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:
Paracetamol 1g every 6 hours (PRN for pain)
Gabapentin 100mg at night
Metformin 500mg twice daily
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.
