxia: nill
Nystagmus: nill
Tone power reflexes sensation: symmetrical
Full rom at ankles
Posture / mobility: nad
PERLA / EOM full rom
Opthalmoscopy: nad
CNS PNS intact symmetrical
Ataxia: nill
Nystagmus: nill
Tone power reflexes sensation: symmetrical
Full rom at ankles
Posture / mobility: nad
Phone Exam
Alert and orientated time place person
Agitation: nill
Alert and orientated time place person
Agitation: nill
OBSTETRIC
Medical conditions/medications affecting pregnancy: Nill
Gravida:
Para:
P1 / yrs ago / nvd / c section / micarriage
Medical conditions/medications affecting pregnancy: Nill
Gravida:
Para:
P1 / yrs ago / nvd / c section / micarriage
Phone consult:
GM Notes Checked:
Consult with
GM Notes Checked:
Consult with
RESPIRATORY Adult m/y/g
Cough cold
last few days / weeks or so
Occasional murky y/g sputum
Fevers: Nill / ?on/off
No haemoptysis,
No chest pains
No pains on deep inspiration.
Wheeze: nill
Breathlessness: nill
Hx asthma/copd: nill
Inhalers: nill
e+d: ok
n+v: nill
Cough cold
last few days / weeks or so
Occasional murky y/g sputum
Fevers: Nill / ?on/off
No haemoptysis,
No chest pains
No pains on deep inspiration.
Wheeze: nill
Breathlessness: nill
Hx asthma/copd: nill
Inhalers: nill
e+d: ok
n+v: nill
CARDIAC
Cardiac type / Exertional chest pain: nill
Palpitations: nill
Orthopnea: nill PND: nill
Cardiac type / Exertional chest pain: nill
Palpitations: nill
Orthopnea: nill PND: nill
Feverish/ generally unwell
Travel: nill
Ill contacts: nill
Fever: Nill
Headache/ irritability: Nill
Photophobia: Nill Ok with light
Nausea/Vomiting:Nill
No neck stiffness or pains
No none blanching rashes / Strep rash
Sore throat: Nill / Some
Ears: Nill obvious
Cough: nill
Phlegm: nill
wheeze: nill
Breathlessness: nill
Eating and drinking:
Normal/ less than usual amounts
Bowel Motion: Normal
Diarrhoea: Nill
Urine output: Normal usual amounts
No dysuria
Travel: nill
Ill contacts: nill
Fever: Nill
Headache/ irritability: Nill
Photophobia: Nill Ok with light
Nausea/Vomiting:Nill
No neck stiffness or pains
No none blanching rashes / Strep rash
Sore throat: Nill / Some
Ears: Nill obvious
Cough: nill
Phlegm: nill
wheeze: nill
Breathlessness: nill
Eating and drinking:
Normal/ less than usual amounts
Bowel Motion: Normal
Diarrhoea: Nill
Urine output: Normal usual amounts
No dysuria
Review post weeks: 2/3/4/
if symptoms not settled
if symptoms not settled
EXAM ADULT QUICK
Appears stable
Alert
Apyrexial
t:
p:
rr:
sats: %
Chest clear
wheeze /crackles: nill
Throat: clear / slight pharyngitis
Appears stable
Alert
Apyrexial
t:
p:
rr:
sats: %
Chest clear
wheeze /crackles: nill
Throat: clear / slight pharyngitis
@//GABAPENT@
Morning/ Afternoon/ Evening
Stop at the level
where symptoms are controlled
or if any side effects noted
1,1,1 Three to Four days
2,1,1 Three to Four days
2,1,2
2,2,2
3,2,2
3,2,3
3,3,3
Morning/ Afternoon/ Evening
Stop at the level
where symptoms are controlled
or if any side effects noted
1,1,1 Three to Four days
2,1,1 Three to Four days
2,1,2
2,2,2
3,2,2
3,2,3
3,3,3
@//pill@
BMI: Good (< 35)
BP: Good (<145 systolic)
Smoker: Nill
No hx/fhx: Migraines with auras
No hx/fhx: CHD / CVD events
No hx/fhx: Thromboembolic events dvt/pe
No hx/fhx: Breast cancers/ gynaecological cancers
No hx/fhx: Cervical cancers/ abnormal smears
No hx/fhx: Liver or renal impairement
No enzyme inducing medication
BMI: Good (< 35)
BP: Good (<145 systolic)
Smoker: Nill
No hx/fhx: Migraines with auras
No hx/fhx: CHD / CVD events
No hx/fhx: Thromboembolic events dvt/pe
No hx/fhx: Breast cancers/ gynaecological cancers
No hx/fhx: Cervical cancers/ abnormal smears
No hx/fhx: Liver or renal impairement
No enzyme inducing medication
@//pill1@
Current pill:
Happy on it
wants to continue
Current pill:
Happy on it
wants to continue
@//pill2@
Current pill:
Side efefcts noted
Try change to:
Current pill:
Side efefcts noted
Try change to:
@//pill3@
Combined pill contraindicated:
Discussed progesterone only methods
minipill
depot injection
implant
coils
Combined pill contraindicated:
Discussed progesterone only methods
minipill
depot injection
implant
coils
EXAM OBS
Apyrexial
t:
p:
hs: normal
bp:
rr:
sats: %
Chest clear
Throat: clear
Apyrexial
t:
p:
hs: normal
bp:
rr:
sats: %
Chest clear
Throat: clear
Face 2 Face Safety net
Urgent attention if any acute deterioration
TCB / Review with own GP if not settled
Urgent attention if any acute deterioration
TCB / Review with own GP if not settled
Allergies: ? Nkda
Medication: ? Nill
PMSH: ? Nill
TODAY:
Medication: ? Nill
PMSH: ? Nill
TODAY:
FACE 2 FACE
GM Notes: seen
TPP: Nill / seen
GM Notes: seen
TPP: Nill / seen
Phone consult:
GM Notes Checked:
GM Notes Checked:
Phone Exam
Sounds stable no distress.
Alert and orientated time place person
Managing sentences No audible wheeze
Sounds stable no distress.
Alert and orientated time place person
Managing sentences No audible wheeze
RESPIRATORY Adult
asthma / copd
Cough cold
last few days / weeks or so
Occasional murky sputum
Fevers: Nill / ?on/off
No haemoptysis,
No chest pains
No pains on deep inspiration.
Wheeze: nill
Breathlessness: nill
Hx asthma/copd:yes
Inhalers: yes
e+d: ok
n+v: nill
Exposure factors:
Dust/mold/pets: nill
smoke: nill
asthma / copd
Cough cold
last few days / weeks or so
Occasional murky sputum
Fevers: Nill / ?on/off
No haemoptysis,
No chest pains
No pains on deep inspiration.
Wheeze: nill
Breathlessness: nill
Hx asthma/copd:yes
Inhalers: yes
e+d: ok
n+v: nill
Exposure factors:
Dust/mold/pets: nill
smoke: nill
PHARMACISTS
Discussed available chemists at this time
Prefers to collect at usual chemist when open
Discussed available chemists at this time
Prefers to collect at usual chemist when open
Phone Exam
Sounds stable no distress.
Managing sentences No audible wheeze
Sounds stable no distress.
