Andrew Barry
Age: 75 years old male
Doctor
Patient’s Data
Patient’s name: Andrew Barry
Age: 75-year-old male
Past medical history:
- Hypertension
- Hypercholesterolemia
- Osteoarthritis of Left knee and both wrists
Drug history /Repeat template
- Amlodipine 10mg OD (Stopped by Dr Beveridge- Reason- Ankle oedema)
- Ramipril 10mg OD (Stopped by Dr Daniel Stubbs- Reason- Dry Cough)
- Indapamide MR 1.5mg OD (Started 2 weeks ago)
- Atorvastatin 20mg OD
- Co-dydramol 10/500mg -2 Tabs up to 4 times daily for pain when needed
Recent notes/consultation
Seen 8 weeks ago by Dr Daniel Stubbs (Clinical practitioner access role)
Presenting complaint:
Reports dried cough ongoing for 6 weeks- he recalled he just had ramipril increased to 10mg at that stage. No red flag features. Recent Chest Xray done was NAD.
Plan: stop ramipril, start on Amlodipine. Re-Check BP in 2 weeks’ time
Seen by Dr Luke Beveridge (Clinical practitioner access role) 2 weeks ago
Presenting complaint:
Reports bilateral pedal oedema. Started on Amlodipine 4 weeks ago. BP controlled at 138/82mmHg. No red flags, likely medication induced.
Plan: Discontinue Amlodipine. Initiate Indapamide 1.5 mg modified-release, to be taken once daily. Arrange blood tests in 2 weeks to monitor renal function. Safety-netting advice given: patient advised to recontact the surgery if symptoms worsen or any concerns arise
Seen yesterday by: Katie Walsh (Health Care Assistant)
Blood tests taken.
Observations:Blood Pressure: 132/75 mmHg. Pulse: 78 bpm
Blood test results
| Test | Result | Reference Range | Previous Result (10 weeks ago) |
|---|---|---|---|
| Na+ (Sodium) | 130 mmol/L | 135 – 145 mmol/L | 134 mmol/L |
| K+ (Potassium) | 3.7 mmol/L | 3.5 – 5.3 mmol/L | N/A |
| Ca2+ (Adjusted) | 2.3 mmol/L | 2.2 – 2.6 mmol/L | N/A |
| Phosphate | 0.78 mmol/L | 0.74 – 1.4 mmol/L | N/A |
| Urea | 2.7 mmol/L | 2.5 – 7.8 mmol/L | N/A |
| Creatinine | 61 μmol/L | 59 – 104 μmol/L | N/A |
| EGFR | 73 | >90 (normal) | 72 |
Note: Laboratory contacted the GP surgery this morning to relay the result.
Patient was advised by Dr Beveridge to book a telephone appointment for review of his blood test results.