Registration Details - Patient No: 623


Personal details... Address details...
Sex M House Name Flat No Test Road
Surname Test No and Street 23
Previous Surname Village
Forenames Terry Town Leeds
Date of birth 01/01/1987 County
Title Mr Post Code
Calling Name Terry
Ethnic Origin
Birth Surname
Marital Status
Forensic Medical Examiner

HA/HB Details... Contact details...
Trading partner Wiltshire Health Authority Home Tel No
Registered GP Dr Peter Crouch Work Tel No
Usual GP Dr Peter Crouch Mobile Tel No
NHS Number E Mail Address
Residential Inst
Branch Surgery


Medical Record Details


Active Problems
Authorised By
Code
20/12/2002Contraception Status Known Oral Established Pill User (SMART) Dr CrouchCON7_SMART
20/12/2002Contraception Status Known Oral Established Pill User (SMART) Dr CrouchCON7_SMART
08/11/2002Night visit unsp.- claimable Mrs Gibson9823.
11/07/2002Hay fever - unspec allergen Dr SupportH172.
02/07/2002Teacher training principal prin Dr Crouch0321.
02/07/2002Moderate asthma Dr CrouchH33..
02/07/2002Seborrhoeic dermatitis Dr CrouchM101.
02/07/2002Infected sebaceous cyst Dr CrouchM0z..
02/07/2002Asthma Status Unknown (SMART) Ms JonesAST0_SMART
02/07/2002Asthma monitoring admin. Ms Jones9OJ..
02/07/2002Athlete's foot Ms JonesAB04.
02/07/2002Tetanus vaccination Ms Jones656..
02/07/2002Pain in lumbar spine Mrs GalletlyN142.
07/01/2002Headache Dr Morris1B1G.

Past Problems
Authorised By
Code
20/12/2002Asthma Status Known Moderate Asthma Dr CrouchAST4_SMART
02/07/2002Asthma Status Unknown (SMART) Dr CrouchAST0_SMART
02/07/2002Test request : Liver Function Test Dr CrouchEMISREQ|44D..
11/07/2002Lobar (pneumococcal) pneumonia Dr PicklesH21..
02/07/2002Domestic helpers/maids Dr Crouch0A8..
02/07/2002Plain X-ray hip/leg 52A..
02/07/2002C/O - low back pain Ms Jones16C5.
02/07/2002Adverse reaction to drug Ms JonesEMISDRGA
02/07/2002Pneumococcal vaccination Mrs Auckland6572.
02/07/2002Adverse reaction to drug Ms JonesEMISDRGA
02/07/2002Influenza vaccination 65E..
02/07/2002Low back pain Mrs GalletlyN142.
02/07/2002Pain in lumbar spine Mrs GalletlyN142.
02/07/2002Pain in lumbar spine Mrs GalletlyN142.
02/05/2001Asthma attack kjhgkhgjkgkjhgkjgkjgkjgkjgkjhgkjgkjgkjhgkjhgkjDr CrouchH33z1

Attachments
Authorised By
Code
08/01/2003Attachment and again
Save080103143456.tif		Mrs GalletlyEMISATTACHMENT
08/01/2003Attachment test again
Save080103143358.tif		Mrs GalletlyEMISATTACHMENT
08/01/2003Attachment testing wed
Save080103143253.tif		Mrs GalletlyEMISATTACHMENT
07/01/2003Attachment test
Save070103092130.tif		Dr CrouchEMISATTACHMENT
07/01/2003Attachment testing
Save070103091944.tif		Dr CrouchEMISATTACHMENT
23/12/2002Attachment test
Save231202142506.tif		Dr CrouchEMISATTACHMENT
19/12/2002Attachment test
Save191202081955.tif		Dr CrouchEMISATTACHMENT
19/12/2002Attachment test
Save191202081931.tif		Dr CrouchEMISATTACHMENT
19/12/2002Attachment test
Save191202081915.tif		Dr CrouchEMISATTACHMENT
11/12/2002Attachment ggggggg
Save111202123009.tif		Dr CrouchEMISATTACHMENT
28/05/2002Attachment 623 b
623b.tif		Ms JonesEMISATTACHMENT
28/05/2002Attachment 623
623.tif		Ms JonesEMISATTACHMENT
28/05/2002Attachment 623 2
6232.tif		Ms JonesEMISATTACHMENT
28/05/2002Attachment test attach 623 a
testattach623a_0.tif		Ms JonesEMISATTACHMENT
28/05/2002Attachment test attach 623 a
testattach623a.tif		Ms JonesEMISATTACHMENT
28/05/2002Attachment Test sheet
Testsheet_0.tif		Mrs GalletlyEMISATTACHMENT
28/05/2002Attachment TEST SHEET
TESTSHEET.tif		Mrs GalletlyEMISATTACHMENT
28/05/2002Attachment test attach to 623
testattachto623.tif		Ms JonesEMISATTACHMENT
28/05/2002Attachment test attach to terry 2
testattachtoterry2.tif		Ms JonesEMISATTACHMENT
06/2001Attachment callviacoop.tif
Dr CrouchEMISATTACHMENT
06/2001Attachment breastfeedinginfo.tif
breastfeedinginfo.tif		Dr MorrisEMISATTACHMENT

