Patient’s Data​

Patient’s name: David Wimpey

Age: 52-year-old male

Past medical history

• Hypertension
• Fatty liver disease (identified on ultrasound)
• Hypercholesterolaemia
• Alcohol excess 

Drug and Allergy History 

• Ramipril 10 mg once daily
• Atorvastatin 20 mg at night
• Tamsulosin 400 mcg once daily
• No known drug allergies

Alerts and QOFs

• Smoker: 20 cigarettes per day for the past 15 years (last update: 6 weeks ago)

Recent Notes/Consultations 

Seen by Dr Mariam Eltayeb (Clinical practitioner access role 6 weeks ago

Presenting complaint: Reports episodes of PR bleed and unintentional weight loss

Examination: Rectal examination revealed a palpable rectal mass. Patient noted to smell strongly of alcohol at the time of assessment

Plan: Blood tests, including FBC and liver function, FIT (Faecal Immunochemical Test). Referral under the 2WW (two-week wait) colorectal cancer pathway due to red flags (bleeding, weight loss, rectal mass)

Note Entry 3 weeks ago

Patient missed 2x appointment for blood test with HCA Mary White –advised if unable to attend to call and reschedule.

Letter from colorectal team 

Dear GP, 

You have referred David on account of PR bleeding, weight loss and rectal mass. David has missed two appointments so far and we have tried ringing him but no response. I do hope he is well.  There will be no further appointments sent. If there are still clinical concerns, please re-refer and we will be happy to see him

Signed

Mr Philip Havant, MCh FRCS(Colorectal)

Consultant colorectal surgeon. 

Caller: Mrs. Rose Rosenborg, Adult Social Worker on the phone seeking to discuss David Wimpey’s case further with a GP