Patient’s Data​

Patient’s Name: Margaret Collins

Age: 68-year-old female

Past Medical History:

• Hypertension 
• Osteoarthritis

Drug and Allergy History:

• Amlodipine 5 mg once daily
• Paracetamol as required
• No known drug allergies

Recent Notes/Consultation: 

Seen by Dr Hasnain Malik (Clinical practitioner access role) 4 Weeks ago 

Presenting complaint: Patient reported multiple symptoms including feeling generally unwell, with ongoing tiredness, a brief episode of sharp pain in her left knee that settled quickly, persistent back discomfort, hair thinning, and occasional abdominal pain. 

Examination: BP 125/60mmHg, Pulse- 65bpm, abdomen soft, non-tender, no masses, no lumps or bumps, chest clinically clear with normal heart sounds 

Impression; Medically unexplained symptoms 

Plan: Bloods including TFTs, LFTs, FBC, U+E’s, Ferritin, Ca-125, Coeliac screen and stool for calprotectin and FIT. Review in 2 weeks.

Investigation Outcome: All results returned within normal limits. Patient informed via standard text message. Advised to recontact if symptoms persisted or worsened. 

Patient booked routine telephone appointment to discuss concerns.