Physician's Assistant

Patient Details

Refined clerking (197 days ago 04:48)

Refined clerking Sun 21 September 2025 04:48

Last Modified: 197 days ago

MRN:

Content:

Medical ST5 Miller Clerking

Presenting Complaint:
Medication review

History of Presenting Complaint:
Patient attended for routine medication review. No specific presenting complaint documented.

Past Medical History:
• Moderate chronic obstructive pulmonary disease
• Atrial fibrillation (on anticoagulation)
• Epilepsy (on carbamazepine since 2008)
• Leg swelling requiring diuretic therapy
• Chronic pain

Drug History:
• Famotidine 20mg PO OD (replaces omeprazole)
• Folic acid 5mg PO OD
• Ventolin 200mcg inhaled PRN QDS
• Furosemide 20mg PO OM (restarted for leg swelling)
• Doublebase gel PRN for washing and moisturising
• Co-dydramol 10mg/500mg PO BD
• Carbocisteine 375mg PO TDS
• Trelegy Ellipta 92mcg/55mcg/22mcg inhaled OD
• Comfifast stockinette 10.75cm PRN
• Octenilin irrigation solution 350ml as directed
• Apixaban 2.5mg PO BD
• Ibuprofen 5% gel topical TDS
• Laxido Orange sachets 1-2 daily
• Adcal-D3 750mg/200unit BD
• Tegretol 200mg PO BD
• Salamol 100mcg inhaler 2 puffs QDS PRN
• Loratadine 10mg PO OD PRN

Allergy History:
Not documented

Social History:
Not documented

On Examination:
Not documented

Investigations:
None mentioned

Impression:
Routine medication review for patient with multiple comorbidities including COPD, atrial fibrillation, and epilepsy.

Management Plan:
1. Continue current medication regimen
2. Monitor for medication interactions and side effects
3. Review medication adherence
4. Consider medication reconciliation given extensive polypharmacy

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Patient Details

Refined clerking Sun 21 September 2025 04:48

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