I am writing to refer Mr. Jone, who represented on 17/02/16 due to worsening back pain and underwent an epidural steroid injection (ESI).
Mr. Jone is retired and lives alone. Although his daughter and son-in-law live nearby, they have not visited him over two months.
In terms of his medical history. Mr. Jone's right arm was broken following a fall on 04/06/15.
He complained of back pain on 09/09/15 and Traceton 300mg twice a day as well as Codeine 200mg daily
were therefore prescribed. On 17/02/16, he was diagnosed with a spinal stenosis following a result of his X-ray.
He received the first ESI dose on 28/02/16. However, he has increased difficulties in his activities of daily living
after the treatment and refused other therapies. Today, he was frustrated due to the worsening pain
and took an extra dose of Traceton by himself.
Regarding his plan, could you please arrange home visits twice per week to ensure that Mr. Jone takes his medication as prescribed
and assist him with daily activities. It will be beneficial if you could encourage him to see a physiotherapist and an occupational therapist.
Please note, his next ESI has been scheduled on 08/06/2016.
If you have any queries, please contact me.
Melbourn Community Clinic
3.Hx and meds
He complained of back pain on 09/09/15
and Traceton 300mg twice a day as well as Codeine 200mg daily were therefore prescribed.
He complained of back pain on 09/09/15, so
and Traceton 300mg twice a day as well as and Codeine 200mg daily were therefore prescribed.
He received the first ESI dose on 28/02/16.
He received the first ESI
dose on 28/02/16.