Thomas Hansford
Age: 75 years old male
Doctor
Patient’s Data
Patient’s name: Thomas Hansford
Age: 75-year old male
Past medical history:
- Hypertension
- Hypercholesterolemia
- Osteoarthritis of Left knee and both wrists
Drug history /Repeat template
- Amlodipine 10mg OD
- Atorvastatin 20mg OD
- Co-dydramol 10/500mg -2 Tabs up to 4 times daily for pain when needed
Recent consultation/notes
Seen by first contact Physiotherapist- Carl Beveridge (Physiotherapy access role) 5 weeks ago due to back pain –
Reports back pain ongoing for 1 week. No red flags, likely musculoskeletal. Analgesia-can try ibuprofen gel and back exercises. Safety netted and advised to Recontact if worsening
Seen 2 weeks ago by Dr Daniel Stubbs (Clinical practitioner access role)
Recurrent back pain, waking patient up at night, weight loss and feeling tired. Plan: continue Analgesia, request bloods and review afterwards
Bloods done
U+E and Bone Profile-Normal, FBC as below:
| Test | Result | Reference Range |
|---|---|---|
| HB (Hemoglobin) | 90 g/L | 130 – 180 g/L |
| Mean Cell Volume (MCV) | 84 fL | 80 – 100 fL |
| WCC (White Cell Count) | 3.1 x 109/L | 3.6 – 11.0 x 109/L |
| Platelet Count | 100 x 109/L | 140 – 400 x 109/L |
| CRP (C-Reactive Protein) | 80 mg/L | <7 mg/L |
| Plasma Viscosity | 6.8 mPa/s | 1.50 – 1.72 mPa/s |
Note: Patient booked appointment to discuss blood test results.