Seen by Dr. Emeka Agu (Clinical practitioner role) – 4 weeks ago.
History: Home visit- reason for visit: Fall at home. Patient had a fall while moving from her room to kitchen this morning and had a long lie, sustaining injury to her right elbow.
Examination– deep laceration to right elbow with some bony
tenderness. BP 130/70
Plan: Admit via Emergency department to rule out fracture of right elbow and also suturing of laceration. Ambulance organised.
Emergency department letter
Dear GP,
I am writing to inform you about the discharge of your patient, Mary Trafford, who was admitted to St Anthony’s Hospital following a mechanical fall at home.
Mary sustained a deep laceration to her right elbow after tripping while moving from her room to the kitchen. There was some bony tenderness but no fracture was identified on X-ray. The wound was sutured under local anaesthesia, and she was stable throughout her stay. No new medications were started during her admission. She has been discharged back to yourcare with district nurses arranged to follow up with wound dressing and remove the stitchesin 10 days.
Please continue to monitor her general health and consider referring her for a falls assessmentor physiotherapy if necessary.
If you require further information, feel free to contact me.
Kind regards,
Dr Koffi Anan, MBBS (Ghana), FRCEM
ED Registrar
St Anthony Hospital
District nurse (Samantha Banks) on phone to discuss issues.