FOLLOW- UP NCD + BLOOD TEST REVIEW

A 58 years old male with underlying:

 HPT on T. Amlodipine 5mg 1/1 daily
 T2DM
 Hyperlipidaemia

CURRENT STATUS

 patient is keeping well

 no symptoms of heart failure or pedal oedema
 no history of hypoglycaemic attack
 compliant to medication, tolerating well
 BP well controlled, HBPM SBP range between 125-135 / DBP 75-85
 SMBG range between 7.5-8.5 mmol Highest 9.5
 Adopting some diet changes especially sugar

VITAL SIGNS on arrival shows BP = 140/90 PR 87 afebrile

ON EXAMINATIONS

– Lungs clear
– CVS, no murmur
– Per abdomen soft not tender
– Both lower limb no pedal oedema

RECENT BLOOD TEST reviewed

– no significant changes

ECG DONE today shows sinus rhythm, no any ischaemic changes

PLAN AND MANAGEMENT

Continue medications + maintain current diet

Advice on dietary concerns and weight loss strategies

- restrict oily and greasy foods

- control portion and eating habits
- engage in physical activity

TCA in 6/12 with FLP, weight measure and BMI

MVA CASE
had h/o falls from MB last 2/52
sustained multiple abrasion wound and right ankle pain.
X-ray was done - right talus chip # - we refer to HSTJ but pt did not turn up.
and 3 days ago alleged MB avoiding a dog,
ankle became more pain, unable to sleep
also having difficulty to walk due to pain
decided to come to our clinic for further check-up and medicine
worked as security guard

CURRENT STATUS AND EXAMINATIONS

keeping well,
vital sign remains stable
BP 130/80
CVS S1S2
Lungs clear
Abdomen soft

Right ankle minimal swelling tender to touch, ROM limited, sensation intact
XRAY - chip # seen, talus area

PLAN AND MANAGEMENT

Reassurance
counsel pt. and refer out to Orto clinic HSTJ for further management
sick leave

Low Back Pain

currently low back pain x 1/52.
dull aching – non radiating pain,
increased pain after wake up from sleep.
Urinating normal, no incontinence / leg numbness.

CURRENT STATUS AND EXAMINATIONS

keeping well,
vital sign remains stable
BP 130/80
CVS S1S2
Lungs clear
Abdomen soft

PLAN AND MANAGEMENT

Reassurance
counsel pt. and refer out to Orto clinic HSTJ for further management
sick leave

was having an acute diarrhoea x 5 times since last night

watery > soft stools, no blood

a/w abdominal pain which started today

however, no fever, no nausea/ vomiting

no h/o gastritis

was having dinner outside

CURRENT STATUS AND EXAMINATIONS
keeping well, right arm sometimes feels numb

claimed the pain now become less localized and lymph node has decreased in size
however, the nodes still hard in consistency

vital sign remains stable

BP 110/80
CVS S1S2
Lungs clear
Abdomen soft

PLAN AND MANAGEMENT

cont antibiotic for 5 more days (total 10 days course)
TCA 1/52 after complete the antibiotic
if no improvement -
for TB workout (CXR, Mantoux and sputum AFB x 3);
after the result, to refer out SOPD for their expertise.