| Patient demographics | |||||
| Patient name | Date of birth | Gender | Ethnicity | NHS number | |
| SMITH, Richard (Mr) | 01-Jan-1957 | Male | British | Verified - 135 246 5790 |
|
Home Address 21, Grove Street |
|
|
GP Practice |
|
| MGP Medical Centre |
Address 1 MGP HouseOvertown Leeds West Yorkshire LS21 7PA |
Phone 01634111222 Email jlorenzo@MMC.co.uk |
|
GP Practice Code GP123456 |
| Document Created | 17-Feb-2015, 10:00 |
|---|---|
| Document Owner | XYZ NHS trust |
| Authored by | XYZ Hospital on 14-Feb-2015, 09:00 |
| Other participant(s) in this document |
|---|
| Participant | |
|---|---|
| Participant Name | Dr John Lorenzo |
|
Work Address 1 MGP House |
Work Phone 01634111222 |
| Referred By | |
|---|---|
| Referrer Name | Mr Richard Smith - Self |
| Admission method | Emergency |
|---|---|
| Date of admission | 12-Feb-2015 |
| Source of admission | Usual place of residence |
| Causative agent | Penicillin |
|---|---|
| Description of the reaction | Rash. No swelling/anaphylaxis |
| Assessment scales | TIMI score=2 |
|---|
| Clinical Summary |
|---|
| 58 year old man with an acute history of cardiac sounding chest pain lasting around 2 hours. |
| Examination unremarkable. |
| Inferior ischaemic changes on ECGs and raised Troponin T. |
| Coronary angiogram demonstrated diseased RCA, drug eluting stent successfully placed. |
| Appropriate secondary prevention medications prescribed and for follow up with Cardiac Rehabilitation team. |
| Diagnosis |
|---|
| Cardiac chest pain/ACS |
| Discharging consultant | Mr Abacus |
|---|---|
| Date of discharge | 16-Feb-2015 |
| Discharge method | Patient discharged on clinical advice |
| Discharge destination | Usual place of residence |
| Information Given |
|---|
| Patient seen by Cardiac Rehab and information given regarding diagnosis, lifestyle change and benefits of rehab programme. |
| Community follow up planned. |
| FBC | 5 x 10 12 /L, WCC: 11.1 x 10 9 /L, Hb: 150 g/dl, neutrophils: 7.0 x 10 9 /L, eosinophils: 0.40 x 10 9 /L, lymphocytes: 3.5x10 9 /L, monocytes: 0.3 x 10 9 /L |
|---|---|
| Arterial Blood Gases | PH: 7.41, pO 2 : 13 kPa, pCO 2 : 6.0kPa, HCO3: 24 mEq/L, B.E.: +2 mmol/L |
| ECG | Inferior ischaemic changes |
| Chest Xray | Normal |
| Advance decisions about treatment |
|---|
| Declines blood products - patient is a Jehovah’s witness |
| Medication Name | Ramipril |
|---|---|
| Dose | 2.5mg |
| Medication Frequency | OD |
| Route | oral |
| Medication Recommendations | continue |
| Medication Name | Omeprazole |
|---|---|
| Dose | 20mg |
| Medication Frequency | OD/PRN |
| Route | oral |
| Medication Recommendations | continue |
| Medication Name | Aspirin |
|---|---|
| Dose | 75mg |
| Medication Frequency | OD |
| Route | oral |
| Medication Recommendations | continue |
| Medication Name | Clopidogrel |
|---|---|
| Dose | 75mg |
| Medication Frequency | OD |
| Route | oral |
| Medication Recommendations | 1 year then stop |
| Medication Name | Simvastatin |
|---|---|
| Dose | 40mg |
| Medication Frequency | OD |
| Route | oral |
| Medication Recommendations | continue |
| Medication Name | Bisoprolol |
|---|---|
| Dose | 5mg |
| Medication Frequency | OD |
| Route | oral |
| Medication Recommendations | Uptitrate according to BP and HR |
| Participation in research |
|---|
| None |
| Patient and carer concerns |
|---|
| Concern re possibility of heart attack/similarity with mothers illness. |
| Worried about ability to drive and work/financial implications. |
| Name | Dr Paul Rastall |
|---|---|
| Designation or role | On call Dr |
| Grade | SpR |
| Specialty | Medicine |
| Actions |
|---|
| GP please continue secondary preventative medication. |
| Doses will be uptitrated by Cardiac Rehab team. |
| Procedures |
|---|
| Coronary Angiogram with stent to right coronary artery (RCA) |
| Safety Alerts |
|---|
| None |
| Household composition | Lives alone |
|---|---|
| Lives alone | No |
| Occupational history | Self employed electrician |