Patient Details
John Smith, 123 Main Street, Dublin 2, Date of Birth: 10/03/1970, Report Date: 01 November 2024
Incident Details
Date: 20 October 2024, Location: Workplace, Type: Fall from height, Description: Mr. Smith fell from scaffolding while working on a construction site. He landed on his feet. Immediate Symptoms: Immediate pain in his lower back and right ankle. He was taken to A&E.
Medical History
Past Medical History: Hypertension, Surgical History: Appendectomy in 1995, Medications: Lisinopril 20mg daily, Allergies: None known, Family History: Father with history of heart disease, Social History: Smoker (10 cigarettes per day), drinks alcohol occasionally.
Clinical Assessments and Follow-Ups
20 October 2024: Attended A&E. Examination revealed tenderness in the lumbar spine and right ankle. X-rays of the ankle were taken and showed a fracture. CT scan of the lumbar spine was unremarkable.
22 October 2024: Seen in outpatient clinic. Examination revealed reduced range of motion in the lumbar spine. Right ankle in plaster cast. Pain score 6/10.
29 October 2024: Review of progress. Pain score 3/10. Ankle cast remains in place. Physiotherapy commenced.
Prognosis
Short-term: Expected to improve with physiotherapy and pain management. Medium-term: Ankle fracture expected to heal within 6-8 weeks. Long-term: Full recovery expected, but some residual stiffness in the ankle is possible.
Conclusion
Mr. Smith sustained a fracture of the right ankle and a lumbar strain as a result of a fall from height. The mechanism of injury is consistent with the reported symptoms. Recovery is progressing well.
Diagnosis & ICD-10 Codes
S92.9 Fracture of foot, unspecified
M54.5 Low back pain
Signed
**Patient Details**
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**Incident Details**
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[Document a brief, factual description of how the incident occurred, including the mechanism of injury] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
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**Medical History**
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**Clinical Assessments and Follow-Ups**
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**Prognosis**
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**Conclusion**
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**Diagnosis & ICD-10 Codes**
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**Signed**
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