Referrals & Referral Activity
Authorised By
Code
None

Alerts
Authorised By
Code
None

Allergies
Authorised By
Code
None

Family History
Authorised By
Code
02/05/2001No relevant family history Dr Morris122..

Immunisations
Authorised By
Code
None

Due Diary
Authorised By
Code
02/11/2005Cervical neoplasia screen Dr Crouch6859.
02/07/2003Influenza vaccination General Practice SurgeryINTERNAL INTERNAL USER65E..
20/06/2003Asthma monitoring admin. Dr Crouch9OJ..

Investigations
Authorised By
Code
None

Values
Date
Last Entry
Normal Range Indicator
Normal Range
11/07/2002 O/E - height 400 cm ........... | 10-250
02/07/2002 O/E - pulse rate 60 beats/minute ........|.. 0-80
02/07/2002 O/E - weight 54 Kg
02/05/2001 Vaginal vault smear-inadequate
02/05/2001 Cerv.smear: mild dyskaryosis
02/05/2001 Cervical smear - candida
02/05/2001 Cervical smear endocervical cells present

Other observations and problem reviews
Authorised By
Code
16/07/2002Athlete's foot (REVIEW) Dr MorrisAB04.
16/07/2002Asthma monitoring admin. (REVIEW) Dr Tahir9OJ..
11/07/2002Athlete's foot (REVIEW) Dr SupportAB04.
11/07/2002Headache (REVIEW) Dr Support1B1G.
11/07/2002Athlete's foot (REVIEW) Dr SupportAB04.
11/07/2002Moderate asthma (REVIEW) Dr PicklesH33..
02/07/2002Asthma Status Unknown (SMART) (REVIEW) Dr CrouchAST0_SMART
02/07/2002Athlete's foot Dr CrouchAB04.
02/07/2002Pain in lumbar spine (REVIEW) N142.
02/07/2002Athlete's foot (REVIEW) AB04.
02/07/2002Asthma monitoring admin. (REVIEW) 9OJ..
02/07/2002Recurrence of problem Ms Jones16Z3.
02/07/2002Asthma monitoring admin. Dr Crouch9OJ..
30/06/2001Asthma attack (REVIEW) Dr CrouchH33z1
02/05/2001Vaginal discharge symptom Dr Morris1A7..
02/05/2001Vaginal discharge symptom Dr Morris1A7..
02/05/2001Cx. smear: repeat 5 years Dr CrouchEMISHGT61
02/05/2001Health ed. - breast exam. Dr Morris6795.
02/05/2001Cough Dr Morris171..