Managing sentences No audible wheeze
F2F Appointment needed (routine / urgent )
Patient will ring Extended access hub
/ own gp surgery / or ooh 111
Patient will ring Extended access hub
/ own gp surgery / or ooh 111
EXAM ADULT FULL
Appears stable
Alert
No meningism
Brudzinski negative
Managing sentences
No use of accessory muscles
Apyrexial
t:
p:
hs: normal
rr:
sats: %
wheeze: nill
crackles: nill
Abdo: verbal consent
snt
Ears: nad
Throat: nad
Lymphadenopathy: nill
Appears stable
Alert
No meningism
Brudzinski negative
Managing sentences
No use of accessory muscles
Apyrexial
t:
p:
hs: normal
rr:
sats: %
wheeze: nill
crackles: nill
Abdo: verbal consent
snt
Ears: nad
Throat: nad
Lymphadenopathy: nill
Safety net advice:
Meningitis / scarlet fever
Discussed signs of dehydration
Meningitis / scarlet fever
Discussed signs of dehydration
? DNA: ? DNA > Reschedule / OOH 111/ A+E
EXAM ADULT QUICK:RESP
Appears stable
Alert
Managing sentences
No use of accessory muscles
Apyrexial
t:
p:
rr:
sats: %
Chest clear
wheeze /crackles: nill
Throat: clear / slight pharyngitis
Appears stable
Alert
Managing sentences
No use of accessory muscles
Apyrexial
t:
p:
rr:
sats: %
Chest clear
wheeze /crackles: nill
Throat: clear / slight pharyngitis
EXAM ADULT QUICK: Meningitis
Appears stable
Alert
No meningism / Brudzinski negative
Apyrexial
t:
p:
rr:
sats: %
Chest clear
wheeze /crackles: nill
Throat: clear / slight pharyngitis
Appears stable
Alert
No meningism / Brudzinski negative
Apyrexial
t:
p:
rr:
sats: %
Chest clear
wheeze /crackles: nill
Throat: clear / slight pharyngitis
F2F ADVICE: URGENT A+E
Advised urgent A+E
Letter given
Has Transport/ Taxi
States will attend as quickly as possible
Advised urgent A+E
Letter given
Has Transport/ Taxi
States will attend as quickly as possible
Face 2 Face Safety net
Urgent attention if any acute deterioration
(ooh 111 / a+e )
TCB / Review with own GP if not settled
Urgent attention if any acute deterioration
(ooh 111 / a+e )
TCB / Review with own GP if not settled
EAR EXAM :
Appears stable Alert
No meningism /
Brudzinski: Negative
Deafness: Nill
Tinnitus: Nill
Vertigo: Nill
Apyrexial
t:
Ear: Right/ Left
Pinna changes: nill
Mastoid tenderness: nill
Trigone tenderness: nill
EAC: Clear / waxy / inflammed
Discharge: nill
TM:
Normal
Dulled
red inflamed
Retraction: nill
Perforations: nill
Other Ear Right/ Left - nad
Throat: Clear
Appears stable Alert
No meningism /
Brudzinski: Negative
Deafness: Nill
Tinnitus: Nill
Vertigo: Nill
Apyrexial
t:
Ear: Right/ Left
Pinna changes: nill
Mastoid tenderness: nill
Trigone tenderness: nill
EAC: Clear / waxy / inflammed
Discharge: nill
TM:
Normal
Dulled
red inflamed
Retraction: nill
Perforations: nill
Other Ear Right/ Left - nad
Throat: Clear
Neuro exam / Plantars
PERLA / EOM full rom
Opthalmoscopy: nad
CNS PNS intact symmetrical
Ataxia: nill
Nystagmus: nill
Tone power reflexes sensation: symmetrical
Plantars: Downgoing symetrical
Ankles: FROM
PERLA / EOM full rom
Opthalmoscopy: nad
CNS PNS intact symmetrical
Ataxia: nill
Nystagmus: nill
Tone power reflexes sensation: symmetrical
Plantars: Downgoing symetrical
Ankles: FROM
Eye hx
Glasses: nill / yes
Contact lenses: nill
Eye conditions: Nill
Glaucoma: nill
Eye meds: nill
Fevers nill
Headache: nill
n+v: nill
Photophobia: nill
Neck stiffnerss pains: nill
Visual disturbance: nill
Eye Trauma
Eye fb: nill
Eye UV exposure: nill
Eye exam
Eye Right/ Left
Periorbital changes: nill
lid/lashes: nad
Conjunctiva: nad
Scleral inflammation: nill
PERLA
EOM Full rom
Photophobia: nill
Opthalmoscopy : nad
va: without glasses
r: 6/6 l: 6/6
Fluroscein: not available
Other Eye - nad
Glasses: nill / yes
Contact lenses: nill
Eye conditions: Nill
Glaucoma: nill
Eye meds: nill
Fevers nill
Headache: nill
n+v: nill
Photophobia: nill
Neck stiffnerss pains: nill
Visual disturbance: nill
Eye Trauma
Eye fb: nill
Eye UV exposure: nill
Eye exam
Eye Right/ Left
Periorbital changes: nill
lid/lashes: nad
Conjunctiva: nad
Scleral inflammation: nill
PERLA
EOM Full rom
Photophobia: nill
Opthalmoscopy : nad
va: without glasses
r: 6/6 l: 6/6
Fluroscein: not available
Other Eye - nad
EXAM FEMALE abdomen
Appears stable
Alert
No Jaccyol
Apyrexial
t:
p:
hs: normal
bp:
rr:
sats: %
wheeze: nill
crackles: nill
Verbal consent
Chaperone declined
Abdo: snt
No rebound peritonism
Throat: nad
Lymphadenopathy: nill
Urine dip
Pregnancy test:
Appears stable
Alert
No Jaccyol
Apyrexial
t:
p:
hs: normal
bp:
rr:
sats: %
wheeze: nill
crackles: nill
Verbal consent
Chaperone declined
Abdo: snt
No rebound peritonism
Throat: nad
Lymphadenopathy: nill
Urine dip
Pregnancy test:
EXAM MALE abdomen
Appears stable
Alert
No Jaccyol
Apyrexial
t:
p:
hs: normal
bp:
rr:
sats: %
wheeze: nill
crackles: nill
Verbal consent
Chaperone declined
Abdo: snt
No rebound peritonism
No LkkS
Ho intact bilat
Scrotum/testes: States nad
Throat: nad
Lymphadenopathy: nill
Urine dip
Appears stable
Alert
No Jaccyol
Apyrexial
t:
p:
hs: normal
bp:
rr:
sats: %
wheeze: nill
crackles: nill
Verbal consent
Chaperone declined
Abdo: snt
No rebound peritonism
No LkkS
Ho intact bilat
Scrotum/testes: States nad
Throat: nad
Lymphadenopathy: nill
Urine dip
.png)
EAR EXAM :
Appears stable Alert
No meningism /
Brudzinski: Negative
Deafness: Nill
Tinnitus: Nill
Vertigo: Nill
Apyrexial
t:
Ear: Right/ Left
Pinna changes: nill
Mastoid tenderness: nill
Trigone tenderness: Slight
EAC: Slightly inflammed
Discharge: nill
TM:
Dulled
red inflamed / slightly
Retraction: nill
Perforations: nill
Other Ear Right/ Left - nad
Throat: Clear
Appears stable Alert
No meningism /
Brudzinski: Negative
Deafness: Nill
Tinnitus: Nill
Vertigo: Nill
Apyrexial
t:
Ear: Right/ Left
Pinna changes: nill
Mastoid tenderness: nill
Trigone tenderness: Slight
EAC: Slightly inflammed
Discharge: nill
TM:
Dulled
red inflamed / slightly
Retraction: nill
Perforations: nill
Other Ear Right/ Left - nad
Throat: Clear
CHEST PAIN
Chest pain episodes
Over timespan:
Frequency:
Duration of each episode:
Chest pain
Nature:
Location:
Radiation:
Relieving:
Worsening:
Exertional effect:
Posture effect:
Food effect:
Fevers: Nil / ?on/off
Chesty cough: Nil
Haemoptysis: Nil
Pain on deep inspiration: Nil
Leg/ calve pains:Nil
Wheeze: nill
Breathlessness: nill
Hx asthma/copd: nill
Inhalers: nill
Palpitations:
Cardiac sounding pains:
Radiation to neck / arms:
Orthopnoea/ pnd:
Indigestion/ heartburn: nill
e+d: ok
n+v: nill
Hx heavy lifting / trauma / impact
Analgesia used:
Previous history chd cvd:
Breast / axillary symptoms or signs
Chest pain episodes
Over timespan:
Frequency:
Duration of each episode:
Chest pain
Nature:
Location:
Radiation:
Relieving:
Worsening:
Exertional effect:
Posture effect:
Food effect:
Fevers: Nil / ?on/off
Chesty cough: Nil
Haemoptysis: Nil
Pain on deep inspiration: Nil
Leg/ calve pains:Nil
Wheeze: nill
Breathlessness: nill
Hx asthma/copd: nill
Inhalers: nill
Palpitations:
Cardiac sounding pains:
Radiation to neck / arms:
Orthopnoea/ pnd:
Indigestion/ heartburn: nill
e+d: ok
n+v: nill
Hx heavy lifting / trauma / impact
Analgesia used:
Previous history chd cvd:
Breast / axillary symptoms or signs
Safety net advice:
Meningitis / scarlet fever
Discussed signs of respiratory distress
Meningitis / scarlet fever
Discussed signs of respiratory distress
Gestation: Term
nvd/ c sectio
Postnatal issues: nill
Feeding: Breast / Bottle
Formula
immunisatiions: utd
Allergies: ? Nkda
Medication: ? Nill
PMSH: ? Nill
TODAY:
nvd/ c sectio
Postnatal issues: nill
Feeding: Breast / Bottle
Formula
immunisatiions: utd
Allergies: ? Nkda
Medication: ? Nill
PMSH: ? Nill
TODAY:
IN THE DARK
See previous consults
No access to test results / opd letters
See previous consults
No access to test results / opd letters
EXAM OBS
Apyrexial
t:
p:
rr:
Chest clear
Throat: clear
Apyrexial
t:
p:
rr:
Chest clear
Throat: clear
Face 2 Face Safety net
TCB as required
Urgent attention if any acute deterioration
Review with own GP if not settled
TCB as required
Urgent attention if any acute deterioration
Review with own GP if not settled
Face 2 Face Safety net
TCB as required
Urgent attention if any acute deterioration
(ooh 111 / a+e )
Review with own GP if not settled
TCB as required
Urgent attention if any acute deterioration
(ooh 111 / a+e )
Review with own GP if not settled
COUGHS AND COLDS
Headache M
Hx headaches:
Hx Duration:
Onset: gradual / sudden
Location:
Lasts:
Other symptoms/ auras:
Triggers discussed: Advised to avoid
Lifestyle: Hunger/ sleepless / stress: nill obvious
Stimuli/ uv lights screens lights etc: nill obvious
Foods: Cheese/ Chocolates/ caffeine nill obvious
Glasses: nill / optician check advised
Examination
Apyrexial
Alert
No meningism
Brudzinski negative
t:
p:
bp:
rr:
Perla/ eom full rom
Opthalmoscopy nad
Cns pns intact symmet no ataxia
Management;
Headache diary
Avoid triggers
Treatments: paracetamol/ibuprofen/Triptan
Prevention: nill for now /
Review in 2-4 weeks
Urgent attention if any acute deterioration
Safety net advise meningitis
New or progressive neurological symptoms or signs
Hx headaches:
Hx Duration:
Onset: gradual / sudden
Location:
Lasts:
Other symptoms/ auras:
Triggers discussed: Advised to avoid
Lifestyle: Hunger/ sleepless / stress: nill obvious
Stimuli/ uv lights screens lights etc: nill obvious
Foods: Cheese/ Chocolates/ caffeine nill obvious
Glasses: nill / optician check advised
Examination
Apyrexial
Alert
No meningism
Brudzinski negative
t:
p:
bp:
rr:
Perla/ eom full rom
Opthalmoscopy nad
Cns pns intact symmet no ataxia
Management;
Headache diary
Avoid triggers
Treatments: paracetamol/ibuprofen/Triptan
Prevention: nill for now /
Review in 2-4 weeks
Urgent attention if any acute deterioration
Safety net advise meningitis
New or progressive neurological symptoms or signs
You may find useful
FOR YOUNGER PEOPLE
https://www.childline.org.uk/
Call 0800 1111
Papayrus for younger people
0800 068 41 41
FOR YOUNGER PEOPLE
https://www.childline.org.uk/
Call 0800 1111
Papayrus for younger people
0800 068 41 41
Drug and Alcohol support contacts
Withyou
https://www.wearewithyou.org.uk
/local-hubs/wigan-and-leigh/services
Withyou
https://www.wearewithyou.org.uk
/local-hubs/wigan-and-leigh/services
Dyspep Risks Factors / Red flags
Discussed upper gi risk factors,
States negative to
nsaids, spirits, spices stress.
