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
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 /
Eye contact: Good
Speech: Normal
Kempt
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
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
Ears: Nill obvious
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
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
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
Phone consult:
GM Notes Checked:
Consult with
GM Notes Checked:
Consult with
RESPIRATORY Adult
Cough cold last few days / weeks
OTC meds: Yes
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
e+d: ok
n+v: nill
Cough cold last few days / weeks
OTC meds: Yes
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
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
Nausea/Vomiting:Nill
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
Nausea/Vomiting:Nill
Bowel Motion: Normal
Diarrhoea: Nill
Urine output: Normal usual amounts
No dysuria
Review post weeks: 2/3/4/
Review post weekend if symptoms not settled
Review post abx if symptoms not settled
Review post weekend if symptoms not settled
Review post abx if symptoms not settled
EXAM ADULT QUICK
Appears stable
Alert
Apyrexial
t:
p:
rr:
sats: %
Chest clear
wheeze /crackles: nill
Throat: clear
Appears stable
Alert
Apyrexial
t:
p:
rr:
sats: %
Chest clear
wheeze /crackles: nill
Throat: clear
@//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
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
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
OTC meds: Yes
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:yes
Inhalers: yes
e+d: ok
n+v: nill
Exposure factors: Dust/mold/pets/smoke
Cough cold last few days / weeks
OTC meds: Yes
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:yes
Inhalers: yes
e+d: ok
n+v: nill
Exposure factors: Dust/mold/pets/smoke
RESPIRATORY Peadiatric
Chesty cough
Occasional murky sputum
Fevers: Nill / ?on/off
Wheeze: nill
Breathlessness: nill
Hx asthma:nill
Inhalers: nill
e+d: ok
n+v: nill
Chesty cough
Occasional murky sputum
Fevers: Nill / ?on/off
Wheeze: nill
Breathlessness: nill
Hx asthma:nill
Inhalers: nill
e+d: ok
n+v: nill
Exposure factors: Dust/mold/pets/smoke
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
RESPIRATORY Peadiatric
Asthma / copd
Chesty cough
Occasional murky sputum
Fevers: Nill / ?on/off
Wheeze: nill
Breathlessness: nill
Hx asthma:yes
Inhalers: yes
e+d: ok
n+v: nill
Asthma / copd
Chesty cough
Occasional murky sputum
Fevers: Nill / ?on/off
Wheeze: nill
Breathlessness: nill
Hx asthma:yes
Inhalers: yes
e+d: ok
n+v: 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
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
EXAM PEAD QUICK
Appears Stable Alert
No meningism /
Kernig / Brudzinski negative
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 Stable Alert
No meningism /
Kernig / Brudzinski negative
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
Safety net advice:
Meningitis / scarlet fever
Discussed signs of dehydration
Meningitis / scarlet fever
Discussed signs of dehydration
? DNA:
>>>>> ? DNA >>> Reschedule / OOH 111/ A+E
>>>>> ? 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
Appears stable
Alert
Managing sentences
No use of accessory muscles
Apyrexial
t:
p:
rr:
sats: %
Chest clear
wheeze /crackles: nill
Throat: clear
EXAM ADULT QUICK: Meningitis
Appears stable
Alert
No meningism / Brudzinski negative
Apyrexial
t:
p:
rr:
sats: %
Chest clear
wheeze /crackles: nill
Appears stable
Alert
No meningism / Brudzinski negative
Apyrexial
t:
p:
rr:
sats: %
Chest clear
wheeze /crackles: nill
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
COUGHS AND COLDS
Cough cold last week or so
Flu like illness last week or so
Cough cold last week or so
Flu like illness last week or so
Likely Viral illness Common cold
Liase with chemist
OTC Cough cold meds
Liase with chemist
OTC Cough cold meds
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
EAR EXAM :
Appears stable Alert
No meningism / Brudzinski: Negative
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
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 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
5 min |
5 |
6 |
7 |
8 |
9 |
10 |
11 |
12 |
13 |
14 |
15 |
16 |
60 min |
60 |
72 |
84 |
96 |
108 |
120 |
132 |
144 |
156 |
168 |
180 |
192 |
EXAM FEMALE abdomen
Appears stable
Alert
No meningism
No Jaccyol
Apyrexial
t:
p:
hs: normal
bp:
rr:
sats: %
wheeze: nill
crackles: nill
Abdo: snt
No LkkS
Ho intact bilat
Throat: nad
Lymphadenopathy: nill
Urine dip
Pregnancy test:
Appears stable
Alert
No meningism
No Jaccyol
Apyrexial
t:
p:
hs: normal
bp:
rr:
sats: %
wheeze: nill
crackles: nill
Abdo: snt
No LkkS
Ho intact bilat
Throat: nad
Lymphadenopathy: nill
Urine dip
Pregnancy test:
EAR TREATMENT :
Keep ears dry
Abx oral:
Ear med:
Deny allergy:
