10 November,2020
The General practitioner Nurse
Greystone General Practice
57 Sand Lane
Greystone
Dear Sir/Madam,
Re:Mr Jonathan Thompson,DOB:01 August,1984
I am writing to refer Mr Thompson who is recuperating after incision and drainage of for perianal abscess.He requires continuity of care and management, after his discharge today.
Mr Thompson was admitted to hospital on 08 November,2020 with the complaints of painful swelling near the anus along with pus collection.On assessment,vital parameters were normal expect temperature and blood pressure noted at 37.6 and 149/80 respectively.In addition,the pus appeared slight yellow in colour without any offensive odour.On the next dayThus,he underwent the aforementioned surgery on 09 November,2020 and was successful.
Good paragraph but no need to write all of these information
Our task is to constrain the information without losing the important data
Post-operatively, he made a good recovery without any complications.Whilst hospitalisation,he adopted treatment plan include a course of oral antibiotics and pain-relief medication.
You have to mention post operative medicines as metronidazole needs to continue and has to mention the advice regarding ibuprofen.
He didn't made recovery immediately after surgery
He made it after some days of dressing and medicines
In context to social history,he resides in a three bedroom rental house.He is not only a chronic smoker but also an alcoholic.Please note that he is allergic to NKDA.
Reader has nothing to do by knowing her residential detail
Do not introduce a patient as alcoholic
You should address this in any other way which should be respectful.
NKDA is not a medicine
No Known Drug Allergies
Pertaining to the above information,it would be greatly appreciated if you could apply perform daily dressing as prescribed and observe the operative site for any sign of infection.Mr Thompson was advised to use stool softener and include fibre based food in his diet. Kindly encourage him to complete the course of antibiotics.Of note he has been scheduled fo a follow-up review at surgical outpatient department in six weeks.
You should mention the name of the antibiotic
You should inform them to refer the patient back to hospital in case of any emergency
For any information regarding Mr Thompson,please do not hesitate to contact me.
Yours faithfully,
Registered Nurse
Needs improvement…
Best wishes!!
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