Advised to avoid.
Discussed upper gi red flag symptoms, signs,
No new or worsening epigastric pains,
No Haematemesis, PR bleed or melaena,
No Dysphagia, No weight loss
Urgent attention If any features
Discussed upper gi risk factors,
States negative to
nsaids, spirits, spices stress.
Advised to avoid.
Discussed upper gi red flag symptoms, signs,
No new or worsening epigastric pains,
No Haematemesis, PR bleed or melaena,
No Dysphagia, No weight loss
Urgent attention If any features
Hx MALE abdomen
Abdo pain:
Location
Radiation:
Relieving:
Worsening:
Analgesia used
Fever: nill
Nausea Vomiting: Nill
Urinary: No dysuria or freq
Bowel: No diarrhoea or constipation /
No pr bleed or melaena
Operations: Nill
HX fHX Bowel conditions; Nill
Weight loss: Nill
Prostate hx:
:
Abdo pain:
Location
Radiation:
Relieving:
Worsening:
Analgesia used
Fever: nill
Nausea Vomiting: Nill
Urinary: No dysuria or freq
Bowel: No diarrhoea or constipation /
No pr bleed or melaena
Operations: Nill
HX fHX Bowel conditions; Nill
Weight loss: Nill
Prostate hx:
:
Hx FEMALE abdomen
Abdo pain:
Location
Radiation:
Relieving:
Worsening:
Analgesia used
Fever: nill
Nausea Vomiting: Nill
Urinary: No dysuria or freq
Bowel: No diarrhoea or constipation /
No pr bleed or melaena
Vaginal: Nill No discharge bleed / Lmp
Operations: Nill
HX fHX Bowel conditions; Nill
Weight loss: Nill
Contraceptive coils/mirena?
Abdo pain:
Location
Radiation:
Relieving:
Worsening:
Analgesia used
Fever: nill
Nausea Vomiting: Nill
Urinary: No dysuria or freq
Bowel: No diarrhoea or constipation /
No pr bleed or melaena
Vaginal: Nill No discharge bleed / Lmp
Operations: Nill
HX fHX Bowel conditions; Nill
Weight loss: Nill
Contraceptive coils/mirena?
Investigations, Previous / Recent.
Specialist assessments
Dietary factors
Specialist assessments
Dietary factors
MART exac Asthma / copd
Antibiotic: Amoxicillin
Clarithromycin / Doxycycline
Deny allergy
Oral prednisolone:
Deny gastritis:
PPI Cover:
Fostair mart regime
treatment dose
maintenance dose
once settled
Avoid exposure factors
Urgent attention if any deterioration 111/ a+e
Review with own gp
in week or so
Antibiotic: Amoxicillin
Clarithromycin / Doxycycline
Deny allergy
Oral prednisolone:
Deny gastritis:
PPI Cover:
Fostair mart regime
treatment dose
maintenance dose
once settled
Avoid exposure factors
Urgent attention if any deterioration 111/ a+e
Review with own gp
in week or so
STREP THROAT Male
Clarithro / Doxy
Clarithromycin
Doxycycline
deny allergy
OTC antipyreticsParacetamol etc
Difflam / deny asthma
Dioralyte if required
TCB as required
Urgent attention
if any acute deterioration
(ooh 111 / a+e )
Review with own GP if not settled
Safety net advise
Meningitis / Scarlet fever
Dehydration
Clarithro / Doxy
Clarithromycin
Doxycycline
deny allergy
OTC antipyreticsParacetamol etc
Difflam / deny asthma
Dioralyte if required
TCB as required
Urgent attention
if any acute deterioration
(ooh 111 / a+e )
Review with own GP if not settled
Safety net advise
Meningitis / Scarlet fever
Dehydration
STREP THROAT pen v
Penicillin v deny allergy
OTC antipyreticsParacetamol etc
Difflam / deny asthma
Dioralyte if required
TCB as required
Urgent attention
if any acute deterioration
(ooh 111 / a+e )
Review with own GP if not settled
Safety net advise
Meningitis / Scarlet fever
Dehydration
Penicillin v deny allergy
OTC antipyreticsParacetamol etc
Difflam / deny asthma
Dioralyte if required
TCB as required
Urgent attention
if any acute deterioration
(ooh 111 / a+e )
Review with own GP if not settled
Safety net advise
Meningitis / Scarlet fever
Dehydration
SABA ? viral and wheeze
Antibiotic: Amoxicillin
Clarithromycin / Doxycycline
Deny allergy:
Oral prednisolone:
Deny gastritis:
PPI Cover:
Salbutamol
Avoid exposure factors
Urgent attention if any deterioration 111/ a+e
Review with own gp
in week or so
Antibiotic: Amoxicillin
Clarithromycin / Doxycycline
Deny allergy:
Oral prednisolone:
Deny gastritis:
PPI Cover:
Salbutamol
Avoid exposure factors
Urgent attention if any deterioration 111/ a+e
Review with own gp
in week or so
EAR TREATMENT :
Keep ears dry
Abx oral: Clarithromycin
Ear med: otomize
Deny allergy:
Gentle valsalva
Urgent attention if any acute deterioration
TCB / Review with own GP if not settled
Keep ears dry
Abx oral: Clarithromycin
Ear med: otomize
Deny allergy:
Gentle valsalva
Urgent attention if any acute deterioration
TCB / Review with own GP if not settled
EAR TREATMENT :
Keep ears dry
Abx oral: Amoxicillin
Ear med: otomize
Deny allergy:
Gentle valsalva
Urgent attention if any acute deterioration
TCB / Review with own GP if not settled
Keep ears dry
Abx oral: Amoxicillin
Ear med: otomize
Deny allergy:
Gentle valsalva
Urgent attention if any acute deterioration
TCB / Review with own GP if not settled
DIAS Domestic abuse issues
https://diasdvc.org/
01942 311365
Mon-Fri 8am & 6pm
for advice and support
https://diasdvc.org/
01942 311365
Mon-Fri 8am & 6pm
for advice and support
UROLOGY: male
Suspected UTI
Dysuria and frequency
last few days,
Fevers: nill ? on/ off
No renal angle pains
No loin to groin pains
No haematuria
Suspected UTI
Dysuria and frequency
last few days,
Fevers: nill ? on/ off
No renal angle pains
No loin to groin pains
No haematuria
SEXUAL HEALTH
STD Concerns possibility? Denies
NHS 111 - Sexual health clinic contacts - if any concerns
STD Concerns possibility? Denies
NHS 111 - Sexual health clinic contacts - if any concerns
UROLOGY: female
Suspected UTI
Dysuria and frequency
last few days,
Fevers: nill ? on/ off
No renal angle pains
No loin to groin pains
No haematuria
Vaginal symptoms: Nill
lmp:
Suspected UTI
Dysuria and frequency
last few days,
Fevers: nill ? on/ off
No renal angle pains
No loin to groin pains
No haematuria
Vaginal symptoms: Nill
lmp:
Abx issued: Nitrofurantoin,
no allergies.
egfr satisfactory
Stop after 3 days if settled
Urine for mc+s if not settling after 3 days
TCB as required
Urgent attention if any acute deterioration
(ooh 111 / a+e )
Review with own GP if not settled
Safety net advise pyelonephritis
no allergies.
egfr satisfactory
Stop after 3 days if settled
Urine for mc+s if not settling after 3 days
TCB as required
Urgent attention if any acute deterioration
(ooh 111 / a+e )
Review with own GP if not settled
Safety net advise pyelonephritis
Abx issued: Trimethoprim,
no allergies.
