Ma Cathy Ina
6 Buchanan St Giasgow G69
25th July 2018
Dear Ms. Ina
RE: Ms.Anna Dijana, 42 years old
Ms Anna Dijana is currently admitted in New Victoria Hospital on 15th July 2018, having sustained night proximal tibia fracture and lateral tibial plateau fracture and with compartment syndrome. She is now ready to be discharged.
On 15th July 2018, Ms Dijana fell off stairs, and was unable to beat weight on the right leg due to feeling pain on the right knee. On arrival to hospital, rushed to operations theatre to stabilized the fractures by external fixator and fasciatomies performed with two incisions.
During her care, wound vacuation done on both fasciotomy incissions and is red in colour, and there is no odour, therefore, she is free from infections. Neither swelling nor pain on the wound and vital signs normal.
Ms Dijana thought about the wound site, signs and symptoms of infection and to inform a nurse if observe any changes. Please teach her about how to maintain sterility by keeping blankets and clothing out of reach of the wound. Encourage her on resting extremities and body parts. Reassure her about expired drainage.
Ms Digana has a medical history of seizure and is an carbamazepine, please continue on monitoring her.
Please do not hesitate to call me if there’s any queries.