Medical Clerking
Created by
Paul Hughes
Specialty
Physician
Last edited
10/20/2026
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About this template
A structured template for documenting comprehensive medical admissions, from the presenting complaint and clinical history through examination, investigations, impression, and management. It supports consistent recording of relevant background, medications, allergies, social factors, observations, and follow-up plans.
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PC
PC: Shortness of breath. Productive cough.
HPC
Patient presented on 24/10/2023 with a 4-day history of worsening SOB and productive cough yielding green sputum. Symptoms started acutely following a coryzal illness. Reports associated pleuritic chest pain on the right side, subjective fevers, and rigors. Reduced exercise tolerance from 500 metres to 10 metres due to dyspnoea. Inhaled salbutamol providing minimal relief. Denied any haemoptysis, orthopnoea, paroxysmal nocturnal dyspnoea, ankle swelling, calf pain, dysuria, diarrhoea, vomiting, or focal neurological symptoms.
PMH
- COPD
- Type 2 diabetes (on insulin)
- Atrial Fibrillation (on apixaban)
- Prostate cancer - Under surveillance
- Laparoscopic cholecystectomy (2015)
DH
- Apixaban 5 mg PO BD (08:00, 20:00)
- Metformin MR 1 gram PO BD
- Insulin glargine (Lantus®) 24 units SC ON (22:00)
- Bisoprolol 2.5 mg PO OD
- Tiotropium 18 mcg INH OD
- Salbutamol 100 mcg INH QDS PRN
- Colecalciferol 20 mcg PO OD
Allergies / ADRs
- Penicillin - Occurred in 1998, developed widespread urticarial rash and facial angioedema within 1 hour of oral dose, required IM adrenaline and hospital observation.
FH
- Father: IHD, MI at age 62
- Mother: T2DM
SH
- Retired carpenter
- Lives in a two-storey house with wife, independent with ADLs
- Ex-smoker - Stopped 5 years ago - 40 pack years
- Drinks 14 units per week (roughly 2 pints of beer three times a week at local pub)
- Denies recreational drug use
O/E
Uncomfortable at rest, speaking in short sentences, using accessory muscles. Chest: Coarse crackles and bronchial breathing at right base, widespread expiratory wheeze. CVS: HS I + II + 0, JVP not elevated, calves SNT, no peripheral oedema. Abdo: SNT, bowel sounds present, no organomegaly.
NEWS
NEWS 6 BP 138/82mmHg; HR 108bpm; Sats 91% on 2L; RR 24/min; Temp 38.2C; Alert
Investigations
CRP 142; Hb 134; WCC 15.8; Neut 12.9; Plt 285; INR 1.1; PT 12.4; APTT 29.0 Urea 8.4; Na 136; K 4.3; Creat 102 (baseline 88); eGFR 61 (baseline 72); cCa 2.35; Phos 1.1; Mg 0.82 Troponins 14 -> 15 ABG (28% Venturi mask) pH 7.38; pCO2 5.6; pO2 8.4; HCO3 24.5; Base Excess -0.5; Lactate 1.8 ECG: AF, rate 105 bpm, normal axis, no acute ST/T wave changes. CXR: Right lower zone consolidation, no pleural effusion or pneumothorax.
Impression
- Community-acquired pneumonia (CURB-65 = 2)
- Infective exacerbation of COPD
Plan
- Admit to respiratory ward
- Target SpO2 88-92% via controlled oxygen therapy
- Clarithromycin 500 mg PO BD and doxycycline 200 mg PO stat then 100 mg PO OD
- Prednisolone 30 mg PO OD for 5 days
- Salbutamol 2.5 mg and ipratropium 500 mcg nebulisers QDS
- Paracetamol 1 gram PO QDS PRN
- Send sputum for MC&S and urinary Legionella/pneumococcal antigens
- Monitor CBG QDS while on corticosteroids
- VTE prophylaxis: continue apixaban
How to use this template
This template can be used to assist with various tasks in the medical field. You can use it to generate notes, manage patient information, or assist with diagnosis and the Assessment and Plan. To use this template, simply click the “Use Template” button above. If you have any questions or need assistance, feel free to reach out to the support team or refer to the description and example output provided above.