Stop after 3 days if settled
Urine for mc+s if not settling after 3 days
TCB as required
Urgent attention if any acute deterioration
(ooh 111 / a+e )
Review with own GP if not settled
Safety net advise pyelonephritis
no allergies.
Stop after 3 days if settled
Urine for mc+s if not settling after 3 days
TCB as required
Urgent attention if any acute deterioration
(ooh 111 / a+e )
Review with own GP if not settled
Safety net advise pyelonephritis
Face 2 Face Safety net / opd letter
Urgent attention if any acute deterioration
TCB / Review with own GP
With full access to
notes test results and specialist letters
Urgent attention if any acute deterioration
TCB / Review with own GP
With full access to
notes test results and specialist letters
Face 2 Face Safety net / opd letter
Urgent attention if any acute deterioration
(ooh 111 / a+e )
TCB / Review with own GP
With full access to
notes test results and Specialist letters
Urgent attention if any acute deterioration
(ooh 111 / a+e )
TCB / Review with own GP
With full access to
notes test results and Specialist letters
RESPIRATORY Adult - dry
Cough cold
last few days / weeks or so
Previously murky y/g sputum
Now mainly dry cough
Fevers: Nill / ?on/off
No haemoptysis,
No chest pains
No pains on deep inspiration.
Wheeze: nill
Breathlessness: nill
Hx asthma/copd: nill
Inhalers: nill
e+d: ok
n+v: nill
Cough cold
last few days / weeks or so
Previously murky y/g sputum
Now mainly dry cough
Fevers: Nill / ?on/off
No haemoptysis,
No chest pains
No pains on deep inspiration.
Wheeze: nill
Breathlessness: nill
Hx asthma/copd: nill
Inhalers: nill
e+d: ok
n+v: nill
Meningitis check
Fever: Nill
Headache: Nill
Photophobia: Nill Ok with light
Nausea/Vomiting:Nill
No neck stiffness or pains
No none blanching rashes / Strep rash
Sore throat: Nill / Some
Ears: Nill obvious
No new or progressive neurological symptoms
face arms legs,
No disturbance to
cognition, vision, speech.
Fever: Nill
Headache: Nill
Photophobia: Nill Ok with light
Nausea/Vomiting:Nill
No neck stiffness or pains
No none blanching rashes / Strep rash
Sore throat: Nill / Some
Ears: Nill obvious
No new or progressive neurological symptoms
face arms legs,
No disturbance to
cognition, vision, speech.
Alert orientated tpp.
CNS PNS intact symmetrical
Perla
EOM full rom
No nystagmus
No ataxia
Perla
EOM full rom
No nystagmus
No ataxia
#neuro: full cns pns
Fever: nill
Trauma impact injury: nill
No new or progressive
neurological symptoms
face arms legs,
no disturbance to cognition,
vision, speech.
Fever: nill
Trauma impact injury: nill
No new or progressive
neurological symptoms
face arms legs,
no disturbance to cognition,
vision, speech.
#neuro: PNS Cervical
Fever: nill
Trauma impact injury: nill
Neck jolts or forces: Nill
Axillary swellings changes: Nill
No new or progressive neurological symptoms Upper limbs Hands,
No association with neck movements
Fever: nill
Trauma impact injury: nill
Neck jolts or forces: Nill
Axillary swellings changes: Nill
No new or progressive neurological symptoms Upper limbs Hands,
No association with neck movements
Lumbosacral
Fever: nill
Trauma impact injury: nill
Excessive strenuous use: Nill
Heavy Lifting: nill
No new or progressive neurological symptoms
lower limbs or perineum,
No urinary or perianal neurological symptoms
Analgesia used: Nill
Apyrexial cvs stable
Gait: ok
Focal spinal tenderness: nill
General ache:
Spinal alignment: Normal
AP Alignment:C/T/L curvature: nad
lateral Alignment: No scoliosis
Tone power reflexes symmetrical
Ankles:Full rom
Plantars: down going
Analgesia issued
Naproxen with ppi cover
Co-codamol with lactulose cover
Gentle heat massage
mobilisation posture advise
Physio viaown surgery
Alliance Physio
Urgent attention if any acute deterioration
(111/ A+E)
Review in 2-4 weeks if not settling
Safety net cauda equina
Fever: nill
Trauma impact injury: nill
Excessive strenuous use: Nill
Heavy Lifting: nill
No new or progressive neurological symptoms
lower limbs or perineum,
No urinary or perianal neurological symptoms
Analgesia used: Nill
Apyrexial cvs stable
Gait: ok
Focal spinal tenderness: nill
General ache:
Spinal alignment: Normal
AP Alignment:C/T/L curvature: nad
lateral Alignment: No scoliosis
Tone power reflexes symmetrical
Ankles:Full rom
Plantars: down going
Analgesia issued
Naproxen with ppi cover
Co-codamol with lactulose cover
Gentle heat massage
mobilisation posture advise
Physio viaown surgery
Alliance Physio
Urgent attention if any acute deterioration
(111/ A+E)
Review in 2-4 weeks if not settling
Safety net cauda equina
NEUROLOGY
No new or progressive neurological symptoms
face arms legs,
No disturbance to
cognition, vision, speech.
No new or progressive neurological symptoms face,
No disturbance to cognition, vision, speech
No new or progressive neurological symptoms
lower limbs or perineum,
No urinary or perianal neurological symptoms
No new functional loss
FAST Face Arm Speech negative
GCS: 15/15
No new or progressive neurological symptoms
face arms legs,
No disturbance to
cognition, vision, speech.
No new or progressive neurological symptoms face,
No disturbance to cognition, vision, speech
No new or progressive neurological symptoms
lower limbs or perineum,
No urinary or perianal neurological symptoms
No new functional loss
FAST Face Arm Speech negative
GCS: 15/15
Neuro exam / Plantars
PERLA / EOM full rom
Opthalmoscopy: nad
CNS PNS intact symmetrical
Ataxia: nill
Nystagmus: nill
Tone power reflexes sensation: symmetrical
PERLA / EOM full rom
Opthalmoscopy: nad
CNS PNS intact symmetrical
Ataxia: nill
Nystagmus: nill
Tone power reflexes sensation: symmetrical
Likely Viral illness Common cold
Liaise with chemist
OTC Cough cold meds
TCB as required
Urgent attention if any acute deterioration
Review with own GP if not settled
Delayed script: Amoxicillin / Clarithromycin/ Doxycycline
Deny allergy
Salbutamol as required
Liaise with chemist
OTC Cough cold meds
TCB as required
Urgent attention if any acute deterioration
Review with own GP if not settled
Delayed script: Amoxicillin / Clarithromycin/ Doxycycline
Deny allergy
Salbutamol as required
PSYCHIATRIC
Previous mental health hx:nill
cahms/ cmt: nill
Mental health meds:
Antidepressant:
Anxiolytic:
Sedative:
PSYCHIATRIC
Home: Any issues: Nill
Lives with:
Work: Any issues: Nill
Job:
Trigger factors:
Recreation:
Denies Excessive Alcohol, Cannabis or other Drugs,
Denies Delusions / Hallucinations Auditory Visual,
DSH: Nill
TOSH: Ideation:nill
TOSH: Intent: nill
Good rapport insight / Not tearful or agitated /
Eye contact: Good
Speech: Normal
Kempt
Discussed
Antidepressant:
Anxiolytic: Propranolol
denies asthma or cardiac conditions
Sedative: promethazine as required
Counselling contacts, wellbeing / samaritans
Crisis team contact / 111 / a+e
TCB as required
Urgent attention if any acute deterioration
(ooh 111 / a+e )
Review with own GP in 2 to 4 weeks
Previous mental health hx:nill
cahms/ cmt: nill
Mental health meds:
Antidepressant:
Anxiolytic:
Sedative:
PSYCHIATRIC
Home: Any issues: Nill
Lives with:
Work: Any issues: Nill
Job:
Trigger factors:
Recreation:
Denies Excessive Alcohol, Cannabis or other Drugs,
Denies Delusions / Hallucinations Auditory Visual,
DSH: Nill
TOSH: Ideation:nill
TOSH: Intent: nill
Good rapport insight / Not tearful or agitated /
Eye contact: Good
Speech: Normal
Kempt
Discussed
Antidepressant:
Anxiolytic: Propranolol
denies asthma or cardiac conditions
Sedative: promethazine as required
Counselling contacts, wellbeing / samaritans
Crisis team contact / 111 / a+e
TCB as required
Urgent attention if any acute deterioration
(ooh 111 / a+e )
Review with own GP in 2 to 4 weeks
BLOOD PRESSURE ( has machine )
BP check, monitoring required.