Consultations
20/12/2002Dr Peter Crouch at Main Surgery
Problem (FIRST)Contraception Status Known Oral Established Pill User (SMART)
- - - - - - - - - - - - - - - -
Problem (FIRST)Contraception Status Known Oral Established Pill User (SMART)
Examination
Colour : #014 LT. YELLOW
#014 LT. YELLOW
GLU NEGATIVE
BIL NEGATIVE
KET NEGATIVE
SG <=1.005
BLD NEGAT
IVE
pH 5.0
PRO NEGATIVE
UBG 3.2 umol/L

LEU NEGATIVE
FB
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20/12/2002Dr Peter Crouch at Main Surgery
Problem (FIRST)Asthma Status Known Moderate Asthma
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19/12/2002Dr Peter Crouch at Main Surgery
Examination
Colour : #013 RED
#013 RED
GLU NEGATIVE
BIL NEGATIVE
KET NEGATIVE
SG <=1.005
BLD* TRA
CE-LYSED
pH 5.0
PRO NEGATIVE
UBG 3.2 umol/L

LEU NEGATIVE
C2
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18/12/2002Dr Peter Crouch at Main Surgery
Examination
Colour : #011 LT. ORANGE
#011 LT. ORANGE
GLU NEGATIVE
BIL NEGATIVE
KET NEGATIVE
SG >=1.030
BLD*
TRACE-INTACT
pH 6.0
PRO NEGATIVE
UBG 3.2 umol/L

LEU NEGATIVE
9E
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18/12/2002Dr Peter Crouch at Main Surgery
Examination
Colour : #010 LT. RED
#010 LT. RED
GLU NEGATIVE
BIL NEGATIVE
KET NEGATIVE
SG >=1.030
BLD* TRACE-INTACT
pH 6.0
PRO NEGATIVE
UBG 3.2 umol/L

LEU NEGATIVE
19
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08/11/2002 01:31Mrs Susan Gibson at Hospital
Problem (FIRST)Night visit unsp.- claimable
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16/07/2002Dr June Morris at Main Surgery
Problem (REVIEW)Athlete's foot
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16/07/2002Dr Mustapha Tahir at Main Surgery
Problem (REVIEW)Asthma monitoring admin.
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16/07/2002Dr June Morris at Main Surgery
Problem (REVIEW)2Nd Hib/Dtp(Triple) + Polio Vaccine
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11/07/2002Dr Emis Support at Main Surgery
Problem (REVIEW)Athlete's foot
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11/07/2002Dr Emis Support at Main Surgery
Comment1St Hib/Dtp(Triple) + Polio Vaccine This is only a test
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11/07/2002Dr Emis Support at Main Surgery
Problem (FIRST)Hay fever - unspec allergen
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11/07/2002Dr Emis Support at Main Surgery
Problem (REVIEW)Headache
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11/07/2002Dr Emis Support at Main Surgery
Problem (REVIEW)Athlete's foot
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11/07/2002Dr Emis Support at Main Surgery
AdditionalCONFIDENTIAL
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11/07/2002Dr Emis Support at Main Surgery
AdditionalCONFIDENTIAL
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11/07/2002Dr Justin Pickles at Main Surgery
HistoryO/E - height, 400 cm
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11/07/2002Dr Emis Support at Night visit
Problem (FIRST)Lobar (pneumococcal) pneumonia
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11/07/2002Dr Emis Support at Main Surgery
Problem (REVIEW)Moderate asthma
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02/07/2002Dr Peter Crouch at Main Surgery
Problem (REVIEW)Asthma Status Unknown (SMART)
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02/07/2002Dr Peter Crouch at Main Surgery
Problem (FIRST)Teacher training principal prin
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02/07/2002Dr Peter Crouch at Main Surgery
Problem (FIRST)Moderate asthma
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02/07/2002Dr Peter Crouch at Main Surgery
ProblemAthlete's foot
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02/07/2002Dr Peter Crouch at Main Surgery
Problem (FIRST)Seborrhoeic dermatitis
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02/07/2002Dr Peter Crouch at Main Surgery
Problem (FIRST)Infected sebaceous cyst
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02/07/2002 at Main Surgery
Problem (FIRST)Plain X-ray hip/leg
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02/07/2002 at Main Surgery
Problem (REVIEW)Pain in lumbar spine
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02/07/2002 at Main Surgery
Problem (REVIEW)Athlete's foot
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02/07/2002 at Main Surgery
Problem (REVIEW)Asthma monitoring admin.
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02/07/2002Ms Delyth Jones at Main Surgery
Problem (FIRST)Asthma Status Unknown (SMART)
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02/07/2002Ms Delyth Jones at Main Surgery
Problem (FIRST)C/O - low back pain
ExaminationRecurrence of problem
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02/07/2002 at Main Surgery
ExaminationO/E - weight, 54 Kg
O/E - pulse rate, 60 /minute
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02/07/2002Mrs Gayle Auckland at Main Surgery
Problem (FIRST)Pneumococcal vaccination
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02/07/2002Dr Peter Crouch at Main Surgery
Problem (FIRST)Asthma Status Unknown (SMART)
MedicationAspirin Dispersible tablets 300 mg 2 tablet(s) 1 DAILY
- - - - - - - - - - - - - - - -
ProblemAsthma monitoring admin.
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02/07/2002Dr Peter Crouch at Main Surgery
Problem (FIRST)Test request : Liver Function Test
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02/07/2002Dr Peter Crouch at Main Surgery
HistoryO/E - weight, 800 Kg
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02/07/2002 at Main Surgery
Problem (FIRST)Influenza vaccination
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11/05/2002Mrs Jane Davies at General Practice Surgery
Comment Bloods
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11/05/2002Mrs Jane Davies at General Practice Surgery
Comment bloods taken FBC
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07/01/2002Dr June Morris at Main Surgery
Test RequestCONFIDENTIAL
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07/01/2002Dr June Morris at Main Surgery
Problem (FIRST)Headache
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08/10/2001Dr June Morris at Main Surgery
Problem test
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30/06/2001Dr Peter Crouch at Main Surgery
AdditionalEMIS attachment reference code callviacoop.tif
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30/06/2001Dr Peter Crouch at Main Surgery
Problem (REVIEW)Asthma attack
Test RequestCONFIDENTIAL
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02/05/2001Dr June Morris at Main Surgery
HistoryVaginal discharge symptom
ExaminationVaginal discharge symptom
Family HistoryNo relevant family history
Comment This is quite strange as this a male patient.
ResultTest request : Anal swab
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02/05/2001Dr June Morris at Main Surgery
Comment Trying to test to see where this is displayed in the consultation.
ExaminationCough
SocialHealth ed. - breast exam.
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02/05/2001Dr June Morris at Main Surgery
Problem A very sore head.
ExaminationDiastolic blood pressure, 222 mm Hg
Comment Patient must try and relax or they may have a stroke or heart attack through high blood pressure.
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02/05/2001Dr Peter Crouch at Main Surgery
Comment ljkhgkjgkjhg
Problem (FIRST)Asthma attack kjhgkhgjkgkjhgkjgkjgkjgkjgkjhgkjgkjgkjhgkjhgkj


