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Exam standard · Referral · Nursing

Urgent: a swollen calf after knee replacement

This case practises: Making urgency clear · A specific request · Keeping the meaning of the notes exact · Writing for what the reader already knows

Writing task

Today's date: 1 December 2026. You are the community nurse with the Parkside Home Nursing Team. Write a letter to Dr Anil Varma, General Practitioner, Parkside Surgery, 61 High Street, Parkside, Mr Moreno's GP, requesting an urgent review today. Write in full sentences, not note form, using letter format. Aim for a body of about 180–200 words.

Case notes

In the test you get 5 minutes to read, then 40 minutes to write.

Patient details
- Mr Rafael Moreno, DOB 09/07/1959 (67 y.o.)
- 4 Linden Way, Parkside
- R total knee replacement 20/11/2026, Parkside Hospital; discharged 24/11/2026
- Home nursing: wound checks, enoxaparin supervision

Social background
- Lives with wife (type 2 diabetes, manages own care)
- Retired bus mechanic; plays lawn bowls
- Owns a small dog; neighbours help with walks
- Daughter visits Sundays; plans a family holiday to Spain in May 2027

Medical history
- Osteoarthritis R knee (replaced)
- Hypercholesterolaemia - atorvastatin 20 mg nocte
- Hypertension - ramipril 5 mg OD
- Hernia repair 2011
- No previous DVT/PE; NKDA

Medications since discharge
- Enoxaparin 40 mg SC OD for 14 days (to 04/12/2026)
- Paracetamol 1 g QID PRN; oxycodone 5 mg PRN at night

Home visits
- 25/11: wound clean, staples intact; BP 132/80; mobilising with crutches
- 27/11: wound clean; mild constipation - advised fluids, resolved; doing physio exercises
- 29/11: wound clean; pt says injections "bruising and painful"
- 01/12 (today): pt admits he stopped enoxaparin on 29/11 (2 doses missed)
  - R calf swollen, warm, tender; calf circumference R 41 cm vs L 37 cm
  - HR 98, BP 128/78, T 37.4 °C, SpO2 97% on air
  - No chest pain, no breathlessness
  - Wound clean and dry, staples intact
  - ?DVT R leg

Plan
- Urgent same-day GP review: assessment for suspected DVT (Doppler ultrasound), decision on anticoagulation
- Pt and wife told to call ambulance if chest pain or breathlessness
- Staples due out 04/12/2026
- Home nursing visits continue alternate days

Write your letter

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Model answer Try writing your own letter first
Dr Anil Varma
General Practitioner
Parkside Surgery
61 High Street
Parkside

1 December 2026

Dear Dr Varma,

Re: Mr Rafael Moreno, DOB 09/07/1959

I am writing to request an urgent review of Mr Moreno today, as I suspect he has a deep vein thrombosis in his right leg following his right total knee replacement on 20 November.

During my home visit this morning, Mr Moreno's right calf was swollen, warm and tender, measuring 41 cm compared with 37 cm on the left. His heart rate was 98, his temperature 37.4°C and his oxygen saturation 97% on air. He has no chest pain or breathlessness. His wound is clean and dry.

Of particular concern, Mr Moreno told me that he stopped his enoxaparin 40 mg injections on 29 November because they caused bruising and pain, so he has missed two doses. The course was due to finish on 4 December.

I would be grateful if you could assess him today, arrange a Doppler ultrasound and decide on further anticoagulation. I have advised him and his wife to call an ambulance if he develops chest pain or breathlessness. His staples are due for removal on 4 December, and our home visits will continue on alternate days.

Yours sincerely,

Community Nurse
Parkside Home Nursing Team

What the reader needs

  • Urgent same-day review requested
  • Suspected (not confirmed) right-leg DVT
  • Right total knee replacement on 20 November
  • Stopped enoxaparin on 29 November, two doses missed, because of bruising and pain
  • Right calf swollen, warm and tender; 41 cm versus 37 cm
  • No chest pain or breathlessness; observations including HR 98
  • Request Doppler ultrasound and a decision on anticoagulation

Details to leave out

  • Wife's diabetes
  • Former job and lawn bowls
  • Dog and neighbours
  • Daughter's visits and holiday plans
  • Hernia repair
  • Cholesterol, blood pressure history and their medicines (known to the GP)
  • Earlier visit details (BP on 25/11, constipation, physio exercises)
  • Discharge date from hospital

One good way to write this letter, not the only one. Written by Kurippu; awaiting nurse review.