Ms Leyla ward
Ashton Health Centre
4 December 2018
Dear Ms Ward
Re: Mrs Charlotte Prince, age 86
I am referring Mrs Charlotte Prince, who has been recuperating from mild concussion followed by a fall at home and an infected toe. For ongoing care and support, community Nurse is required for home visit following the discharge today.
Mrs Prince is a retired postal worker and lived alone as her son lives aboard. She lives in a 3 bedroom house. Consequently, risk of fall and lack of personal hygiene have been observed. Additionally, unwillingness to visit general practitioner has been seen.
In addition, recurrent conjunctivitis and gastroenteritis have been reported. In regards to her surgical history knee replacement, removal of skin cancerous mole has been carried out in the year 1998 and 2000 respectively. Hence unable to perform her activity of daily living. Smoking heavily and occasional consumption of alcohol were reported. Walking is possible with the support of a stick.
The right toe has been dressed and antibiotics is commenced. Initial CT scan and finger-nose-finger test is satisfactory. Hygiene education regarding food and hand has been imparted. Medication compliance to be monitored, also change of dressing twice a week is required. Assistance to be provided for showering and dressing. The list of medication is attached with the letter for your kind perusal.
Based on the aforementioned circumstances, your unceasing care and home visit twice a week would be profoundly beneficial for Mrs Prince's health conditions. In case you require any additional information please do not hesitate to contact me.