Scenario date: 15 January 2025
You are the orthopaedic registrar writing a discharge summary for an 82-year-old female patient, Mrs Dorothy Walsh.
Writing Task:
Using the information in the case notes, write a discharge summary to Dr Paul Okonkwo, General Practitioner.
In your answer:
- Expand the relevant notes into complete sentences
- Do not use note form
- Use letter format
- Include all information relevant to ongoing care
The body of the letter should be approximately 200–230 words words.
Patient Details:
| Name: | Dorothy Walsh (Mrs) |
| DOB: | 7 Apr 1942 |
| Height: 158cm Weight: 58kg |
| Social History: | Retired school librarian; Widow – husband deceased 2019; Lives alone, single-storey home; Daughter (Margaret) – primary carer, visits daily; Mobilises with 4-wheel walker indoors |
| Substance Intake: | Nil alcohol, nil smoking |
| Allergies: | Sulfonamides; latex |
| Family History: | - Mother – osteoporosis, hip fracture age 78
- Father – prostate cancer
|
Previous Medical History:
- Osteoporosis – on alendronate 70mg weekly + calcium/vitamin D
- Hypertension – amlodipine 5mg, perindopril 4mg
- Atrial fibrillation – apixaban 2.5mg BD
- Mild cognitive impairment (MoCA 22/30, 2023)
- Macular degeneration – right eye
- 2019 right knee arthroscopy
15 Jan 2025
- Admission: 8 Jan 2025 – mechanical fall at home (tripped on rug)
- Left intracapsular neck of femur fracture – confirmed X-ray/CT
- Surgery: 9 Jan 2025 – left total hip replacement (cemented)
- Procedure uncomplicated; EBL 300mL, no transfusion required
- Post-op: early mobilisation with physiotherapy from Day 1
- Walking 30m with frame by Day 3
- Apixaban withheld pre-op, restarted Day 2 post-op
- DVT prophylaxis: enoxaparin bridging completed
- Wound: healing well, staples in situ – remove Day 14 (22 Jan 2025)
- Bloods at discharge: Hb 98 (pre-op 112), CRP 45 (trending down)
- Pain: well controlled on paracetamol + PRN oxycodone (weaning)
- Physio recommendations: hip precautions ×6 weeks, continue walker
- OT: home assessment completed – raised toilet seat and grab rails installed
Plan:
- • Discharge home with daughter (15 Jan 2025)
- • Community nursing – wound review + staple removal 22 Jan
- • Outpatient orthopaedic review: 6 weeks (26 Feb 2025)
- • Continue apixaban 2.5mg BD
- • Wean oxycodone over next 2 weeks
- • Resume alendronate after 6-week review
- • GP to arrange DEXA scan and rheumatology review (osteoporosis optimisation)
- • Falls risk assessment by GP
- • Cognitive review: geriatric outpatient referral recommended