NOTES

HELEN NOTES General note advice NO BULLET POINTS OR EM DASHES, each new bit of info on a new line wihtout gaps. Please can you make a NEW problem SECTION FOR EACH INDIVIDUAL ISSUE, unless directly related please do not use hyphens/dashes First Problem: Chest Pain History (what has happened in a few lines in patient words). Each on a new line NO GAPS in paragraphs and no bullet points Using Heidi Health for note taking - consent gained and that notes have been verfied by myself before importing Seen alone/who with in this section please (please do not use - at the start of the sentences. formal and concise) Please ensure that all the negative findings are also included Use abbreviations where possible Examination: including consent for any intimate examination Comment to include: impression management plan (does not need to be dates of follow up, eg if just bloods can be bloods rather than list of which ones and dates of appointments safety netting and when to return if no better Summary: - The patient presented with chest pain. Examination was unremarkable. Plan includes blood tests and safety netting advice. Using Heidi Health for note taking - consent gained Seen alone. History: - Chest pain, started yesterday. - Patient reports a sudden onset of sharp chest pain, radiating to the left arm, associated with shortness of breath. No previous history of chest pain. - Location: left side of chest. Onset: sudden. Character: sharp. Radiation: left arm. Timing: intermittent. Exacerbating factors: exertion. Relieving factors: rest. Severity: 7/10. - No cough, fever, or recent travel. - No relevant risk factors. - No previous consultations. Relevant Investigations: - ECG performed, showing no ST elevation. B/G - Nil Meds - Nil FH - Father with history of IHD SH - Smoker, 20 cigarettes per day. Drinks alcohol occasionally. Lives with partner. Examination: - General appearance: Appears anxious but in no acute distress. - Temp 36.8 C, Sats 98%, HR 88 bpm regular, BP 130/80 mmHg, RR 18, - Cardiovascular examination: Normal heart sounds, no murmurs or rubs. - Respiratory examination: Clear lung fields bilaterally. Impression: Possible angina, rule out cardiac cause. Plan: - Discussed options with patient, patient happy with plan - Blood tests: FBC, U&Es, Troponin. - Advised to stop smoking. - Safety netting advice: return to the surgery immediately if chest pain worsens or new symptoms develop. Second problem: Shortness of Breath History (what has happened in a few lines in patient words). Each on a new line NO GAPS in paragraphs and no bullet points Using Heidi Health for note taking - consent gained and that notes have been verfied by myself before importing Seen alone/who with in this section please (please do not use - at the start of the sentences. formal and concise) Please ensure that all the negative findings are also included Use abbreviations where possible Examination: including consent for any intimate examination Comment to include: impression management plan (does not need to be dates of follow up, eg if just bloods can be bloods rather than list of which ones and dates of appointments safety netting and when to return if no better Summary: - The patient presented with shortness of breath. Examination was unremarkable. Plan includes blood tests and safety netting advice. Using Heidi Health for note taking - consent gained Seen alone. History: - Shortness of breath, started yesterday. - Patient reports a sudden onset of shortness of breath, associated with chest pain. No previous history of shortness of breath. - No cough, fever, or recent travel. - No relevant risk factors. - No previous consultations. Relevant Investigations: - ECG performed, showing no ST elevation. B/G - Nil Meds - Nil FH - Father with history of IHD SH - Smoker, 20 cigarettes per day. Drinks alcohol occasionally. Lives with partner. Examination: - General appearance: Appears anxious but in no acute distress. - Temp 36.8 C, Sats 98%, HR 88 bpm regular, BP 130/80 mmHg, RR 18, - Cardiovascular examination: Normal heart sounds, no murmurs or rubs. - Respiratory examination: Clear lung fields bilaterally. Impression: Possible angina, rule out cardiac cause. Plan: - Discussed options with patient, patient happy with plan - Blood tests: FBC, U&Es, Troponin. - Advised to stop smoking. - Safety netting advice: return to the surgery immediately if chest pain worsens or new symptoms develop.