Denies allergy.
No pregnancy or breast feeding
No pregnancy or breast feeding
HYDRATION
Eating and drinking: Normal usual amounts
Nausea/Vomiting:Nill
Bowel Motion: Normal
Diarrhoea: Nill
Urine output: Normal usual amounts
Eating and drinking: Normal usual amounts
Nausea/Vomiting:Nill
Bowel Motion: Normal
Diarrhoea: Nill
Urine output: Normal usual amounts
PSYCHIATRIC
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 / Speech: Normal
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 / Speech: Normal
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
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 Via 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 Via 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 / Strep rash
Sore throat: Nill / Some
Tonsilitis: Nill obvious
Hoarse voice: Nill
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
Tonsilitis: Nill obvious
Hoarse voice: Nill
RESPIRATORY
Cough: nill
Phlegm: nill
wheeze: nill
Breathlessness: nill
Cough: nill
Phlegm: nill
wheeze: nill
Breathlessness: nill
Exam
Managing sentences No audible wheeze
Managing sentences No audible wheeze
GENERALLY UNWELL
Feels generally unwell
Travel: nill
Ill contacts: nill
Fever: nill
Headache: Nill
Photophobia: Nill Ok with light
Nausea/Vomiting:Nill
No neck stiffness or pains
No none blanching rashes
Eyes: nad
Ears:Nose: nad
Throat soreness : nad
Rashes: Nill
Cough: nill
Phlegm: nill
wheeze: nill
Breathlessness: nill
Increased work of breathing: nill
Eating and drinking: Normal usual amounts
Nausea/Vomiting:Nill
Abdominal pain: Nill
Bowel Motion: Normal
Diarrhoea: Nill
pr bleed melaena: Nill
Urine output: Normal usual amounts
Vaginal: Nill lmp
Feels generally unwell
Travel: nill
Ill contacts: nill
Fever: nill
Headache: Nill
Photophobia: Nill Ok with light
Nausea/Vomiting:Nill
No neck stiffness or pains
No none blanching rashes
Eyes: nad
Ears:Nose: nad
Throat soreness : nad
Rashes: Nill
Cough: nill
Phlegm: nill
wheeze: nill
Breathlessness: nill
Increased work of breathing: nill
Eating and drinking: Normal usual amounts
Nausea/Vomiting:Nill
Abdominal pain: Nill
Bowel Motion: Normal
Diarrhoea: Nill
pr bleed melaena: Nill
Urine output: Normal usual amounts
Vaginal: Nill lmp
RESPIRATORY Adult
Chesty cough
Occasional murky 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
Chesty cough
Occasional murky 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
Examination Adult: Quick
Appears well, stable Alert
No meningism / Brudzinski negative
Managing sentences
No use of accessory muscles
Apyrexial:
p:
hs: normal
rr:
sats: %
Chest clear
wheeze: nill
crackles: nill
Appears well, stable Alert
No meningism / Brudzinski negative
Managing sentences
No use of accessory muscles
Apyrexial:
p:
hs: normal
rr:
sats: %
Chest clear
wheeze: nill
crackles: nill
Face 2 Face Safety net
To call back 111 as required
Review with own GP if not settled
Urgent attention if any acute deterioration
(Own GP / ooh 111 / a+e )
To call back 111 as required
Review with own GP if not settled
Urgent attention if any acute deterioration
(Own GP / ooh 111 / a+e )
Face 2 Face Patient and other
Seen with Mother/ Father /Partner /Son/Daughter/ Carer
Hx as below
Seen with Mother/ Father /Partner /Son/Daughter/ Carer
Hx as below
Neuro exam
PERLA / EOM full rom
Opthalmoscopy: nad
CNS PNS intact symmetrical
Ataxia: nill
Nystagmus: nill
Tone power reflexes sensation: symmetrical
Plantars: Downgoing symetrical
PERLA / EOM full rom
Opthalmoscopy: nad
CNS PNS intact symmetrical
Ataxia: nill
Nystagmus: nill
