Patient’s Data​

Patient’s name: Philip Gorman 

Age: 68 years old male 

Past medical history

• Hypertension
• Benign prostatic hyperplasia
• Aspergers syndrome 
• Severe learning disability – non-verbal
• Lives in a care home
• Deprivation of Liberty Safeguards (DOLS) in place
• Lacks mental capacity
• Brother, Andrew Gorman, holds Lasting Power of Attorney (LPA) for health and finance

Drug history/Repeat template

• Ramipril 2.5mg OD
• Tamsulosin 400mcg OD

Recent consultation/Notes

11 weeks ago – Seen by Dr Babatunde Peters (Clinical Practitioner Access Role)

Presenting Complaint: District nurses reported that the patient had declined annual blood tests on four occasions and had been aggressive during attempts

Patient was reviewed in person – appeared well, but continued to refuse bloods and was unable to stay for assessment

Plan: Withhold blood tests for the time being, as there was no imminent risk and the patient was clinically stable. To reassess in future

Andrew Gorman (patient’s brother and LPA) has booked a telephone appointment and is now on the line, requesting to speak with the GP to discuss his brother’s care and some issues.