Ms Jane Gold
Head Nurse
Primrose Nursing Home
3 Blackwood Street
Oldtown
15 May 2021
Dear Ms Gold,
Re: Mr George Gale, aged 85
Mr George Gale, who has been recuperating from disorientation and fever following a fall, requires short-term care and evaluation from your service. He is scheduled for discharge today.
On 9 may 2021, he collapsed while brushing due to weakness. An ambulance was called by his neighbours on 10 May 2021 at 03:00 am. On assessment, confusion and deranged vital signs were noted. Urine report revealed infection of the urinary tract with unknown etiology. In addition to the regular medication. injenction amoxicillin 750 mg thrice daily was commenced. Consequently, the vital signs returned to normal limits. Mr Gale, a retired retaile manager, lives alone in a flat. He has no close relatives nearby; however, he has a good contacts with his neighbours. He smokes 10 cigarettes daily and drinks occassionally. Apart from that, he has had osteoarthritis and hypertension since 2003 and 2009, respectively, for which paracetamol 500 mg 2 tablets 4 times daily and felodipine 5 mg once daily were prescribed. Gastro-oesophageal reflux disease, since 2013, has been well managed with self administered antacids. Also, non - specific colitis was diagnosed in 2019 and has been receiving regular follow-up care.
Currently, he walks 30 minutes daily, and confusion is still present. It would be greatly appreciated if you could educate Mr Gale regarding the importance of increased mobilization, and evaluate his mental status to live without assistance.
In case additional information is required, please do not hesitate to contact me.
Yours sincerely,
Registered Nurse
Oldtown Hospital
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