Patient Details

70 year old woman

Current Medical History

  • Total knee replacement
  • GI reflux
  • Hypothyroidism
  • Hypertension

Results

  • All blood results are normal
  • Normal X ray
  • Normal MRI
  • BMI 23.5 kg/m2
  • BP 123/74 mmHg (sitting)
  • Cholesterol  4.5 mmol/l

Lifestyle

  • Retired cleaner
  • Ex-smoker 20 years
  • Little exercise
  • Alcohol units 20 /week

Current Medication

  • Co-codamol 30/500 8 tablets daily
  • Ibuprofen 400 mg 1 three times daily – as required (max 1.2 g in 24 hrs)
  • Omeprazole 20 mg once daily
  • Levothyroxine 25 micrograms once daily
  • Bendroflumethazide 2.5 mg once daily
  • Simvastatin 40 mg every night

Previous medication

  • Buprenorphine patch 20 micrograms/hour , post knee replacement 18 months ago

Current Function

  • A brief Pain Inventory questionnaire was completed showing an average pain score of 6 and an average interference score of 4 (see Pain Strategy)
  • No inflammation or swelling of joints, some stiffness on remaining in the same position for a long time
  • Good range of movement
  • No neuropathic symptoms
  • Some symptoms of postural hypotension on standing

Most Recent Consultations

  • At her most recent consultation her pain management was stable and she was feeling a bit constipated and tired
  • Feels tiredness is impacting on looking after her granddaughter  
  • Dizzy on standing