QQ-3481. Mr George Gale - Nursing – Reena Vineesh – Post-Fall Care
Ms Jane Gold
Head Nurse
Primase Nursing Home
3 Blackwood street
Oldtown
15 May 2021,
Dear Ms Gold,
Re: Mr George Gale, aged 85
I am writing to introduce Mr George Gale, who fell down on 09 May 2021. He requires ongoing temporary care and assistance, as he us being discharged today.
Mr Gale, a retired retail manager who resides alone in flat. He has a fall at home, while brushing teeth and hit his head. After few hours his neighbours heard his cry and call ambulance. Felt weak and had single episode of vomiting, palpitations and dysuria two weeks before the incident. On assessment his vital signs were elevated along with confusion and this orientation. His symptoms were diagnosed and as Urinary tract infection, for which he was treated with intravenous antibiotics and other regular medication need to be continued.
Mr Gale Has history of osteoarthritis and hypertension in 2003 and 2009 respectively. He is managed with paracetamol, 500 mg and felodipine 5mg. In addition, has Gastro-oesophageal reflex disease and needs regular monitoring for non-specific colitis.
Based on the above circumstances, it would be appreciated, if you could encourage Mr Gayle, to perform 30 minutes of physical activity to regain his mobility. He needs an assessment, for or independent living is recommended prior to discharge.
In case if any additional information is required, please do not hesitate to contact me.
Yours sincerely,
Registered nurse
Old town Hospital.