Patient’s Data​

Patient’s name: Fred Callaway 

Age: 77-year-old male

Past medical history

• Hypertension
• Myocardial infarction Feb 2023- significant blockage in the proximal segment of the Left Anterior Descending (LAD) artery, with 85% stenosis—2 stents fitted
• Benign prostatic hyperplasia
• Right hip hemiarthroplasty following a fall (4 months ago)
• Housebound due to reduced mobility 

Drug and Allergy History 

• Ramipril 2.5mg OD
• Clopidogrel 75mg OD
• Atorvastatin 80mg OD
• Tamsulosin 400mcg OD

Recent consultation/Notes

Seen by Dr Babatunde Peters (Clinical practitioner access role) 1 week ago  

Presenting Complaint: recent fall and confusion 

Examination findings: BP 100/76, Pulse 75bpm. Patient appears to be intermittently confused, but it’s difficult to determine whether this is an acute change, as he lives alone and there are no carers or family members available to provide collateral history. 

Plan: Admit to hospital 

Emergency Department discharge letter 

Dear GP, 

RE: Fred Callaway | 77 years | Male 

The above named was admitted due to fall and confusion—patient admits fall is mechanical. Bloods (CRP, U +E’s Thyroid function, LFTs, FBC) and CT head came back satisfactory. No bony injury to indicate any fracture. He has carers come in twice daily to help with house chores and meals. Sustained a minor cut to his right leg-cleaned and for regular dressing by district nurse 

Plan: Discharge back to home, can do with physio and OT assessment. If further deterioration, needs GP assessment 

Signed: 

Dr Emeka Okonkwo, MBChB, MRCEM

ED Registrar. 

District nurse Alice Goodenough has visited the patient and is now on the phone wishing to discuss his condition with the GP.