Medicine — Transfer to Orthopaedics for a Hip Fracture with Medical Complexity
An emergency physician transfers an 80-year-old woman with a fractured neck of femur and significant medical complexity to the orthopaedic registrar. The proficient challenge is dual: conveying the acute fracture and current stability, then identifying the three pre-operative concerns that must be addressed before surgery, while cutting the stable chronic history and incidental social details.
Letter type
Transfer
Write to
Orthopaedic Registrar
Target length
180–200 words
The case notes
Patient: Mrs Gladys Thompson, 80 years old
Presentation: Fell getting out of bed; right hip pain and inability to weight-bear; X-ray confirms fractured neck of femur (intracapsular)
Acute findings: BP 88/60 on arrival (improved to 104/72 with 500 mL IV fluid); HR 118 (now 98); Hb 9.2 g/L (chronic, confirmed by recent haematology review)
Pre-operative concerns: (1) Anticoagulation — on apixaban 5 mg BD for AF; last dose this morning; DOAC reversal may be needed; (2) Anaemia — Hb 9.2, chronic, may require pre-operative optimisation; (3) Capacity — advanced dementia (vascular), MMSE 18/30; capacity to consent for surgery requires urgent assessment
ECG: AF, ventricular rate 98, no acute ischaemic changes — consistent with known atrial fibrillation
Medications held: Apixaban held as of arrival; all other medications continued
Medical history: Atrial fibrillation, vascular dementia, hypertension, osteoporosis, hypothyroidism (TSH 2.4, reviewed 3 months ago — stable)
Social: Widowed, lives in residential aged care; daughter contacted and travelling in; facility notified
Task: Write a transfer letter to the orthopaedic registrar, Dr Kumar, summarising the admission findings and the three pre-operative issues requiring their attention before surgery.
Writing task
Write a transfer letter to the orthopaedic registrar, Dr Kumar, summarising the admission findings and the three pre-operative issues requiring their attention before surgery.
What to include, what to cut
The hardest mark to win is selection. The same case notes contain decision-relevant facts and distractors. Here is what an examiner expects to see in a Grade B letter for this scenario, and what should be left out.
Include
-
The fracture confirmed on X-ray and current haemodynamic stability
The opening must convey the acute diagnosis and that initial resuscitation has been performed so the team knows the immediate risk is controlled.
-
The three pre-operative concerns: apixaban management, chronic anaemia, and capacity assessment
These are the actionable handover items the orthopaedic team must address before surgery. Each one missed could delay or complicate the operation; all three belong.
-
Apixaban already held and the DOAC reversal consideration
The team needs the anticoagulation status on arrival to calculate their options. 'Held as of arrival' is the specific information that lets them plan reversal timing.
Leave out
-
Hypothyroidism and TSH result
Stable, recently reviewed, TSH within range. It does not affect surgical planning and is a classic distractor in a dense case note.
-
The daughter travelling in and residential care contact
Social logistics with no bearing on pre-operative management. Include only the capacity concern — not the family location.
-
Bisoprolol and atorvastatin narrative
Routine chronic medications with no special perioperative concern in this scenario. The medication list covers them; a narrative sentence wastes words.
Criterion in focus · Purpose
Transfer letters in complex acute cases have a dual purpose: communicate what has happened and communicate what must happen next. The orthopaedic team is not being given a narrative — they need the diagnosis, the pre-operative concerns, and the anticoagulation status. A transfer that is all narrative and no action list fails Purpose even when all facts are present.
Now write the letter — and find out what is blocking your Grade B
Write a 180–200 words transfer letter from these notes, paste it into the free checker for an instant read, then submit it for a human grade against all six criteria. Dr Mariam's team returns line-by-line feedback, from $12.