This section may contain the following subsections Adverse Reactions and Alerts.
This section may contain the following subsections Problems/Diagnoses This Visit, Clinical Interventions Performed This Visit and Clinical Synopsis and Diagnostic Investigations.
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 |
- There was a non-displaced fracture of the left neck of femur (Principle diagnosis)
Clinical Intervention Description
Value(s) |
Pin and plate surgery of left neck of femur |
This section may contain the following subsections Pathology Test Result and Imaging Examination Result.
Pathology Test Result(s)
Result DateTime |
Result Name |
Overall Result Status |
Diagnosis |
13 Jan 2011 10:59+0300 |
FBE (Full Blood Examination) |
Amended |
|
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 |
|
Final |
Cell Count |
Haematocrit |
|
Final |
Cell Count |
RCC |
|
Final |
Cell Count |
MCV |
|
Final |
Cell Count |
WCC |
|
Final |
Cell Count |
Platelets |
|
Final |
Test Result Group
Group Name |
Result Name |
Result Value |
Result Status |
White cell count differential |
Neutrophils |
|
Final |
White cell count differential |
Lymphocytes |
|
Final |
White cell count differential |
Monocytes |
|
Final |
White cell count differential |
Eosinophils |
|
Final |
White cell count differential |
Basophils |
|
Final |
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 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. |
This section may contain the following subsections Current Medications On Discharge and Ceased Medications.
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
Medication |
Change Made |
Change Status |
Change Reason |
Avapro/HCT |
Replace with Avapro 300mg only |
Ceased |
Optimise drug therapy. |
This section may contain the following subsections Arranged Services and Record Of Recommendations And Information Provided.
Recommendation
Description |
Name |
Phone |
Please ensure aspirin is recommenced 3 days post discharge. |
Dr Ely BLACK |
0255886622 (WorkPlace) |