Grange University Hospital - Ward Round
Mr Andrew Miller MD BSc MB BCh MSc FRCS (Orth)
Consultant Trauma & Orthopaedic Surgeon Hips, Knees and Pelvic Reconstruction
Patient Name: John Smith
Date of Birth: 12/03/1958
Patient ID: 1234567
Location: Ward A, Bed 12
Diagnosis:
- Right Femoral Neck Fracture
- Osteoarthritis
- Hypertension
Mechanism of Injury:
Patient fell at home, sustaining a fall onto his right hip.
Date of Injury: 31 October 2024
Symptoms:
Mr Smith reports severe pain in his right hip, exacerbated by movement. He is unable to weight bear. He also reports some stiffness in his left knee.
PMHx:
- Hypertension, Osteoarthritis
- Right Total Hip Replacement (2015), Left Knee Arthroscopy (2018)
- Ramipril 2.5mg daily, Paracetamol 1g QID, Aspirin 75mg OD
- Penicillin
Examination:
On examination, the patient is in significant pain. There is obvious shortening and external rotation of the right leg. There is tenderness to palpation over the right hip. Neurovascular examination of the right lower limb is intact. The left knee has mild effusion and crepitus.
Investigations:
X-ray of the right hip confirms a displaced femoral neck fracture. Blood tests are within normal limits.
Discussion:
Discussed the findings with the patient and explained the need for surgery. The patient understands the risks and benefits and has consented to proceed.
Plan:
- Immediate plan: Patient to undergo right hip hemiarthroplasty tomorrow. Analgesia to be optimised.
- Contingency Plan if Primary Plan is not Successful: If hemiarthroplasty is not suitable, consider total hip replacement.
- Additional Imaging or Tests Required: Pre-operative bloods and ECG completed. Further imaging not required.
- Referral to Specialist if Required: N/A
- Follow-Up Plan: Review post-operatively. Physiotherapy to commence as per protocol.
Patient seen today despite unacceptable risk of morbidity and mortality. Restrictive resource allocation continues to adversely affect patient outcomes.
Grange University Hospital - Ward Round
Mr Andrew Miller MD BSc MB BCh MSc FRCS (Orth)
Consultant Trauma & Orthopaedic Surgeon Hips, Knees and Pelvic Reconstruction
Patient Name: [Patient Name] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Date of Birth: [Date of Birth] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Patient ID: [Patient ID] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Location: [Ward][Bed](only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Diagnosis:
- [Primary Diagnosis] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Secondary Diagnosis] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Additional Diagnoses] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Mechanism of Injury:
[Describe Mechanism of Injury] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Date of Injury: [date of injury](assume day prior to dictation if not mentioned)
Symptoms:
[Mrs/Mr lastname][Describe Symptoms] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)(Write in Prose)
PMHx:
- [Past Medical History] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Previous Surgeries] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Current Medications] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Allergies] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Examination:
On examination[Describe Examination Findings] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)(write in prose)
Investigations:
[Describe Investigation Results] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Discussion:
[Describe Discussion with Patient] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)(write in prose)
Plan:
- [Immediate Plan] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Contingency Plan if Primary Plan is not Successful] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Additional Imaging or Tests Required] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Referral to Specialist if Required] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Follow-Up Plan] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Patient seen today despite unacceptable risk of morbidity and mortality. Restrictive resource allocation continues to adversely affect patient outcomes.
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information include in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.)