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Canberra Hospital
AuthorDr Matthew Kessler
Phone 0262442222
Discharge To Other/Home
Discharge From Ward 4F

Health Profile

This section may contain the following subsections Adverse Reactions and Alerts.

Adverse Reactions (Health Profile > Adverse Reactions)

None known

Event

This section may contain the following subsections Problems/Diagnoses This Visit, Clinical Interventions Performed This Visit and Clinical Synopsis and Diagnostic Investigations.

Clinical Synopsis (Event > Clinical Synopsis)

Clinical Synopsis
Clinical Synopsis
Patient fell in his bathroom and could not weight bear on his feet when the ambulance arrived. He was found to have a fractured neck of femur. He was taken to theatre for a pin and plate of the fracture. His post op recovery was complicated by acute delirium and hyponatraemia. His Avapro/HCT was changed to Avapro with marked improvement. Sodium normal on discharge. Please follow up his BP control. He will have private follow up via Rehabilitation Specialist

Problems/Diagnoses This Visit (Event > Problems/Diagnoses This Visit)

  • There was a non-displaced fracture of the left neck of femur (Principle diagnosis)

Clinical Interventions Performed This Visit (Event > Clinical Interventions Performed This Visit)

Clinical Intervention Description
Value(s)
Pin and plate surgery of left neck of femur

Diagnostic Investigations (Event > Diagnostic Investigations)

This section may contain the following subsections Pathology Test Result and Imaging Examination Result.

Pathology Test Result (Event > Diagnostic Investigations > Pathology Test Result)

Pathology Test Result(s)
Result DateTime Result Name Overall Result Status Diagnosis
13 Jan 2011 10:59+0300 FBE (Full Blood Examination) Amended
  • Test normal
Pathology Test Specimen Detail
Collection Date
11 Jan 2011 14:49+0300
Test Result Group
Group Name Result Name Result Value Result Status
Cell Count Haemoglobin
  • 132 g/L (115 – 165)
 Final
Cell Count Haematocrit
  • 0.41 (0.35 – 0.47)
 Final
Cell Count RCC
  • 0.45 10^12/L (3.9 – 5.6)
 Final
Cell Count MCV
  • 91 fL (80 – 100)
 Final
Cell Count WCC
  • 5.5 10^9/L (3.5 – 10)
 Final
Cell Count Platelets
  • 246 10^9/L (150 - 400)
 Final
Test Result Group
Group Name Result Name Result Value Result Status
White cell count differential Neutrophils
  • 3.08 10^9/L (1.5 – 6.5)
 Final
White cell count differential Lymphocytes
  • 1.75 10^9/L (0.8 – 4.0)
 Final
White cell count differential Monocytes
  • 0.45 10^9/L (0 – 0.9)
 Final
White cell count differential Eosinophils
  • 0.20 10^9/L (0 – 0.6)
 Final
White cell count differential Basophils
  • 0.03 10^9/L (0 – 0.15)
 Final

Imaging Examination Result (Event > Diagnostic Investigations > Imaging Examination Result)

Imaging Examination Result Details
Field Value
Imaging Examination Result Date Time 10 Nov 2010 16:33+1000
Result name Xray left hip
Modality Xray
Result Status Final
Findings Fracture left neck of femur

Imaging Examination Result (Event > Diagnostic Investigations > Imaging Examination Result)

Imaging Examination Result Details
Field Value
Imaging Examination Result Date Time 10 Nov 2010 16:33+1000
Result name CT Head
Modality CT
Result Status Final
Findings No fracture or internal bleeding, cerebral atrophy consistent with age.

Medications

This section may contain the following subsections Current Medications On Discharge and Ceased Medications.

Current Medications On Discharge (Medications > Current Medications On Discharge)

Current Medications On Discharge
Medication Directions Dispensed Clinical Indication Duration Change Status Change Description Change Reason
Avapro 300 mg One tablet Current Change Changed from Avapro/HCT 300mg/12.5mg
Actonel 35 mg One tablet weekly every Sunday morning Current No change No change

Ceased Medications (Medications > Ceased Medications)

Ceased Medications
Medication Change Made Change Status Change Reason
Avapro/HCT Replace with Avapro 300mg only Ceased Optimise drug therapy.

Plan

This section may contain the following subsections Arranged Services and Record Of Recommendations And Information Provided.

Record of Recommendations and Information Provided (Plan > Record of Recommendations and Information Provided)

Recommendation
Description Name Phone
Please ensure aspirin is recommenced 3 days post discharge. Dr Ely BLACK 0255886622 (WorkPlace)
ADMINISTRATIVE DETAILS
Encounter Details
Admission Date3 Jun 2013 16:33+1000
Discharge Date4 Jun 2013 12:08+1000
Discharge To Other/Home
Discharge From Ward 4F
Specialties
  • Orthapaedics
  • Emergency medicine
Responsible Health Professional At Time Of Discharge
Name Doctor John Smith
Work Place256 Sandgate Rd, Albion, QLD, 4010, Australia
Facility
Name Canberra Hospital
Work Place12 Yamba Ave, Garran, ACT, 2605, Australia
Phone0262442222 (Workplace)
Department Accident and Emergency
Patient
Name Frank HARDING
Sex Male
Indigenous Status Aboriginal but not Torres Strait Islander origin
Date of Birth 4 Oct 1949 (64y)
IHI 8003 6086 6670 1594
Home Address1 Australia Lane, North Adelaide, SA, 5006, Australia
Phone0755886699 (Workplace)
Email[email protected] (Home)
Author
Name Dr Matthew Kessler (HPI-I: 8003612033304440)
OrganisationCanberra Hospital (HPI-O: 80036266077708880)
DepartmentSurgical Ward
Work Place12 Yamba Ave, Garran, ACT, 2605, Australia
Phone0245754566 (Workplace)
Clinical Document Details
Document Type e-Discharge Summary
Creation Date/Time 4 Jun 2013 14:25+1000
Date/Time Attested 24 Jun 2013 14:25+1000
Document ID 2.25.264831083669540063556139584026533783920
Document Set ID 6fd39228-9a8e-4629-8c2b-a45cbb9d2053
Document Version 1
Completion Code Final

 Participants

Name Contact Address Organisation Department
Dr Phillip Lang (Nominated Primary Healthcare Provider Person)
  • 0745754566 (Workplace)
301 Vulture Street, North Adelaide, SA, 5006, Australia
Medical Practice
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