TEST 26 – REFERRAL LETTER (Wound Management)
Writing Task:
Using the information given in the case notes, write a referral letter to Dr. Helen Grace, a general practitioner at Southville Medical Centre, requesting further wound management for Mr. Harry Nolan. Address the letter to Dr. Helen Grace, Southville Medical Centre, 215 George St, Southville.
Patient Details:
• Name: Mr. Harry Nolan
• DOB: 21 March 1951
• Address: 78 Market Street, Southville
• Admission: 12 June 2025 (Following fall at home)
• Discharge: 16 June 2025
Medical History:
• Type 2 Diabetes (diagnosed 2015)
• Hypertension
• Osteoarthritis
Incident:
• Slipped in bathroom
• Deep laceration to right leg
• No fracture
• Required stitches and dressing
Progress:
• Wound healing slowly due to diabetes
• Daily dressing changes required
• Blood sugar controlled (HbA1c: 6.7)
• Mobile with walker
• Lives alone, receives Meals on Wheels
Plan:
• Needs ongoing wound dressing and observation
• Monitor for signs of infection