Jeffrey Smith
Age: 34 years old male
Doctor
Patient’s Data
Patient’s name: Jeffrey Smith
Age: 34 years old Male
Past medical history
- Hypertension – Newly diagnosed
Drug history/Repeat template
- Ramipril 5mg OD
Recent consultation/notes
Seen by Dr Yetunde Bakare (Clinical practitioner access role) 4 weeks ago
Presenting Complaint: The patient attended following a routine occupational health check at work, where elevated blood pressure was noted. He was advised to consult his GP for further assessment.
Examination findings: BP 185/110, Pulse 75bpm.
- Urinalysis done-negative—no blood, no leucocytes, no protein, no nitrates.
- Fundoscopy- normal
Impression: Severe hypertension
Plan:
- Urgent blood tests requested with plan to review results promptly
- Urine ACR
- Review blood pressure in 5 days
- Safety netting advice given
Seen by Dr Amanda Armitage (Clinical practitioner role) 3 weeks ago.
Results of Bloods filed
| Test | Result | Reference Range |
|---|---|---|
| Na⁺ (Sodium) | 139 mmol/L | 135 – 145 mmol/L |
| K⁺ (Potassium) | 3.7 mmol/L | 3.5 – 5.3 mmol/L |
| Ca²⁺ (Adjusted) | 2.3 mmol/L | 2.2 – 2.6 mmol/L |
| Phosphate | 0.78 mmol/L | 0.74 – 1.4 mmol/L |
| Urea | 2.7 mmol/L | 2.5 – 7.8 mmol/L |
| Creatinine | 104 μmol/L | 59 – 104 μmol/L |
| eGFR | 68 | >90 (normal) |
Additional Blood Tests:
Thyroid function test, HbA1c, cholesterol, CRP, LFTs – all reported as normal. Urine ACR – normal.
Examination Findings:
Blood pressure: 185/112 mmHg
Q-risk: 3%
Plan:
- Start on Ramipril 5mg OD.
- Discussed blood test results with the patient.
- Advised renal ultrasound scan (USS) to assess for any underlying structural abnormalities of the kidneys.
Renal Ultrasound Scan:
Patient had renal Ultrasound scan yesterday.
Findings:
Kidneys:
Both kidneys are enlarged with numerous bilateral cortical and medullary cysts of varying sizes.
The largest cyst in the right kidney measures 4.5 cm, and in the left kidney 3.8 cm.
There is no evidence of solid masses or suspicious lesions.
No hydronephrosis is noted.
Renal Parenchyma:
Cortical thinning is noted bilaterally.
There is no evidence of calcification or nephrolithiasis.
Other:
The bladder appears normal. No abnormal findings in the surrounding abdominal organs.
Impression:
Ultrasound findings are consistent with polycystic kidney disease (PKD).
Recommendations:
Correlation with clinical and laboratory findings is recommended.
Reported by: Dr. A. Johnson, Consultant Radiologist
Follow-up: Patient booked an appointment to discuss his scan results.