Record for a patient who has just been to see their General Practitioner. Read and interpret the recor
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Get it written →Below is the record for a patient who has just been to see their General Practitioner. Read and interpret the record:
Sample patient medical record
Name: Jane Doe DOB: 29/05/1963
Presenting complaint: 3 month history of haemoptysis, shortness of breath and pleuritic chest pain with weight loss
Past History: prev L knee replacement, known ↑BP, ↑cholesterol. +smoking for 30 years, +alcohol 3-4 units per week.
Family history: Nil of note
Medication: Ramipril 2.5mg daily
Examination: BP 137/85, HR 88, O2 sats 96%. Chest: good air entry bilaterally. Weight 68kg (weight loss 8kg in 2 months)
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