04/04/2022

Dr. Catherine Kopkash

Family Medicine
Coburg Medical center
Coburg St, Upper Heights

Dear, Dr. Koapkash

Re: Mrs. Cindy Larson, DOB: 07/05/1935

Your patient, Mrs. Cindy Larson, was admitted to our facility with a head wound, a
dislocation on the right shoulder and a possible concussion after a fall. She is now ready
for discharge and follow up at your clinic.

On 03/03/2022, Mrs. Larson presented to the emergency department disoriented and

unable to stand following a fall from the stairs that was witnessed by her family. On
physical examination, a wound on the head and pain in the right arm after movements
was noted. The head wound was stitched and a CT head discarded bleeding of the brain.
In addition, an ultrasound of the right shoulder revelated a dislocation that was treated by
relocating the right shoulder into the socket and placing the arm in a sling.

On the next day, Mrs. Larson’s complained about a throbbing headache that decreased
over the days after administration of ibuprofen every 6 hours. On 08/03/2024, Mrs.
Larson developed a high fever, accompanied by, swollen and redness of the skin around
the head wound. The WBC count was over 14,000 mm3 and a wound culture was taken
reporting MRSA infection 2 days later. Vancomycin was started.

Today, the infection has resolved and the arm sling has been removed. Physio discussed
with Mr. Larson about arm exercise and OT spoke with her family regarding home
safety. Mrs. Larson will be discharged to home with ibuprofen, therefore, I would like
you to provide further follow-up.

Please do not hesitate in contact me if you have any queries

Yours sincerely,

Doctor