Y3 Medical Documentation - Working Example by Dr Matthew Mathieson (School of Medicine and Dentistry) https://padlet.com/nommathieson3/4osua0lqieofqncf en-us 2025-08-29 07:53:50 UTC 2025-09-02 10:51:41 UTC hello@padlet.com Presenting Complaint and Background/PMH: nommathieson3 https://padlet.com/nommathieson3/4osua0lqieofqncf/wish/3560866693

  • 28-year-old admitted with SOB. Referred to Medicine for ? PE due to positive D-dimer. She has had x1 treatment dose of clexane. ​

  • Background: Previous DVT, previous investigations for asthma

    • ]]>     2025-08-29 14:46:54 UTC https://padlet.com/nommathieson3/4osua0lqieofqncf/wish/3560866693     nommathieson3 https://padlet.com/nommathieson3/4osua0lqieofqncf/wish/3560867907 2025-08-29 14:48:17 UTC https://padlet.com/nommathieson3/4osua0lqieofqncf/wish/3560867907 Initial Information: nommathieson3 https://padlet.com/nommathieson3/4osua0lqieofqncf/wish/3560874978

  • Patient: Mrs Ellen ID number: 123456​

  • 06/09/22  12:00​

  • Ward round: Dr Sherif (Medical Consultant)

    • ]]>     2025-08-29 14:55:39 UTC https://padlet.com/nommathieson3/4osua0lqieofqncf/wish/3560874978     Ward Round Information nommathieson3 https://padlet.com/nommathieson3/4osua0lqieofqncf/wish/3562101005

  • Today: 

    • Still feeling short of breath, denies chest pain. She is concerned about a clot in her lungs.​ CTPA discussed with her.           ​

  • ​O/E:

    • NEWS = 4. 99% RA. HR 115, RR 22​

    • ​Alert. Looks well. Speaking in full sentences​

    • Bilateral wheeze. No focal signs. Calves SNT​

    • ]]>     2025-08-31 16:06:17 UTC https://padlet.com/nommathieson3/4osua0lqieofqncf/wish/3562101005     nommathieson3 https://padlet.com/nommathieson3/4osua0lqieofqncf/wish/3562102554 2025-08-31 16:08:58 UTC https://padlet.com/nommathieson3/4osua0lqieofqncf/wish/3562102554 Investigations: nommathieson3 https://padlet.com/nommathieson3/4osua0lqieofqncf/wish/3562103271

  • Inv: Troponin negative

    • ]]>     2025-08-31 16:10:42 UTC https://padlet.com/nommathieson3/4osua0lqieofqncf/wish/3562103271     nommathieson3 https://padlet.com/nommathieson3/4osua0lqieofqncf/wish/3562104265 2025-08-31 16:13:23 UTC https://padlet.com/nommathieson3/4osua0lqieofqncf/wish/3562104265 Impression, Plan, and Sign Off: nommathieson3 https://padlet.com/nommathieson3/4osua0lqieofqncf/wish/3562105991

  • Imp: Need to exclude PE​

  • ​Plan:

    1. Salbutamol nebs ​

    2. Peak flow pre/post nebs​

    3. CTPA this morning (needs new cannula)​

    4. If CTPA +ve may need anticoagulation – discuss with haematology​

    5. Confirm above plan with supervising clinician​

    ]]>     2025-08-31 16:16:31 UTC https://padlet.com/nommathieson3/4osua0lqieofqncf/wish/3562105991     nommathieson3 https://padlet.com/nommathieson3/4osua0lqieofqncf/wish/3562107552 2025-08-31 16:19:58 UTC https://padlet.com/nommathieson3/4osua0lqieofqncf/wish/3562107552 nommathieson3 https://padlet.com/nommathieson3/4osua0lqieofqncf/wish/3562107872 2025-08-31 16:20:40 UTC https://padlet.com/nommathieson3/4osua0lqieofqncf/wish/3562107872 Completed Example: nommathieson3 https://padlet.com/nommathieson3/4osua0lqieofqncf/wish/3562109434 2025-08-31 16:23:58 UTC https://padlet.com/nommathieson3/4osua0lqieofqncf/wish/3562109434 nommathieson3 https://padlet.com/nommathieson3/4osua0lqieofqncf/wish/3564711995 2025-09-02 08:56:54 UTC https://padlet.com/nommathieson3/4osua0lqieofqncf/wish/3564711995