Referral to ED Doctor

Telephone:
Fax:

Patient Details:
Name Mr Mohammed Islam (M) NHS No. 629 122 6170
Address 39 Austen Close, Loughton, Essex, IG10 Date of Birth 03 Jan 1961
3TX Home Telephone 020 8418 0782
Work Telephone
Email Mobile Telephone 07985 225535

Referrer Details:
Referring Clinician Dr Daniel Woodcroft GP Practice The Forest Practice
Address 26 Pyrles Lane, Loughton, Essex, IG10 Telephone 020 85084580
2NH Email

Referred To:
Name Date 02 November 2023

Reason for Referral:

?infective exac undiagnosed COPD
low sats

Further Details and Previous Consultations:

02 Nov 2023
H: 2/52 cough, flu like illness, wife had similar
fever/feeling unwell improved but ongoing cough and some SOB (only mentions SOB when asked directly)
no haemoptysis
not productive
ex long term smoker quit 3 years ago
no DX COPD E: does seem to be in some resp distress
tachypnoea
low sats 89-90%
chest - bilateral wheeze, few creps R base
NEWS score is 6 P: refer to A&E will attend now with letter
referred to PAH clinical navigator
NEWS2, NICE & SIRS Sepsis
NEWS2
NEWS2 National Early Warning Score: 6
Consultation
General
Encounter: Consultation (Xa1qL)
Temp: 36.9 C
RR: 26 breath/min
Sats: 90 %
BP: 121 / 79
HR: 83 bpm
Pulse: Pulse regular (XM02J)
NEWS2, NICE & SIRS Sepsis
NEWS2
NEWS2 National Early Warning Score: 6

Medical Problems:
Atypical chest pain (1828.), Jul 2000
Immunisation status unknown (68NK.), Jul 2005
Lloyd George and problem summary (9311.), Jul 2005
Notes summary on computer (9344.), Jun 2006

Mr Mohammed Islam 03 Jan 1961 629 122 6170 Page 1 of 2

Medication:
Acutes None
Repeats Budesonide 200micrograms/dose / Formoterol 6micrograms/dose inhaler CFC free, use as directed

Allergies:
None

Social Issues That May Affect Discharge Planning

e.g. Living alone, dependency, frailty, carer, cognitive impairment

Communication Needs
Main Language
Interpreter Not required
Hearing + Vision .
Communication Aids None recorded

Relationships
Carer

Care Co-ordinator
Next of Kin

L.Power of Attorney
Other
(eg family, medical teams, nurses, palliative care)

Key Information
Key Message / Special Note
Resuscitation Status Not recorded
Treatment Escalation None recorded.. . . No record of a signed advance decision (if incorrect, please
contact GP)

Blood Results (Last 2m):

FBC 22 Sep Hb 142 g/L, WCC 8.4 10^9/L, Plts 199 10^9/L, MCV 92 fL, Neut 4.4 10^9/L
2023
UE Na 139 mmol/L, K 3.9 mmol/L, Urea , Creat 79 umol/L, eGFR > 60
LFT 22 Sep 2023 ALT 14 iu/L, Alk Phos 82 iu/L, Bili 12 umol/L, Alb 40 g/L, GGT , Serum globulin , Total
Protein
CRP ESR
TFTs TSH , Free T4 INR
Bone Ca , Ca cor , Ca adj , Phos
Iron Ferritin , Iron Saturation , TIBC
Vitamins B12 , Folate
Lipids 22 Sep Chol 4.5 mmol/L, LDL 2.7 mmol/L, HDL 1.2 mmol/L,Chol:HDL ratio , Tri 1.4 mmol/L
2023
Random Glucose Fasting
Chol.
Fasting Glucose HbA1c 22 Sep 2023, 46
mmol/mol

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