1. Has own machine
2. Check twice, twice daily.
Send in 7 days readings.
3. Check during any headaches
4. Urgent attention if above 180/90
or any new or worsening headaches.
Here / ooh 111/ a+e
BP check, monitoring required.
1. Has own machine
2. Check twice, twice daily.
Send in 7 days readings.
3. Check during any headaches
4. Urgent attention if above 180/90
or any new or worsening headaches.
Here / ooh 111/ a+e
Meningitis / neuro check
Fever: Nill
Headache: Nill
Photophobia: Nill
Ok with light
Nausea/Vomiting:Nill
No neck stiffness or pains
No none blanching rashes
Sore throat: Nill / Some
Ears: nill
No new or progressive neurological symptoms
face arms legs,
No disturbance to cognition, vision, speech.
Fever: Nill
Headache: Nill
Photophobia: Nill
Ok with light
Nausea/Vomiting:Nill
No neck stiffness or pains
No none blanching rashes
Sore throat: Nill / Some
Ears: nill
No new or progressive neurological symptoms
face arms legs,
No disturbance to cognition, vision, speech.
You may find useful
Emergency
111/ A+E
CRISIS TEAM mental health
08 000 513 253
Wellbeing counselling
24/7 Helpline 08 08 23 89 888
Samaritans 116 123
Cruise Bereavement
0808 808 1677
Google: THE BRICK
DIAS Domestic abuse issues
https://diasdvc.org/
01942 311365
ANDYS MANS CLUB
Emergency
111/ A+E
CRISIS TEAM mental health
08 000 513 253
Wellbeing counselling
24/7 Helpline 08 08 23 89 888
Samaritans 116 123
Cruise Bereavement
0808 808 1677
Google: THE BRICK
DIAS Domestic abuse issues
https://diasdvc.org/
01942 311365
ANDYS MANS CLUB
You may find useful
Emergency
111/ A+E
CRISIS TEAM mental health
08 000 513 253
Wellbeing counselling
24/7 Helpline 08 08 23 89 888
Samaritans 116 123
Cruise Bereavement
0808 808 1677
Google: THE BRICK
DIAS Domestic abuse issues
https://diasdvc.org/
01942 31136
Emergency
111/ A+E
CRISIS TEAM mental health
08 000 513 253
Wellbeing counselling
24/7 Helpline 08 08 23 89 888
Samaritans 116 123
Cruise Bereavement
0808 808 1677
Google: THE BRICK
DIAS Domestic abuse issues
https://diasdvc.org/
01942 31136
| Headache | Gradual onset Comes and goes No sudden severe thunder clap |
| Meningism | No meningism, fever neck stiffness photophobia purpuric rash |
| Migraine and Auras | No Auras Visual auras scotomas Discussed migraine triggers No Cheese chocolate caffeine computer screens, stress Contraceptive meds |
| Medication linked | Combined pill use noted Medication overuse headache possible Lymecycline use noted |
| Tension type headache | |
Temporal arteritis
|
Tenderness in area of temples Local inflammation Jaw claudication |
| Trigeminal neuralgia | Radiation out from trigone area |
| Cluster type headache |
|
| Concussion type headache |
| PILL CHECK | |
| PILL CHECK | ?Request Contraceptive pill ?
?BP: ?
?BMI: ?
?Smoking: ?
?Hx fhx: Breast, cervical, gynaecological conditions: nill ?
?Hx fhx: Thromboembolic conditions: nill ?
?Hx Migraines with Auras: Nill ?
?Breast feeding ?
?Enzyme inducing meds: ?
?LARCS: discussed / declined / TCB if changes mind ?
?Discussed lmp starting pill / late / missed pill / Concurrnet abx protocols ?
|
| EMERGENCY CONTRACEPTION | ?Requests emergency contraception ?
?Current contraceptive: ?
?Condoms: ?
?Position in cycle/ lmp:?
?Upsi timing: ?
?Previous Emergency contraception in this cycle? ?
?levonelle 1 step within 60 hrs ?
??
??
?Has a failure rate ?
?If vomit soon after use will need another pill ?
|
?Ulipristal within 5 days.. but will stop pop pill working ?
?abstain after use ?
?pregnancy test if next period late ?
|
|
BREASTS
Previous breast conditions:
Previous breast operations:
Hx/Fhx Breast conditions:
Smoking:
Hormonal Medication:
Breast implants:
Right breast
Nipple:
Areola:
Breast:
Axilla:
Leftbreast
Nipple:
Areola:
Breast:
Axilla:
Previous breast conditions:
Previous breast operations:
Hx/Fhx Breast conditions:
Smoking:
Hormonal Medication:
Breast implants:
Right breast
Nipple:
Areola:
Breast:
Axilla:
Leftbreast
Nipple:
Areola:
Breast:
Axilla:
Wax seen
keep ears dry
avoid ear buds
olive oil drops /
sodium bicarb drops
Review in 2 weeks
May need syringing
No history of perforations
History of perforations
Referred to ENT
for microsuction clearance
keep ears dry
avoid ear buds
olive oil drops /
sodium bicarb drops
Review in 2 weeks
May need syringing
No history of perforations
History of perforations
Referred to ENT
for microsuction clearance
Headache F
Hx headaches:
Hx Duration:
Onset: gradual / sudden
Location:
Lasts:
Other symptoms/ auras:
Triggers discussed: Advised to avoid
Lifestyle: Hunger/ sleepless / stress: nill obvious
Stimuli/ uv lights screens lights etc: nill obvious
Foods: Cheese/ Chocolates/ caffeine nill obvious
Glasses: nill / optician check advised
Hormonal meds: combined pill/ hrt: nill obvious
Examination
Apyrexial
Alert
No meningism
Brudzinski negative
t:
p:
bp:
rr:
Perla/ eom full rom
Opthalmoscopy nad
Cns pns intact symmet no ataxia
Management;
Headache diary
Avoid triggers
Treatments: paracetamol/ibuprofen/Triptan
Prevention: nill for now /
Review in 2-4 weeks
Urgent attention if any acute deterioration
Safety net advise meningitis
New or progressive neurological symptoms or signs
Hx headaches:
Hx Duration:
Onset: gradual / sudden
Location:
Lasts:
Other symptoms/ auras:
Triggers discussed: Advised to avoid
Lifestyle: Hunger/ sleepless / stress: nill obvious
Stimuli/ uv lights screens lights etc: nill obvious
Foods: Cheese/ Chocolates/ caffeine nill obvious
Glasses: nill / optician check advised
Hormonal meds: combined pill/ hrt: nill obvious
Examination
Apyrexial
Alert
No meningism
Brudzinski negative
t:
p:
bp:
rr:
Perla/ eom full rom
Opthalmoscopy nad
Cns pns intact symmet no ataxia
Management;
Headache diary
Avoid triggers
Treatments: paracetamol/ibuprofen/Triptan
Prevention: nill for now /
Review in 2-4 weeks
Urgent attention if any acute deterioration
Safety net advise meningitis
New or progressive neurological symptoms or signs
BLOOD PRESSURE ( needs machine)
BP check, monitoring required.
1. Advised to get own machine/ Has own machine
2. Check twice, twice daily. Send in 7 days readings.
3. Check during any headaches
4. Urgent attention if above 180/90
or any new or worsening headaches.
Here / ooh 111/ a+e
5. Otherwise check by chemist
or Reception Appointment
Practice HCA or Nurse
BP check, monitoring required.
1. Advised to get own machine/ Has own machine
2. Check twice, twice daily. Send in 7 days readings.
3. Check during any headaches
4. Urgent attention if above 180/90
or any new or worsening headaches.
Here / ooh 111/ a+e
5. Otherwise check by chemist
or Reception Appointment
Practice HCA or Nurse
BLOOD PRESSURE ( has machine )
BP check, monitoring required.
1. Has own machine
2. Check twice, twice daily.
Send in 7 days readings.
3. Check during any headaches
4. Urgent attention if above 180/90
or any new or worsening headaches.
Here / ooh 111/ a+e
BP check, monitoring required.
1. Has own machine
2. Check twice, twice daily.
Send in 7 days readings.
3. Check during any headaches
4. Urgent attention if above 180/90
or any new or worsening headaches.
