{"text":"CH! Number: 0809555328 Patient Name: CLELLAND, AGNES \nLeft foot 1st MTPJ fusion \nPMH _ \nHTN - BP 121\/90 17\/08\/18 \nType 2 diabetes --medication controlled \nVit B12 deficiency \nOA \nGORD \nPrevious benign oesophageal stricture (stretched) \nErythema multiforme \nPrevious psittacosis from budgies \nRecurrent + persistent haematuria 2011 \nChronic fatigue syndrome \nDepression \nAngina - last used GTN spray a few months ago \nAsthma - last used blue inhaler 2 weeks ago, never been in hospital with breathlessness \nAppeaf:s in good general health at present. Mobilising with a stick today \nAppears to have good ROM to head\/neck\/jaw, skin integrity is intact at present, no allergies or MRSA history \nnoted. \nFasting instructions given and information leaflets provided. \nAdvised to bring all medication to admission & omit Ramipril and Aspirin on morning-of surgery. \nAdvised to contact pre op clinic should any changes occur with general health, including any hospital admissions \nor medication changes, failure to do so may lead to surgery being cancelled. ' \nLives with husband & has good family support daily, has own transport arrangements for admission\/discharge. \nStobhil\/GRI SDAU - amber? Previous amber for lefi foot \nClerk in \nPMH as documented in above assessment. \nCvs \nHypertension \nAngina, last used GTN spray approx 3months ago, on exertion \nHS 141140 . \nNo obvious murmur \nWell perfused \nNo oedema - \nRESPIRATORY \nAsthma, well controlled, doesn't use inhalers daily. No recent infections \nAE+EXP= Good L=R \nVesicular sounds \nPercussion resonant \nABDOMEN \nType 2 diabetes - medication controlled \nOmeprazole secondary to 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