The Head Nurse
Geriatric Nursing Home
20 May 2019
Re: Mr Robert Jai, aged 70
Mr Robert Jai, who underwent appendicectomy, requires continue wound dressing, assistance with personal care and physiotherapy services following the discharge into your facility today.
On 10 may, Mr Jai was admitted to hospital with the complaints of severe abdominal pain. On examination CBC, WBC and RBC showed elevated. USG was confirmed inflamed appendix. Postoperatively, injection diclofenac and injection taxim 1 gram has been prescribed. Subsequently, wound oozing, redness and itching around wound site were noticed; however, managed with regular wound dressing. Additionally, prescription was changed to Augmentin.
On 19 may, Mr Jai showed good progress and wound healing was noticed. In addition, mobilization was started and assisting him with showering and personnel care. Currently, vital signs are stable and ready to be discharged today.
Mr Jai is a widower and lives alone in a rental flat. He has been smoking for the past 30 years and crazy for sweet food. His diabetic is controlling by tablet metformin 500 mg and hypertension is controlling by tab alphadopa 250 mg. He was suffered with right side paralysis and slurred speech as a result of CVA in 2018. Last year, undergone tonsillectomy. Allergic to pandine forte.
Based on aforementioned circumstances, requires regular wound dressing, needs assistance for showering and personal care. Regular monitoring of a blood glucose level and medications comply is required. Physiotherapy has been recommended for improving mobility. Mr. Jai has a follow-up appointment after 1 week.