{"text":"' CLINICAL INFORMATION \nPage 2 of 3 \n\u00a2 | Presenting complaint \nMain presenting \nReason for veferral \nCare type requested: Out Patient \nExpected outcome: Investigate \nPast medical history \nAt risk of chronic kidney disease - \nHypercaicaemia NEC .- \nHypokalaemia - \nAcute kidney injury - \nEmphysema . - \nGastritis unspecified - \nIron deficiency anaemias - \nBody mass index less than 20 - \nTermination of pregnancy - \nH\/Q: depresslon - \nDrug addiction - \nSchool problem - \nLifestyle risks \nHigh and Medium Priority Pre-existing conditions \nDescription o L aterality \nUnsteady on feet and general malaise . \nHistory of presenting complaint \/ examination findings \/ investigation resuits \nComplaint: \nReason for - Past few days feeling very unsteady on feet and generally weak \/ lethargic . Feels speech is also b!t \nReferral: slurred at times No headache \/ No vertigo . Had some LBP but now settled . \n' Temp 36.1 P= 88 reg BP 122\/78 Unsteady gait . looks frali and pale . No neuro deficit but heel toe gatt \nabnormal . \nAdmit medics \nDate Recorded \nModifier Extenslon \nNew event Acute of chronic kidney disease - \nNew event - \nNew event severe \nNew event - \nNew event - \nNew event - Mild: \nNew event \/ admitted. \nmedical \nand suicidal ideation \nCODEINE \nextreme school avoidance \nCurrent medication (Active Repeat medication issued within the fast 12 months) \nDrug name BNF code Formulation Dosage Frequency \n. 10MLTWICE DAILY AS \nPotassium citrate mixture 55968020 mi PER DR NO[more] \n. 1 TABLET ONCE A DAY \nMirtazapine 45mg tablets 88881020 tablet AT NIGHT \nColecalciferol 400unit 99763020 capsule ONE TO BE TAKEN DALY - \ncapsules \nEsomeprazole 40mg gastro- ) \nresistant capsules 98761020 capsule ONE DAILY \nFerrous fumarate 210mg 61843020 tablet ONE TABLET DAILY - \ntablets \nRecent medication (Any medication issued within fast 90 days not shown above) \nDrug hame BNF code Formulation Dosage Frequency \nFerious fumarate 210Mg 1443050 tablet 1 TABLET TWICE DAILY . \nTrimethoprim 200mg 68194020 tablet { TWICE A DAY - \ntablets \u2018 \n. ONE TABLET THREE TIMES \nDiazepam 2mg tablets 58980020 tablet A DAY [more] \nClinical warnings Smoking status \n- Course \nCourse \nstarted \n16-Dec- \n2022 \n14-Sep- \n2017 \n19-Dec- \n2023 \n04-May- \n2021 \n\u00a919-Jul- \n2022 \n. Duration \n3 \nstarted Duration \n23-Oct- \n2025 \n14-Oct- \n2025 \n10-Oct- \n2025 \nAlcohol consumption \nfile:\/\/\/N:\/PCTI\/Docman7\/Data_S1\/Document\/DMEDOC01\/00003900\/01919688 HTM ~ 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