Read the case notes and complete the writing task which follows.
Notes:
You are the hospital phyisotherapist.
Patient:Wilfrid Morcom (Mr)
DOB: 31 August 1947
Address: 19 Pine Crescent, Stillwater
Occupation: Retired carpenter
Social: Lives with wife (very supportive)
Relevant history:
- Nov 2011 – R high tibial osteotomy due to medial compartment osteoarthritis (O.A.)
- Jun 2012 – arthroscopy showed tricompartmental O.A. R knee
Pre-operation:
- Long history knee pain, R more than L. Walked w. single point stick 100m; limited by pain.
- Required assistance w. dressing, steps, stairs, etc.
Operation:
- R total knee replacement 1/08/13
2/08/13
Post-operation:
O/E: R.I.B. Zimmer splint in situ.
Treatment:
- Routine post-op chest physiotherapy.
- Taught isometric quads, SLR, foot & ankle exercises.
Plan:
- To commence partial weight bearing (PWB) walking in 5/7 (7/08/13).
3/08/13
Medical:
- Complaining of central chest pain & shortness of breath (S.O.B.).
- O2 x 2L via prongs.
- P = 84, BP = 110/70, RR = 18, ECG – flattening T wave in V5-V6.
- ? Ischaemic heart disease (IHD). Anginine (glyceryl trinitrate) started.
7/08/13
O/E: No chest pain, no S.O.B.
Treatment:
- Commenced PWB in pick-up frame with Zimmer splint. Required assistance with transfers only.
- Commenced knee flexion ex. = 25 deg. Continuous passive movement (CPM) commenced (2 hrs on,
2 hrs off) 20°-30°. - Sitting out of bed with leg elevated.
8/08/13
O/E:
- Episode of chest pain last night; relieved by Anginine.
- Occupational therapist completed home assessment – ordered appropriate equipment.
Treatment:
- Ambulating well with frame.
- Polly Farmer knee brace ordered.
- CPM (2 hrs on, 2 hrs off) 15°-50°.
9/08/13
O/E: Feeling well.
Treatment:
- Progressed to elbow crutches. Managing well with Polly Farmer knee brace.
- CPM (2 hrs on, 2 hrs off) 15°-65°.
- Continue active exercise program. Flexion = 60 deg, Extension = -18 deg.
- For discharge home tomorrow (10/08/13). To continue physiotherapy at Stillwater Rehabilitation
Hospital x 3 per week. Review in Outpatient Clinic 9/09/13.
Writing task:
Using the information given in the case notes, write a letter of referral to the Physiotherapist-in-Charge at Stillwater Rehabilitation Hospital. Address the letter to Physiotherapist-in-Charge, Stillwater Rehabilitation Hospital, 14 Lake Road,Stillwater.
In your answer:
- Expand the relevant notes into complete sentences
- Do not use note form
- Use letter format
The body of the letter should be approximately 180–200 words.