Patient’s Data​

Patient’s name: Dorothy Evans

Age: 80-year-old female

Past Medical History

• Frailty 
• learning disability 
• Hypertension (Diagnosed 10 years ago) 
• Hypercholesterolaemia

Drug and Allergy History

• Ramipril 10 mg once daily 
• Amlodipine 5 mg once daily
• No known drug allergy 

Recent Notes/Consultation

Seen 2 months ago by Dr. Shane Stone (General Practitioner)

Visit at nursing home

Presenting complaint: Nursing staff reports persistent cough for 4 weeks. No red flags 

Examination findings: Chest clear, BP 120/62mmHg, Pulse 65bpm, RR 18cpm, Sp02 98% on air. Chest clear 

Plan: As cough is persistent, treat with oral antibiotics, Chest Xray arranged. 

Chest X-Ray Report

Patient Name: Mrs. Dorothy Evans
Date of Examination: 2 months ago 

Findings:

Lungs are clear with no evidence of consolidation, mass, or pleural effusion.

Cardiothoracic ratio is within normal limits.

No signs of pulmonary fibrosis or interstitial lung disease.

No bony abnormalities detected.

Conclusion:
No acute abnormalities identified.

Reported by: Mr Seun Tinubu
Designation: Advanced reporting radiographer 

John Butler, a Paramedic Practitioner from your practice, is calling to discuss some concerns about patient.