Notes

A: Patent airway, no stridor
B: Chest clear on auscultation with normal breath sounds and air entry
C: HS |+||+0, regular, CRT <2sec
D: GCS 15 (4,5,6)
E: PEARL, Mouth: Moist MM
Tonsils: No redness, pus or exudate.
Abdomen SNT, Bowel sounds present.
Calf SNT no peripheral oedema.

Mental Status: Alert and oriented to person, place, and time.
Language and Speech: Fluent, intact naming, repetition, and comprehension.
Cranial Nerves:
II: Pupils equal and reactive, no relative afferent pupillary defect, normal visual fields and fundoscopic examination.
III, IV, VI: Extraocular movements intact, no gaze preference or deviation.
V: Normal sensation and motor function.
VII: No facial asymmetry.
VIII: Normal hearing to speech.
Motor: Full strength (5/5) in both upper and lower extremities.
Reflexes: Normal (2/4) throughout, bilateral flexor plantar response.
Sensory: Normal sensation to touch, temperature, and pinprick in all extremities.
Coordination: Normal finger-to-nose and heel-to-shin tests, no tremor or dysmetria.

A&E Template:

Presenting Complaint:

History of Presenting Complaint:

Past Medical History:

Medications:

Social History:

Family History:

Systems Review:

Immunisation History:

Previous A&E Attendances:

Current Health and Vital Signs:

F2F | Seen alone

Presenting complaint:
Persistent cough and shortness of breath for 2 weeks. Associated with occasional wheezing.

History:
No red flag symptoms (e.g. chest pain, haemoptysis, weight loss, night sweats).
ICE: Patient is concerned this may be asthma and expects medication to relieve symptoms.
PMH: Hypertension (diagnosed 5 years ago).
DH: Lisinopril 10mg OD. No known drug allergies.
FH: Father had COPD.
SH: Lives alone, works as a teacher. Smokes 5 cigarettes/day (10 pack-year history). No alcohol or illicit drug use.

Examination:

• Temp: 37.2°C
• SpO₂: 95% on air
• HR: 78 bpm
• BP: 130/85 mmHg
• RR: 18
• Chest: Bilateral wheeze on auscultation

Impression:
Persistent cough — likely diagnosis: chronic bronchitis.
Differential diagnoses: asthma, COPD.

Plan:

Safety netting: Advised to seek medical attention if symptoms worsen or new red flags develop (e.g. chest pain, haemoptysis). Call 111 or attend A&E if acute deterioration.

Arrange spirometry to assess lung function

Prescribe Salbutamol inhaler for symptomatic reliefa

Consider respiratory referral if no improvement or worsening symptoms

Review in 2 weeks

Date: [DD/MM/2025]
Time: [HH:MM]
Procedure: Venepuncture
Indication: Blood tests as requested on [form / electronic system]
Consent: Verbal consent obtained
Site: [e.g., Left antecubital fossa]
Technique: Aseptic technique used. Skin cleaned with alcohol wipe and allowed to dry. Appropriate vacutainer tubes filled.
Outcome: Blood sample obtained successfully with minimal discomfort. No immediate complications.
Post-procedure: Haemostasis achieved with cotton wool and tape. Patient advised to keep area clean and report any swelling or pain.
Tubes sent to lab for: [e.g., FBC, U&E, CRP]
Patient tolerated procedure well.

Presenting Complaint:

 
History of Presenting Complaint: 

Obstetric History (GxPxxx):

Gravida:

Para:

Gestation (EDD):

Booking history:

Previous pregnancies (mode of delivery, complications):

Current pregnancy: [e.g. antenatal care, scans, complications so far]

Past Medical History:
 

Surgical History:

Medications:
 

Allergies:
 

Social History:

Family History:

Obstetric complications:

Medical/genetic conditions:

Systems Review:

Pain/bleeding/leaking fluid:

Foetal movements:

Urinary symptoms:

Immunisation History:

Previous Obstetric/Delivery Notes (if applicable):

 
Current Health and Vital Signs:

BP:

HR:

RR:

Temp:

SpO₂:

Fundal height:

Lie and presentation:

Foetal heart rate: