1. HEALTH SERVICES
SCOTLAND
BRANCH A
PATIENT ADMIN
CLINICIAN REPORT
FAO: DR A SMITH
PATIENT: BAAS18052008
Name: Alisha Sarr
DOB: 18/05/2008
Age: 4 years
Symptoms: Headaches, Fatigue, Pain of the joints, Swelling of hands and feet
Signs: Jaundice, Swelling to the left hand, Weak response
Past medical History: None available
Past Surgical History: None available
Medications: Calpol (5ml twice a day)
Allergies: None known
Family History: Not available
Social History: Patient is of Angolan origin, immigrated to UK September 2012. No previous
interactions with medical service.
Vitals: BP- 100/70 Resting heart rate – 120 Weight- 28lbs Height 36inches
Physical Exam – Taken by GP: Patient presented pale with visible swelling of the left hand, cold
to the touch. Lungs open and clear, no chest pain. Abdominal abnormalities included swelling of
upper left region and limited digestive sounds.
Testing – By GP: Urine – raised leukocytes
Testing – Nurse: Complete Blood Count (CBC), Fasting Blood Glucose (BG)
CBC: Venus blood taken, deposited and labeled into EDTA Whole blood (purple) tube.
01/09/2012 – 09.35
Name: Alisha Sarr DOB: 18/05/2008
GP: Dr A Smith Surgery: Branch A
Sample: Venus Info: CBC- 1805200899
Fasting BG: Venus blood taken, deposited and labeled into fluride and oxidate (grey) tube.
01/09/2012 – 09.39
Name: Alisha Sarr DOB: 18/05/2008
GP: Dr A Smith Surgery: Branch A
Sample: Venus Info: Fasting BG - 1805200898
Clinician
Sister Adams
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1 Albert Street Glasgow WWW.SCOTTISH-HEALTHCENTRE.COM