Annual Medical Letter

Please find below a copy of your medical report. If you have any queries, please let me know. Aged: 48 GP practice name: Evergreen Family Practice Reason for Medical: Routine Annual Health Check HISTORY / CURRENT CONCERNS * Fatigue, mild, for the past 3 months. * Occasional headaches, typically once a week, relieved with paracetamol. * Mild ankle pain, right ankle, exacerbated by prolonged standing. PAST MEDICAL HISTORY * Hypertension, diagnosed 5 years ago, well-controlled with medication. * Appendectomy, aged 12. * Seasonal allergies (pollen), managed with antihistamines. FAMILY HISTORY * Mother: Type 2 Diabetes, age 65. * Father: Coronary Artery Disease, age 70. * Sister: Breast Cancer, age 55. MEDICATION * Lisinopril 10mg, daily, oral. * Atorvastatin 20mg, daily, oral. * Cetirizine 10mg, as needed, oral. ALLERGIES * Penicillin: Rash (hives) ADVERSE CHILDHOOD EXPERIENCES * None reported. LIFESTYLE Smoking: Nil Alcohol: 2-3 units per week, social drinking (wine) Fluid Intake: Approximately 1.5 - 2 litres of water daily Diet: Balanced diet, occasional fast food. Attempts to limit processed foods. Exercise: Walking 30 minutes, 3-4 times per week. Occasional swimming. Sleep: Generally good, 7-8 hours per night. Occasional difficulty falling asleep due to stress. Stresses: Moderate work-related stress due to project deadlines. Optician: November 1, 2023, uses reading glasses. Audiology: No hearing issues or concerns. GENERAL SYSTEMIC ENQUIRY Respiratory System: * No shortness of breath * No wheezing * No chronic cough Cardiovascular System: * No chest pain * No palpitations * No fainting episodes Abdominal System: * Regular bowel habits (daily) * No abdominal pain * No blood in stool Gynaecological System: * Last menstrual period 2 weeks ago, regular cycles. * No abnormal bleeding or discharge. Genitourinary System: * No pain on passing urine * No blood in urine * No increased frequency or urgency Neurological System: * Occasional mild headaches * No dizziness * No visual disturbances (beyond presbyopia) Musculoskeletal System: * Right ankle pain, mild, intermittent. * No joint swelling or stiffness. Ear, Nose and Throat: * No earache * No nasal congestion * No sore throat Mental Health: * Reports feeling generally well, occasional low mood associated with work stress but resolves quickly. * No symptoms of depression or anxiety. EXAMINATION Height: 165 cm Weight: 75 kg BMI: 27.5 kg/m² Cardiovascular System: Pulse Rate: 72 bpm, regular rhythm Blood Pressure: 128/82 mmHg Heart Sounds: S1, S2 audible, no murmurs, rubs, or gallops. Lymph Nodes: Not palpable in cervical, axillary, or inguinal regions. Respiratory System: Chest clear to auscultation, good air entry bilaterally, no added sounds. Abdomen: Soft, non-tender, no masses or organomegaly. Bowel sounds present. Skin: No rashes, lesions, or suspicious moles noted. Musculoskeletal: Full range of motion in all major joints, mild tenderness on palpation of right ankle joint, no swelling or effusion. Neurological: Cranial nerves intact, normal tone and power, reflexes 2+ bilaterally, normal coordination. Ear, Nose and Throat: Tympanic membranes clear, no nasal polyps, pharynx clear. Breast Examination: No lumps, masses, or nipple discharge observed or palpated. DISCUSSION OF BLOOD RESULTS Full Blood Count: Within normal limits. Haemoglobin 13.8 g/dL. Renal Function: eGFR 85 mL/min/1.73m², creatinine 0.8 mg/dL. Within normal limits. Liver Function: All parameters within normal limits. ALT 30 U/L, AST 25 U/L. Metabolic Panel: Electrolytes and glucose within normal range. Glucose / Diabetes Screen: HbA1c 5.5%, random glucose 95 mg/dL. No evidence of diabetes. Iron Studies: Ferritin 80 ng/mL, TIBC 320 mcg/dL. Within normal limits. Lipid Profile: Total Cholesterol: 4.8 mmol/L LDL: 2.8 mmol/L HDL: 1.5 mmol/L HDL/TC Ratio: 0.31 Qrisk: 8% (10-year CVD risk) Thyroid Function: TSH 2.1 mIU/L, Free T4 1.2 ng/dL. Within normal limits. Prostate Specific Antigen (PSA): N/A (female patient) Vitamins: Vitamin D 28 ng/mL (mildly insufficient, requires supplementation). Hormones: N/A IMPRESSION * Essential Hypertension (controlled) * Hypercholesterolemia (managed) * Mild Vitamin D insufficiency * Non-specific fatigue (likely multifactorial, including stress) * Right ankle discomfort (likely musculoskeletal strain) MANAGEMENT PLAN * Continue current antihypertensive and statin medications. * Advise Vitamin D 1000 IU daily supplementation; recheck levels in 3 months. * Encourage stress management techniques and consistent sleep hygiene for fatigue. * Recommend RICE (Rest, Ice, Compression, Elevation) for right ankle discomfort; consider physiotherapy referral if pain persists. * Discuss lifestyle modifications: increase regular exercise, maintain balanced diet, and limit alcohol intake. * Follow-up in 6 months for routine review, sooner if concerns arise.