Health Record

Your rheumatologist can't guess your medical history or issues.  The more you tell him or her the better the treatment will be.  See this fun video.

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A health record example is a one page document which you and your patient carries with them (in your purse or wallet) at all times.  In an emergency clinical situation you would pass the one pager to the clinician.  It saves a lot of form filling and does not rely on anyone’s memory.  Use the following example.

Mary Smith

Severe Rheumatoid Arthritis

Immunosuppressed

Condition List

  • Blepharitis – diagnosed 2010
  • Total knee replacement of the right leg –June 2013
  • Cataract operation, right eye, 28 January 2014
  • Vasadepressor-type syncope episode 6 March, 2105
  • Sjögren's syndrome as a secondary  - diagnosed July, 2015

Regular Medications:

  • Tocilizumab,
  • Denosmab 60mg subcut injection 6 monthly from July 2014
  • Endone 5 mg tablets for flares, as required
  • Ezetrol, 10 mg for LDL per day
  • Prednisolone 3.5 mg per day
  • APO-Tramadol SR 150, 1 per day plus 200 1 per day
  • Pantoprazole 20mg per day
  • Sterilid eye cream

Bloods as at 7 July 2016

  • Rheumatoid factor 464 (less then 16)
  • CCP Abs 291 (less than 5)
  • Cholesterol Fasting 5.6 (less than 5.5); HDL = 0.9, LDL = 4.1
  • ESR 1 (less than 30)
  • ANA 320 homogeneous
  • CRP 0.4 (0-5)

Allergies, reactions and warnings:

Sulphur based drugs (swelling), Tetracycline (rash), Aspirin (if high dose Prednisolone, stomach bleeding), Atorvastatin (pain increase), Rosuvastatin (weakness and pain surge), Lyrica (depressed), Alendronate Sodium (pain increase), Risedronate (ill, jaw pain), Ciclosporin (not compatible) and Protos (not compatible).

End of Life Will - yes

Clinicians

Rheumatologist: Dr C. XXXX

GP : Dr Craig XXX. 

Colorectal Surgeon: Dr Chris XXX

Cardiac Specialist: Dr R. XXXX

Knee Surgeon: Dr Peter XX

Eye Specialist: Dr Ken XXX

Immunologist: Dr Kate XXX

ENT: Dr  J XXX

Carer:  Christine YYYY + (phone No.)

 

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