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NEW WRITING TASK-MRS ELIZA HARPER

 Case Notes:

Date: 26 January 2025
Patient Name: Mrs. Eliza Harper
Date of Birth: 12 August 1965 (59 years old)
Address: 45 Gardenia Lane, Chelmsford, UK
Marital Status: Married

Medical History:

  • Type 2 Diabetes Mellitus (diagnosed 2008)

  • Osteoarthritis (diagnosed 2018)

  • Hypertension (diagnosed 2010)

  • Allergic to penicillin

Social History:

  • Retired schoolteacher

  • Lives with her husband (primary carer)

  • Exercises minimally due to joint pain

  • Diet: Frequently consumes processed foods

Current Admission:
Date of Admission: 20 January 2025
Reason for Admission: Exacerbation of osteoarthritis causing severe knee pain and limited mobility.

Hospital Course:

  • X-ray: Severe degenerative changes in the right knee.

  • Medications adjusted:

    • Increased dosage of Paracetamol (1g every 6 hours).

    • Addition of Gabapentin (100mg at night) for neuropathic pain.

    • Tapering dose of Prednisolone (10mg daily for 5 days).

  • Physiotherapy sessions initiated to strengthen the knee joint.

  • Pain management with intra-articular corticosteroid injection (administered 23 January 2025).

Discharge Plan:

  • Discharge Date: 26 January 2025

  • Referral to outpatient physiotherapy for continued rehabilitation (twice a week for six weeks).

  • Recommended lifestyle changes:

    • Diet consultation to support weight management and glycaemic control.

    • Low-impact exercises such as swimming or cycling.

Medications on Discharge:

  1. Paracetamol 1g every 6 hours (PRN for pain)

  2. Gabapentin 100mg at night

  3. Metformin 500mg twice daily

  4. Amlodipine 10mg daily

Follow-Up:

  • General Practitioner (GP) to review in two weeks.

  • Orthopaedic specialist follow-up in six weeks to assess suitability for knee replacement surgery.

Writing Task:

Using the case notes provided, write a letter to Mrs. Harper's General Practitioner, Dr. Susan Evans, at Chelmsford Medical Centre, 22 St. Mary’s Road, Chelmsford, UK. Include relevant details to facilitate ongoing care and support.

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