Here / ooh 111/ a+e
SLEEP
Mentions poor sleep
Duration
Sleep Onset: Good / Poor
Duration : Good / Poor
Waking: Early/ Late
Stimulants: caffeine others:
Advised to avoid
Shift work:
Sedatives Used:
Sleep hygiene :
MANAGEMENT
Stimulants: caffeine others: to avoid
Avoid naps during day
Evening Exercise / heavy meal
Bedroom warm quiet dark
MEDS:
Prochlorperazine
Zopiclone
DORI Daridoroxant
Mentions poor sleep
Duration
Sleep Onset: Good / Poor
Duration : Good / Poor
Waking: Early/ Late
Stimulants: caffeine others:
Advised to avoid
Shift work:
Sedatives Used:
Sleep hygiene :
MANAGEMENT
Stimulants: caffeine others: to avoid
Avoid naps during day
Evening Exercise / heavy meal
Bedroom warm quiet dark
MEDS:
Prochlorperazine
Zopiclone
DORI Daridoroxant
UPPER LIMB / SHOULDER
Hand Dominance: L/R
Functional Job:
Functional Hobbies:
Previous shoulder problems:
Previous operations / injections:
Rheumatological conditions:
Fever
Trauma / impact/ injury/ pull
Foosh injury: nill
Hx dislocations: nill
Shoulder Look:
Local erythema bruising: nill
Deltoid curve present
Shoulder Feel:
Clavicle
AC/joint
Shoulder Move
Rotation int/ ext
Abduction anterior: Active / Passive
Abduction lateral: Active / Passive
Distal nvi: nad
ADJACENT JOINTS:
Elbow / Wrist / Hand: nbi full rom
Hand Dominance: L/R
Functional Job:
Functional Hobbies:
Previous shoulder problems:
Previous operations / injections:
Rheumatological conditions:
Fever
Trauma / impact/ injury/ pull
Foosh injury: nill
Hx dislocations: nill
Shoulder Look:
Local erythema bruising: nill
Deltoid curve present
Shoulder Feel:
Clavicle
AC/joint
Shoulder Move
Rotation int/ ext
Abduction anterior: Active / Passive
Abduction lateral: Active / Passive
Distal nvi: nad
ADJACENT JOINTS:
Elbow / Wrist / Hand: nbi full rom
UPPER LIMB / ELBOW
Hand Dominance: L/R
Functional Job:
Functional Hobbies:
Previous shoulder problems:
Previous operations / injections:
Rheumatological conditions:
Fever
Trauma / impact/ injury/ pull
Hx dislocations: nill
Foosh injury: nill
Elbow Look:
Local erythema bruising: nill
Olecranon Bursitis: nill
Elbow Feel:
Radial head: nbi
Olecranon: nbi
Elbow Move
Held position: normal
Flexion: full rom
Extension: full rom
Pronate / Supinate: full rom
Distal nvi: nad
ADJACENT JOINTS:
Shoulder/wrist: nbi full rom
Hand Dominance: L/R
Functional Job:
Functional Hobbies:
Previous shoulder problems:
Previous operations / injections:
Rheumatological conditions:
Fever
Trauma / impact/ injury/ pull
Hx dislocations: nill
Foosh injury: nill
Elbow Look:
Local erythema bruising: nill
Olecranon Bursitis: nill
Elbow Feel:
Radial head: nbi
Olecranon: nbi
Elbow Move
Held position: normal
Flexion: full rom
Extension: full rom
Pronate / Supinate: full rom
Distal nvi: nad
ADJACENT JOINTS:
Shoulder/wrist: nbi full rom
HAND
Hand Dominance: L/R
Functional Job:
Functional Hobbies:
Previous hand problems:
Previous operations / injections:
Rheumatological conditions:
Wrist: nbi full rom
Foosh injury: nill
Scaphoid: nbi
Thenar: nbi
Hypothenar:nbi
Thumb: mcpj / ipj: nbi full rom
Mcpj
Pip
Dip
Dupuytrens: nill
Carpal Tunnel
Tinnel test: negative
Radial ulnar median
sensory motor: intact
Rock paper scissors ok sign: ok
Muscle wasting: nill
Fingers flex / extend: ok
Strength: ok
Strength symmetry: ok
Hand Dominance: L/R
Functional Job:
Functional Hobbies:
Previous hand problems:
Previous operations / injections:
Rheumatological conditions:
Wrist: nbi full rom
Foosh injury: nill
Scaphoid: nbi
Thenar: nbi
Hypothenar:nbi
Thumb: mcpj / ipj: nbi full rom
Mcpj
Pip
Dip
Dupuytrens: nill
Carpal Tunnel
Tinnel test: negative
Radial ulnar median
sensory motor: intact
Rock paper scissors ok sign: ok
Muscle wasting: nill
Fingers flex / extend: ok
Strength: ok
Strength symmetry: ok
FUNNY DO
Episode: date / time
Pre Episode:
Episode:
Post Episode:
Chest pains:
Palpitations:
Hypotensives
Hypoglycaemics
Blood sugars/ diabetes: nill
Related to head movements: nill
Vertebrobasilar:
Vertigo: nill
Epileptic?
Petit mals: nill
Grand mals: nill
Tonic clonic:
Eye rolling:
Incontinence
Neurological deficit
Tia / cva
Fast negative
Episode: date / time
Pre Episode:
Episode:
Post Episode:
Chest pains:
Palpitations:
Hypotensives
Hypoglycaemics
Blood sugars/ diabetes: nill
Related to head movements: nill
Vertebrobasilar:
Vertigo: nill
Epileptic?
Petit mals: nill
Grand mals: nill
Tonic clonic:
Eye rolling:
Incontinence
Neurological deficit
Tia / cva
Fast negative
LOWER LIMB / hip
Usual mobility:
Previous issues hip /knee/ ankle: nill
Previous operations: hip /knee/ ankle: nill
Rheumatological conditions: nill
Hip Look:
Local Erythema: Nill
Local bruise: Nill
Hip Feel:
Warmth: nill
Tenderness: nill
Hip: move:
Held: neutral
Rotation: int ext
SLR: active / passive
Abduction: active / passive
Usual mobility:
Previous issues hip /knee/ ankle: nill
Previous operations: hip /knee/ ankle: nill
Rheumatological conditions: nill
Hip Look:
Local Erythema: Nill
Local bruise: Nill
Hip Feel:
Warmth: nill
Tenderness: nill
Hip: move:
Held: neutral
Rotation: int ext
SLR: active / passive
Abduction: active / passive
LOWER LIMB / knee
Usual mobility:
Previous issues hip /knee/ ankle: nill
Previous operations: hip /knee/ ankle: nill
Rheumatological conditions: nill
Knee Look
Local Erythema: Nill
Local bruise: Nill
Local swelling
Knee Feel
Warmth: nill
Tenderness: nill
Patella ballotment: nill
Tibial tuberosity: nad
Knee Move
Held: neutral
Flex: Good ROM / Crepitus: nill
Extend: Good ROM / Crepitus: nill
Collaterals: Intact
Cruciates: Intact
Menisci: Intact
Popliteal area: nad
Calve: no clinical dvt
Usual mobility:
Previous issues hip /knee/ ankle: nill
Previous operations: hip /knee/ ankle: nill
Rheumatological conditions: nill
Knee Look
Local Erythema: Nill
Local bruise: Nill
Local swelling
Knee Feel
Warmth: nill
Tenderness: nill
Patella ballotment: nill
Tibial tuberosity: nad
Knee Move
Held: neutral
Flex: Good ROM / Crepitus: nill
Extend: Good ROM / Crepitus: nill
Collaterals: Intact
Cruciates: Intact
Menisci: Intact
Popliteal area: nad
Calve: no clinical dvt
Erectile dysfunction
Mood Libido:
Relationship issues:
Mental health:
Medications:
Alcohol / recreational drugs
Pornography:
Prostate issues:
Previous treatments
CHD CVD contra indications
Early morning Erections
Erection: onset
Erection duration:
Pde5 Meds
Mood Libido:
Relationship issues:
Mental health:
Medications:
Alcohol / recreational drugs
Pornography:
Prostate issues:
Previous treatments
CHD CVD contra indications
Early morning Erections
Erection: onset
Erection duration:
Pde5 Meds
DIZZYNESS bppv
Episodes of dizzyness
Come and go
Lasts: ? Minutes ? Longer
Relation to head movements: Yes / No
Cardiac chest pains: nill
Palpitations: nill
Postural hypotension effect : nill
Antihypertensive medications: nill
Deafness/ tinnitus: nill
On examination
Apyrexial alert no meningism
t;
p:
bp:
rr:
Otoscopy: nad
Perla eom full rom
cns pns intact symmetrical
no ataxia
Episodes of dizzyness
Come and go
Lasts: ? Minutes ? Longer
Relation to head movements: Yes / No
Cardiac chest pains: nill
Palpitations: nill
Postural hypotension effect : nill
Antihypertensive medications: nill
Deafness/ tinnitus: nill
On examination
Apyrexial alert no meningism
t;
p:
bp:
rr:
Otoscopy: nad
Perla eom full rom
cns pns intact symmetrical
no ataxia
DIZZYNESS Cardiac
Episodes of dizzyness
Come and go
Lasts: ? Minutes ? Longer
Relation to head movements: Yes / No
Cardiac chest pains: nill
Palpitations: nill
Postural hypotension effect : possible
Antihypertensive medications: noted
Deafness/ tinnitus: nill
