CAREPACT Medical Officer Call

CAREPACT Medical Officer Referral Line Note: Patient Information: - John Smith - 12/03/1938 - 86 years - **Rosewood Aged Care Facility**, permanent resident Referring Clinician Information: - Dr. Emily Carter - Hospital Doctor, Emergency Department Reason for Referral: - Patient presents with a fall and altered mental status. Patient History: - Current issues: Patient fell in the dining room, now confused and complaining of hip pain. - Medical History: Hypertension, Osteoarthritis, previous right hip replacement. - Medications: Lisinopril 10mg daily, Paracetamol as needed, Vitamin D supplement. - Social History: Lives at Rosewood Aged Care Facility, widowed, enjoys reading. - Allergies: NKDA - Falls History: Patient fell in the dining room. No loss of consciousness. Patient is mobilising at baseline with a walker. No obvious injuries, but patient is complaining of hip pain. The cause of the fall is unclear. The patient's goals of care would not include neurosurgical intervention. Examination Findings: - GCS 14/15. Confused but oriented to person and place. - BP 160/90, HR 88, RR 18, SpO2 96% on room air. - Right hip tender to palpation. No obvious deformity. - Neurological exam intact. Investigations: - X-ray right hip ordered. Results pending. Patient goals of care: - Advance Care Planning Documents: Patient has an Advance Health Directive in place, stating preference for comfort care. - Trajectory of care: Patient wishes to remain at the aged care facility and avoid hospitalisation if possible. Focus is on symptom management and maintaining quality of life. Management Plan: - **Hospital Transfer** - Discussed with family, who agree with transfer for further assessment and management of potential hip fracture. - Notify Rosewood Aged Care Facility of transfer. Additional Notes: - Patient to be transferred via ambulance. - Dr. Thomas Kelly to be notified of the patient's arrival.