Safety net advise meningitis/ mastoiditis
Keep ears dry
Abx oral:
Ear med:
Deny allergy:
Safety net advise meningitis/ mastoiditis
EXAM MALE abdomen
Appears stable
Alert
No meningism
No Jaccyol
Apyrexial
t:
p:
hs: normal
bp:
rr:
sats: %
wheeze: nill
crackles: nill
Abdo: snt
No LkkS
Ho intact bilat
Throat: nad
Lymphadenopathy: nill
Urine dip
Scrotum/testes:
Appears stable
Alert
No meningism
No Jaccyol
Apyrexial
t:
p:
hs: normal
bp:
rr:
sats: %
wheeze: nill
crackles: nill
Abdo: snt
No LkkS
Ho intact bilat
Throat: nad
Lymphadenopathy: nill
Urine dip
Scrotum/testes:
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Counselling contacts, wellbeing / samaritans
Crisis team contact / 111 / a+e
Crisis team contact / 111 / a+e
Counselling contacts, wellbeing / samaritans
Drug and Alcohol support contacts
Crisis team contacts / 111/ a+e
Drug and Alcohol support contacts
Crisis team contacts / 111/ a+e
EXAM PEAD FULL
Appears Stable
Alert
interacting
No meningism
Kernig / 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 Stable
Alert
interacting
No meningism
Kernig / 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
EXAM PEAD QUICK
Appears Stable Alert
No meningism /
Brudzinski negative
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 Stable Alert
No meningism /
Brudzinski negative
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
EAR TREATMENT :
Keep ears dry
Abx oral:
Ear med:
Deny allergy:
Safety net advise meningitis/ mastoiditis
Keep ears dry
Abx oral:
Ear med:
Deny allergy:
Safety net advise meningitis/ mastoiditis
EAR EXAM :
Appears stable Alert
No meningism /
Brudzinski: Negative
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
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
RESPIRATORY Croup
Chesty cough
Occasional murky sputum
Fevers: Nill / ?on/off
Wheeze: nill
Stridor: nill
Salivary pooling: nill
Croupy cough: nill
Breathlessness: nill
Hx asthma:nill
Inhalers: nill
e+d: ok
n+v: nill
Chesty cough
Occasional murky sputum
Fevers: Nill / ?on/off
Wheeze: nill
Stridor: nill
Salivary pooling: nill
Croupy cough: nill
Breathlessness: nill
Hx asthma:nill
Inhalers: nill
e+d: ok
n+v: nill
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
Safety net advice:
Meningitis / scarlet fever
Discussed signs of dehydration
Meningitis / scarlet fever
Discussed signs of dehydration
COUGHS AND COLDS
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
Liaise with chemist
OTC Cough cold meds
TCB as required
Urgent attention if any acute deterioration
Review with own GP if not settled
Headache
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
Hormonal meds: combined pill/ hrt: nill obvious
Examination
Apyrexial
Alert
T:
P:
Bp:
Rr:
No meningism
Perla/ eom full rom
Opthalmoscopy nad
Cns pns inytact 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
Hormonal meds: combined pill/ hrt: nill obvious
Examination
Apyrexial
Alert
T:
P:
Bp:
Rr:
No meningism
Perla/ eom full rom
Opthalmoscopy nad
Cns pns inytact 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
Emergency contacts,
Crisis team contacts / 111/ a+e
CRISIS TEAM Wigan mental health
08 000 513 253
Counselling contacts
Wellbeing counselling
24/7 Helpline 08 08 23 89 888
Samaritans 116 123
Bereavement Support
Cruise bereavement 0808 808 1677
Google:
ANDYS MANS CLUB
THE BRICK
Crisis team contacts / 111/ a+e
CRISIS TEAM Wigan mental health
08 000 513 253
Counselling contacts
Wellbeing counselling
24/7 Helpline 08 08 23 89 888
Samaritans 116 123
Bereavement Support
Cruise bereavement 0808 808 1677
Google:
ANDYS MANS CLUB
THE BRICK
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
PSYCHIATRIC
Previous mental health hx:nill
cahms/ cmt: nill
Mental health meds:
Antidepressant:
Anxiolytic:
Sedative:
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:
Discussed
Antidepressant:
Anxiolytic:
Sedative:
Home: Any issues: Nill
Lives with:
Work: Any issues: Nill
Job:
Trigger factors:
Recreation:
Discussed
Antidepressant:
Anxiolytic:
Sedative:
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
RESPIRATORY Adult
Cough cold last few days / weeks
OTC meds: Yes
Chesty cough
Occasional yellowy/ 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
OTC meds: Yes
Chesty cough
Occasional yellowy/ 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
Infective exacerbation
Asthma / copd
Antibiotic: Dey 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
Asthma / copd
Antibiotic: Dey 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 Clarithro
Clarithromycin deny allergy
Calpol / otc neurofen if required
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 deny allergy
Calpol / otc neurofen if required
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
Calpol / otc neurofen if required
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
Calpol / otc neurofen if required
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