Medication Details


Current
Date Commenced
Drug Details
Date Last Issue
Authorised By
Type
None

Past
Date Commenced
Drug Details
Date Last Issue
Authorised By
Type
18/02/2002 Paracetamol Capsules 500 mg 1-2 FOUR TIMES DAILY 100 capsules 18/02/2002P Dr Peter Crouch ACUTE
26/09/2002 Aspirin Dispersible tablets 300 mg 1 DAILY 2 tablet(s) 26/09/2002P Dr Peter Crouch ACUTE
19/12/2002 Prozac Capsules 60 mg 1-2 FOUR TIMES DAILY 12 capsule(s) 19/12/2002H Dr Peter Crouch ACUTE

All Issues
Date Isssued
Drug Details
Authorised By
Type
01/05/2001 Prozac Capsules 60 mg 1-2 FOUR TIMES DAILY 12 capsule(s) Dr Justin Pickles ACUTE
18/02/2002 Paracetamol Capsules 500 mg 1-2 FOUR TIMES DAILY 100 capsules Dr Peter Crouch ACUTE
02/07/2002 Aspirin Dispersible tablets 300 mg 1 DAILY 2 tablet(s) Dr June Morris ACUTE
26/09/2002 Aspirin Dispersible tablets 300 mg 1 DAILY 2 tablet(s) Dr Peter Crouch ACUTE
19/12/2002 Prozac Capsules 60 mg 1-2 FOUR TIMES DAILY 12 capsule(s) Dr Peter Crouch ACUTE