On examination
Apyrexial alert no meningism
t;
p:
bp:
Sitting:
bp: p:
Stainding :
bp: p:
rr:
Otoscopy: nad
Perla eom full rom
cns pns intact symmetrical
no ataxia
Episodes of dizzyness
Come and go
Lasts: ? Minutes ? Longer
Relation to head movements: Yes / No
Cardiac chest pains: nill
Palpitations: nill
Postural hypotension effect : possible
Antihypertensive medications: noted
Deafness/ tinnitus: nill
On examination
Apyrexial alert no meningism
t;
p:
bp:
Sitting:
bp: p:
Stainding :
bp: p:
rr:
Otoscopy: nad
Perla eom full rom
cns pns intact symmetrical
no ataxia
Paramedics No longer on site
Consult with Patient
Paramedics called:
Paramedics on site:
Paramedics left:
Consult with Patient
Paramedics called:
Paramedics on site:
Paramedics left:
Paramedic phone consult
GM Notes accessed:
TODAY:
Consult with Paramedic
Paramedic Obs
Appears: well, stable
AVPU: Alert
GCS: 15/15
t:
p:
hs: normal
rr:
sats: %
BP:
BM:
12Lead:
GM Notes accessed:
TODAY:
Consult with Paramedic
Paramedic Obs
Appears: well, stable
AVPU: Alert
GCS: 15/15
t:
p:
hs: normal
rr:
sats: %
BP:
BM:
12Lead:
Stay at home / careful observation
To call back 111 as required
To contact own GP for further assessment / review
Urgent attention if any acute deterioration
(Own GP / ooh 111 / a+e )
To call back 111 as required
To contact own GP for further assessment / review
Urgent attention if any acute deterioration
(Own GP / ooh 111 / a+e )
Face 2 face appointment scheduled
Urgent attention if any acute deterioration
(ooh 111 / a+e )
Urgent attention if any acute deterioration
(ooh 111 / a+e )
Paramedic advised needs urgent A+E
Ambulance will take in
Ambulance will take in
Home visit booked
Advised can be up to 4 hours untill seen
Urgent attention if any acute deterioration
(ooh 111 / a+e )
Advised can be up to 4 hours untill seen
Urgent attention if any acute deterioration
(ooh 111 / a+e )
Phone Exam
Alert and orientated time place person
Agitation: nill
Alert and orientated time place person
Agitation: nill
REFUSING HOSPITAL
Alert Orientated Time place person
Compos mentis
Aware refusal is against medical advise
with risk of deterioration or worse
Can call back OOH 111 / 999
A+E Own transport
Alert Orientated Time place person
Compos mentis
Aware refusal is against medical advise
with risk of deterioration or worse
Can call back OOH 111 / 999
A+E Own transport
Face 2 face appointment scheduled
RAEI OOH
States can get here for:
Scheduled:
Urgent attention if any acute deterioration
(ooh 111 / a+e )
RAEI OOH
States can get here for:
Scheduled:
Urgent attention if any acute deterioration
(ooh 111 / a+e )
Home visit booked
Advised can be up to 4 hours untill seen
Urgent attention if any acute deterioration
(ooh 111 / a+e )
Advised can be up to 4 hours untill seen
Urgent attention if any acute deterioration
(ooh 111 / a+e )
Phone consult: MEDICATION REQUESTED
Medication requested:
Reason: Ran out
Will bring in proof of medications
Aware will only be issued short quantity untill able to contact own gp for full prescription.
Controlled drugs required
Will bring in proof of meds and proof of identity
Medication requested:
Reason: Ran out
Will bring in proof of medications
Aware will only be issued short quantity untill able to contact own gp for full prescription.
Controlled drugs required
Will bring in proof of meds and proof of identity
https://www.locala.org.uk/locations/wigan-sexual-health-service
Wigan and Leigh
01942 949 167
Our phone lines are open
Monday 8:30am-4:30pm
Tuesday 8:30am-5:30pm
Wednesday 8:30am-5:30pm
12-2pm Closed
Thursday 8:30am-3:30pm
Friday 8:30am-3:30pm
Wigan and Leigh
01942 949 167
Our phone lines are open
Monday 8:30am-4:30pm
Tuesday 8:30am-5:30pm
Wednesday 8:30am-5:30pm
12-2pm Closed
Thursday 8:30am-3:30pm
Friday 8:30am-3:30pm
Abx issued: Cephalexin
no allergies.
Stop after 3 days if settled
Urine for mc+s if not settling after 3 days
TCB as required
Urgent attention if any acute deterioration
(ooh 111 / a+e )
Review with own GP if not settled
Safety net advise pyelonephritis
no allergies.
Stop after 3 days if settled
Urine for mc+s if not settling after 3 days
TCB as required
Urgent attention if any acute deterioration
(ooh 111 / a+e )
Review with own GP if not settled
Safety net advise pyelonephritis
STREP THROAT fem Clarithro / Doxy
Clarithromycin
Doxycycline
deny allergy
Preg/brf: nill
OTC antipyreticsParacetamol etc
Difflam / deny asthma
Dioralyte if required
TCB as required
Urgent attention
if any acute deterioration
(ooh 111 / a+e )
Review with own GP if not settled
Safety net advise
Meningitis / Scarlet fever
Dehydration
Clarithromycin
Doxycycline
deny allergy
Preg/brf: nill
OTC antipyreticsParacetamol etc
Difflam / deny asthma
Dioralyte if required
TCB as required
Urgent attention
if any acute deterioration
(ooh 111 / a+e )
Review with own GP if not settled
Safety net advise
Meningitis / Scarlet fever
Dehydration
EYE TREATMENT :
Lid hygiene
Explained contagious nature
Abx oral: Flucloxacillin
Eye med: Chloramphenicol drops
Deny allergy:
Urgent attention if any acute deterioration
TCB / Review with own GP if not settled
Lid hygiene
Explained contagious nature
Abx oral: Clarithromycin
Eye med: Chloramphenicol drops
Deny allergy:
Urgent attention if any acute deterioration
TCB / Review with own GP if not settled
Eye med: Chloramphenicol ointment (age precaution)
deny allergy
Lid hygiene
Explained contagious nature
Abx oral: Flucloxacillin
Eye med: Chloramphenicol drops
Deny allergy:
Urgent attention if any acute deterioration
TCB / Review with own GP if not settled
Lid hygiene
Explained contagious nature
Abx oral: Clarithromycin
Eye med: Chloramphenicol drops
Deny allergy:
Urgent attention if any acute deterioration
TCB / Review with own GP if not settled
Eye med: Chloramphenicol ointment (age precaution)
deny allergy
Face 2 Face Safety net / test results
Urgent attention if any acute deterioration
Review with own GP with test results
Sooner if required
tcb alliance (may not get test results)
Urgent attention if any acute deterioration
Review with own GP with test results
Sooner if required
tcb alliance (may not get test results)
Face 2 Face Safety net / test results
Urgent attention if any acute deterioration
(ooh 111 / a+e )
Review with own GP with test results
Sooner if required
tcb alliance (may not get test results)
Urgent attention if any acute deterioration
(ooh 111 / a+e )
Review with own GP with test results
Sooner if required
tcb alliance (may not get test results)
Review post weekend
if symptoms not settled
if symptoms not settled
Review post abx
if symptoms not settled
if symptoms not settled
RESPIRATORY Adult Greeny
Cough cold
last few days / weeks or so
Occasional Greeny sputum
Fevers: Nill / ?on/off
No haemoptysis,
No chest pains
No pains on deep inspiration.
Wheeze: nill
Breathlessness: nill
Hx asthma/copd: nill
Inhalers: nill
e+d: ok
n+v: nill
Cough cold
last few days / weeks or so
Occasional Greeny sputum
Fevers: Nill / ?on/off
No haemoptysis,
No chest pains
No pains on deep inspiration.
Wheeze: nill
Breathlessness: nill
Hx asthma/copd: nill
Inhalers: nill
e+d: ok
n+v: nill
RESPIRATORY Adult yellow
Cough cold
last few days / weeks or so
Occasional yellowy sputum
Fevers: Nill / ?on/off
No haemoptysis,
No chest pains
No pains on deep inspiration.
Wheeze: nill
Breathlessness: nill
Hx asthma/copd: nill
Inhalers: nill
e+d: ok
n+v: nill
Cough cold
last few days / weeks or so
Occasional yellowy sputum
Fevers: Nill / ?on/off
No haemoptysis,
No chest pains
No pains on deep inspiration.
