Health Professional's Report (Form 8)

Specialty: General Practitioner Health Professional's Report Form Date: 1 November 2024 Patient Name: [Sarah Jenkins] Date of Birth: [15/03/1988] Address: [42 Elm Street, London, SW1A 0AA] Referring GP: [Dr. Emily Clark] Practice Name: [City Central Medical Practice] Practice Address: [10 High Road, London, NW1 5CD] Reason for Referral/Report: [Patient presenting with persistent fatigue, generalised muscle aches, and difficulty concentrating for the past 3 months. Suspected chronic fatigue syndrome for further evaluation.] Relevant Medical History: * Previous hospital admissions: [None relevant to current presentation.] * Chronic conditions: [Mild asthma, well-controlled with inhaler. No other significant chronic conditions.] * Medications: [Salbutamol inhaler as needed. Fexofenadine 120mg daily for seasonal allergies.] * Allergies: [Penicillin (rash), Dust mites.] * Immunisation history: [Up to date with routine immunisations, including COVID-19 and annual flu jab.] Current Symptoms/Presenting Complaint (including duration and severity): * Fatigue: [Constant and debilitating, rated 8/10 on severity scale, significantly impacting daily activities and work performance. Present for approximately 3 months.] * Muscle Aches: [Widespread, migratory muscle aches, particularly in the neck, shoulders, and back. Rated 6/10. Present for 2.5 months.] * Cognitive Impairment: ["Brain fog", difficulty with memory recall and concentration. Affecting work productivity. Present for 2 months.] * Sleep Disturbances: [Unrefreshing sleep despite adequate hours. Frequent awakenings. Present for 3 months.] * Other: [Occasional headaches, mild gastrointestinal upset (intermittent constipation).] Physical Examination Findings (as relevant): * General: [Appears tired but alert. No acute distress.] * Cardiovascular: [S1 S2 normal, no murmurs. HR 72 bpm, regular. BP 120/75 mmHg.] * Respiratory: [Clear to auscultation bilaterally. No wheezes or crackles. RR 16 breaths/min.] * Abdominal: [Soft, non-tender, non-distended. Bowel sounds present.] * Musculoskeletal: [Mild diffuse tenderness to palpation in trapezius and paraspinal muscles. Full range of motion in major joints, no synovitis.] * Neurological: [Cranial nerves intact, normal tone and power 5/5 in all four limbs, reflexes 2+, plantars downgoing. No focal neurological deficits.] Investigations Performed and Results: * Full Blood Count (FBC): [Within normal limits.] * Erythrocyte Sedimentation Rate (ESR): [8 mm/hr (normal <20).] * C-Reactive Protein (CRP): [<1.0 mg/L (normal <5.0).] * Thyroid Function Tests (TFTs): [TSH 2.5 mIU/L, Free T4 15 pmol/L (all within normal range).] * Ferritin: [85 µg/L (normal 20-300).] * Vitamin D: [45 nmol/L (mildly insufficient, supplementation advised).] * Liver Function Tests (LFTs) & Renal Function Tests (RFTs): [All within normal limits.] * Urinalysis: [Negative for protein, glucose, and nitrites.] Impression/Provisional Diagnosis: [Chronic Fatigue Syndrome (CFS) / Myalgic Encephalomyelitis (ME) is suspected based on symptom profile and exclusion of other medical conditions. Further specialist evaluation recommended.] Management Plan/Recommendations: * Refer to a specialist chronic fatigue clinic for definitive diagnosis and management. * Advise pacing strategies and energy management techniques. * Recommend gentle, graded exercise program, avoiding post-exertional malaise. * Suggest cognitive behavioural therapy (CBT) for symptom management and coping strategies. * Prescribe Vitamin D supplement (Colecalciferol 20,000 IU weekly). * Regular follow-up with GP to monitor symptoms and progress. Additional Notes/Comments: [Patient is distressed by her symptoms and their impact on her quality of life. Emphasised a multidisciplinary approach will be beneficial.]