Tone power reflexes sensation: symmetrical
Plantars: Downgoing symetrical
Ear exam
Ear Right/ Left
Pinna changes: nill
Mastoid tenderness: nill
Trigone tenderness: nill
EAC: Clear / waxy / inflammed
Discharge: nill
TM:
Normal
red inflamed
Retraction: nill
Perforations: nill
Other Ear Right/ Left - nad
Ear Right/ Left
Pinna changes: nill
Mastoid tenderness: nill
Trigone tenderness: nill
EAC: Clear / waxy / inflammed
Discharge: nill
TM:
Normal
red inflamed
Retraction: nill
Perforations: nill
Other Ear Right/ Left - nad
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
Other Eye - nad
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
Other Eye - nad
Exam
Alert and orientated time place person
Agitation: nill
Alert and orientated time place person
Agitation: nill
CARDIAC
Cardiac type / Exertional chest pain: nill
Plapitations: nill
Orthopnea: nill PND: nill
Cardiac type / Exertional chest pain: nill
Plapitations: nill
Orthopnea: nill PND: nill
BABY
Antenatal: no problems
Delivery gestation: Term
Delivery: nvd / c section
Postnatal: no problems
Breast Feeding: y/n
Bottle feeding:y/n
Formula:
Antenatal: no problems
Delivery gestation: Term
Delivery: nvd / c section
Postnatal: no problems
Breast Feeding: y/n
Bottle feeding:y/n
Formula:
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
Face 2 Face Patient
Hx as below
Hx as below
HYDRATION LOW
Eating and drinking: Off solids
Fluids less than usual amounts
Nausea/Vomiting:Nill
Bowel Motion: Normal
Diarrhoea: Nill
Urine output: Less than usual amounts
Eating and drinking: Off solids
Fluids less than usual amounts
Nausea/Vomiting:Nill
Bowel Motion: Normal
Diarrhoea: Nill
Urine output: Less than usual amounts
Access to main records: Nill
GM Notes accessed:
Allergies: ? Nkda
Medication: ? Nill
PMSH: ? Nill
GM Notes accessed:
Allergies: ? Nkda
Medication: ? Nill
PMSH: ? Nill
Examination Peadiatric
Appears well
Alert
interacting
No meningism / Brudzinski negative
No irritability
Colour/Tone: Good
Moist mucous membranes
t:
p:
hs: normal
rr:
wheeze: nill
crackles: nill
tracheal tug: nill recessions ics scs: nill
Abdo: snt
Ears: nad
Throat: nad
Lymphadenopathy: nill
Rashes: nill
Appears well
Alert
interacting
No meningism / Brudzinski negative
No irritability
Colour/Tone: Good
Moist mucous membranes
t:
p:
hs: normal
rr:
wheeze: nill
crackles: nill
tracheal tug: nill recessions ics scs: nill
Abdo: snt
Ears: nad
Throat: nad
Lymphadenopathy: nill
Rashes: nill
Examination Adult
Appears well, stable Alert
No meningism / Brudzinski negative
Managing sentences
No use of accessory muscles
Apyrexial:
p:
hs: normal
rr:
sats: %
BP:
wheeze: nill
crackles: nill
Appears well, stable Alert
No meningism / Brudzinski negative
Managing sentences
No use of accessory muscles
Apyrexial:
p:
hs: normal
rr:
sats: %
BP:
wheeze: nill
crackles: nill
Abdo: snt
Ears: nad
Throat: nad
Lymphadenopathy: nill
Ears: nad
Throat: nad
Lymphadenopathy: nill
Examination Peadiatric: Quick
Appears well
No meningism / Brudzinski negative
t:
p:
hs: normal
rr:
wheeze: nill
crackles: nill
Appears well
No meningism / Brudzinski negative
t:
p:
hs: normal
rr:
wheeze: nill
crackles: nill
Abdo: snt
Ears: nad
Throat: nad
Lymphadenopathy: nill
Rashes: nill
Ears: nad
Throat: nad
Lymphadenopathy: nill
Rashes: nill
Face 2 Face Patient
Amunir4695828
Hx as below
Amunir4695828
Hx as below
Face 2 Face Patient and other
Amunir4695828
Seen with Mother/ Father /Partner /Son/Daughter/ Carer
Hx as below
Amunir4695828
Seen with Mother/ Father /Partner /Son/Daughter/ Carer
Hx as below