GP Notes

Patient advises they have recently given up alcohol Heavy Drinker Usual daily consumption: Experiencing the following symptoms: - headaches - nausea - tremors - anxiety - hallucinations  - seizures. - Insomnia On Examination Appears agitated / in a withdrawal State Vital signs noted  Impression: Alcohol Withdrawal Management: 1. Valium 5mg qid 2. Maxolon 10mg tds prn 3. Thiamine 4. Given details to contact nearest detox centre for phone assessment and admission as soon as possible 5. Continue to try to maintain abstinence 6. Mental Health Plan prepared and referral psychologist arranged Present to ED or call ambulance if any seizures

A prescription for Temazepam has been provided to be used as a short term treatment for insomnia. The patient was advised of the risk associated with this treatment: 1. Possible dependence 2. Tolerance ie.  Continued use may cause the drug to lose its effectiveness 3. Morning sedation Encouraged to only use for a short term and try not to use more than 2 nights in a row I have also suggested other methods to assist with insomnia : - Guided meditation with apps / youtube - Don't drink coffee after 3pm - Reduce blue light exposure before bed or use apps to remove blue light on iphone/ipad - Increase physical output during the day but not immediately before bed Advised patient I would not prescribe this medication on an ongoing basis

Patient presents with lower back pain Associated burning pain going down the back of leg Side: Denies numbness of the leg Denies any weakness No trouble toileting and no numbness around the perianal region On Examination: Palpation of the lower back in the midline does not elicit any tenderness Straight Leg Raise: Pain on lifting the affected leg Unaffected leg did not cause any pain Slump Test - Positive Brief neurological examination of the lower limbs: - Normal power both sides - Normal gross sensation - Normal knee and ankle reflex Imp:   Sciatica ? Lumbar Disc prolapse Management: Explained the diagnosis to the patient and that usually improves in 6-12 weeks Discussed possible investigations: - Xray not advised - MRI-  Will usually determine the cause of pain but private fee involved Suggested seeing a physio for further assessment and exercise program Exercise and stretching particularly swimming Weight control Return immediately here or t

Patient presents with: - Redness of the skin - Itchiness - Dry scaly flaky skin Commenced: Recent exposure: Areas Affected: On examination: Red, dry and flaky skin in the following areas: Impression: Contact Dermatitis Suspected Allergen:  Plan: Advised the patient to remove exposure to the allergen If hands involved use gloves next time in contact with it Hydrocortisone Cream Prednisone 50mg daily for 3 days Return if symptoms worsen If develops shortness of breath or chest tightness call an ambulance

Presents for a refill of her oral contraceptive pill script Has been on this medication for some time without any ill effect No history of - Hypertension - DVT / PE - Migraine with aura Preventiative health screen: Cervical smears up to date Good Diet Exercises regularly Non smoker No concerns about mood Examination: BP:  Reason for contact: Oral contraceptive pill script Management: Script as requested

MENTAL HEALTH ASSESSMENT AND PLAN Patient Details: Name: _____________________________________________ DOB: ___________________ Gender:   Female  / Male Medical History:    Medications: Social History: Occupation: Marital status:   Single   / Married   / Defacto / Divorced  / Widowed / Other ____________ Sexual Orientation:       Heterosexual  / Homosexual / _________________ Lives with:   Is a Carer:     No Has a Carer: Self Alcohol:  Non Drinker / Social Light Drinker /  _______________________ Smoking:   Non Smoker  / Ex smoker /  _______________ PART 1- MENTAL HEALTH ASSESSMENT Reasons for Preparation of Mental Health Plan: Outcome Measurement Tool: Tool :  K10 Result: Other issues: Previous Mental Health or other behavioural Diagnosis: Substance Abuse History:    RISK ASSESSMENT: Thoughts of self harm? Occasional  / Regularly /  Has a Plan / Other _______________

Patient presents with  hearing loss Side Affected: Examination: The affected ear is inpacted with wax There is no trauma to the canal Reason for visit: Ear wax Management: Patient advised of treatment options: Treatment with Waxsol for a few days and return for syringing or Ear syringing now Patient elected to have ear syringed Advised of the following risks: - Perforation of the ear drum - otitis externa, damage to the external canal - pain, deafness, vertigo - tinnitus Ear Syringing performed - Large clumps of wax removed Relief of patient symptoms achieved Return if increasing ear pain

Patient presents with a painful tooth Tooth involved: Describes pain in the tooth when touched Jaw Pain Also reports subjective fevers On Examination: Patient appears well Palpation of the affected tooth elicits pain Some swelling around the tooth Impression:   Infected tooth Plan: 1. Oral antibiotics as prescribed 2. Regular panadol and nurofen for the pain 3. Arrange urgent dental review