Wheeze: nill
Breathlessness: nill
Hx asthma/copd: nill
Inhalers: nill
e+d: ok
n+v: nill
COLDS / FLU
Likely Viral illness
Common cold / Flu like illness
Liaise with chemist
OTC Cough cold meds
Antipyretics
Keep hydrated
TCB as required
Urgent attention if any acute deterioration
Review with own GP if not settled
Delayed script: Amoxicillin / Clarithromycin/ Doxycycline
Deny allergy
Salbutamol as required
Common cold / Flu like illness
Liaise with chemist
OTC Cough cold meds
Antipyretics
Keep hydrated
TCB as required
Urgent attention if any acute deterioration
Review with own GP if not settled
Delayed script: Amoxicillin / Clarithromycin/ Doxycycline
Deny allergy
Salbutamol as required
EXAM ADULT FULL
Appears stable
Alert
No meningism
Brudzinski negative
Managing sentences
No use of accessory muscles
Apyrexial
p:
hs: normal
rr:
sats: %
wheeze: nill
crackles: nill
Abdo: verbal consent
snt
Ears: nad
Throat: nad
Lymphadenopathy: nill
Appears stable
Alert
No meningism
Brudzinski negative
Managing sentences
No use of accessory muscles
Apyrexial
p:
hs: normal
rr:
sats: %
wheeze: nill
crackles: nill
Abdo: verbal consent
snt
Ears: nad
Throat: nad
Lymphadenopathy: nill
EXAM ADULT FULL
Appears stable
Alert
No meningism
Brudzinski negative
Managing sentences
No use of accessory muscles
Apyrexial
t:
p:
hs: normal
bp:
rr:
sats: %
wheeze: nill
crackles: nill
Abdo: verbal consent
snt
Ears: nad
Throat: nad
Lymphadenopathy: nill
PERLA / EOM full rom
Opthalmoscopy: nad
CNS PNS intact symmetrical
Ataxia: nill
Nystagmus: nill
Appears stable
Alert
No meningism
Brudzinski negative
Managing sentences
No use of accessory muscles
Apyrexial
t:
p:
hs: normal
bp:
rr:
sats: %
wheeze: nill
crackles: nill
Abdo: verbal consent
snt
Ears: nad
Throat: nad
Lymphadenopathy: nill
PERLA / EOM full rom
Opthalmoscopy: nad
CNS PNS intact symmetrical
Ataxia: nill
Nystagmus: nill
Mood stable
No acute triggers /
Ongoing past issues
No acute triggers /
Ongoing past issues
Household: Alone / Partner,
Kids: nill
Relationship:
Support network: Family / Friends
Job/Study:
Med3 offered:
Kids: nill
Relationship:
Support network: Family / Friends
Job/Study:
Med3 offered:
No Delusions / Hallucinations
No suicidal ideation or intent
No suicidal ideation or intent
Is on …
Feels it is helping.
Denies side effects.
Feels it is helping.
Denies side effects.
Face 2 Face Safety net / abx
Urgent attention if any acute deterioration
TCB / Review with own GP if not settled
Urgent attention if any acute deterioration
TCB / Review with own GP if not settled
Face 2 Face Safety net / abx
Urgent attention if any acute deterioration
(ooh 111 / a+e )
TCB / Review with own GP if not settled
Urgent attention if any acute deterioration
(ooh 111 / a+e )
TCB / Review with own GP if not settled
Apyrexial
t:
p:
Verbal consent:
No renal angle pains
No urine for dip:
t:
p:
Verbal consent:
No renal angle pains
No urine for dip:
Urine for dip:
Neg leucocytes:
Neg Nitrites:
Neg blood:
Neg Protein:
Neg glucose:
Neg ketones
Neg leucocytes:
Neg Nitrites:
Neg blood:
Neg Protein:
Neg glucose:
Neg ketones
Pregnancy test negative:
LETTERS
| INVESTIGATIONS | |
ROUTINE |
Fbc u+e calcium tft lft lipids hba1c esr |
HAEMATINICS |
Iron studies |
HAEMATINICS |
B12 folate ferritin |
BOWELS |
Esr, Coeliac screen, amylase Feacal calprotectin level |
RHEUMATOLOGY |
Esr rf ccp rheumatology screen Urate |
LIVER |
LFT / Split Bilirubin |
Hepatitis Screen B+C |
|
HELICOBACTER |
Helicobacter test breath / stool / serology |
MICROBIOLOGY |
|
| MC+S: urine | |
| MC+S: sputum | |
| MC+S: stools | |
| MC+S: Wound | |
| MC+S: Ear L/R | |
STOOL TESTS |
Feacal calprotectin level / Stool for mc+s |
DIABETES |
|
Type 1 dm |
GAD Antibodies |
Type 2 dm |
HbA1c |
| Albumin: Creatinine ratio | |
| Glucose tolerance test | |
MALE SPECIFIC TESTS |
|
| Prostate | PSA |
| Testosterone level | |
| Abdo M | Fbc u+e calcium tft lft lipids hba1c Esr, Coeliac screen, amylase Feacal calprotectin level |
FEMALE SPECIFIC TESTS |
|
| FSH/LH | |
| Day 21 progesterone | |
| ca125 | |
| ABDO F | Fbc u+e calcium tft lft lipids hba1c Esr, Coeliac screen, amylase ca125 Feacal calprotectin level |
| IMAGING | |
X-ray Request |
|
MRI Request |
|
CT Request |
|
DEXA SCAN |
|
CARDIOLOGY |
|
| ECG request | |
| Ambulatory ECG request | |
| Home BP monitoring check twice twice daily: Send in 7 days readings. | |
| Ambulatory BP request | |
RESPIRATORY |
|
| Reversibility Testing | |
| Spirometry | |
THROAT / SWALLOWING
Fevers: nill
Sore throat: nill
Acid reflux:
Salivary pooling:
Stridor:
Dyspnoea:
Bony food scratch: nill
Heat cold intolerance:
Thyroid/ parathyroid hx: nilll
Hoarse Voice:
Exposure factors:
Smoke dustfumes
Apyrexial
t:
p:
rr:
wheeze / stridor
sats:
voice: nad
throat:nill
Salivary pooling: nill
lymhadenopathy: nill
tracheal deviation: nill
neck swellings: nill
Fevers: nill
Sore throat: nill
Acid reflux:
Salivary pooling:
Stridor:
Dyspnoea:
Bony food scratch: nill
Heat cold intolerance:
Thyroid/ parathyroid hx: nilll
Hoarse Voice:
Exposure factors:
Smoke dustfumes
Apyrexial
t:
p:
rr:
wheeze / stridor
sats:
voice: nad
throat:nill
Salivary pooling: nill
lymhadenopathy: nill
tracheal deviation: nill
neck swellings: nill
https://www.gov.uk/support-for-veterans
https://www.gov.uk/support-for-veterans/op-courage-the-veterans-mental-health-and-wellbeing-service
https://www.gov.uk/support-for-veterans/op-courage-the-veterans-mental-health-and-wellbeing-service
LEG PAIN SWELLING
Thigh:nad
Polpiliteal area: nad
Calve:nad
swollen tender
Varicose veins: nill / noted
Risk factors:
Protective fators:
Leg circumference 10 cm below tibilai tuberosity
r: cm
l: cm
Apyrexial
t:
p:
rr:
sats:
wells score:
Suspected DVT
Letter given
Urgent D dimer asessment via walk in or a+e
Thigh:nad
Polpiliteal area: nad
Calve:nad
swollen tender
Varicose veins: nill / noted
Risk factors:
Protective fators:
Leg circumference 10 cm below tibilai tuberosity
r: cm
l: cm
Apyrexial
t:
p:
rr:
sats:
wells score:
Suspected DVT
Letter given
Urgent D dimer asessment via walk in or a+e
LOWER LIMB / Ankle
Malleoli: No bony temderness
Navicular: nad
Base of 5th ,etatarsal: nad
No local swelling erythema
Full rom at anklle
No distalNVI
WB: ok
Walk: ok
Malleoli: No bony temderness
Navicular: nad
Base of 5th ,etatarsal: nad
No local swelling erythema
Full rom at anklle
No distalNVI
WB: ok
Walk: ok
HAEMORRHOIDS
Hx haemorrhoids
Fever: nill
Abdo pains: nill
Hx bowel conditions: nill
Passing Bowel motions: ok
Otc laxative if required
Haemorrhoid preparations used: ? Nill
Bleeding: on wiping/ in pan
Not mixed with motions
No Melaena
Anticoagulants: nill
Verbal consent / Chaperone declined
Perianal: nad
Fissures: nill
Piles:
DRE: not required
Management
Avoid straining
Otc laxative if required
Scheriproct ointment suppositories
Tcb if any deterioration
Hx haemorrhoids
Fever: nill
Abdo pains: nill
Hx bowel conditions: nill
Passing Bowel motions: ok
Otc laxative if required
Haemorrhoid preparations used: ? Nill
Bleeding: on wiping/ in pan
Not mixed with motions
No Melaena
Anticoagulants: nill
Verbal consent / Chaperone declined
Perianal: nad
Fissures: nill
Piles:
DRE: not required
Management
Avoid straining
Otc laxative if required
Scheriproct ointment suppositories
Tcb if any deterioration
