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004. Ankitha Setia - Maria John

Writer's picture: GrandMasterClassGrandMasterClass

 

Dr Patric Dsauza

senior Endocrinologist

Blue well Hospital Australia

468 St Kilda Rd

Melbourne

VLC 3004

14 December, 2014

Re: Mrs Maria John, aged 60

Mrs Maria John who has been suffering with hyperthyroidism for the past six months, requires further assessment and treatment after being discharged today.

On 11 December, 2014 Mrs Maria John was admitted with joint pain,Abdominal pain, constipation as well as dry mouth.Also slurred speech, dizziness, fatigue were reported.Blood Pressure 170/110 mmhg, pulse rate 92 per minute, respiratory rate 18 per minute and temperature 98.6° Fahrenheit were indicated.

During hospitalization, lab investigations revealed decrease value of TSH and T3 T4 were increased. Haemoglobin 8 gram was reported, and also blood sugar value more than 400 mg per dl showed. Slight bleeding in temporal bone revealed in MRI scan.Along with that, Slight bulging in the right upper quadrant of the abdomen was found in ultrasonography.Enlarged gland in the neck was indicated. Mrs Maria John was treated with medications.

Mrs Maria John lives with her husband and her mother has diabetes mellitus. Also, she is having irritable bowel syndrome, hypertension, seizure disorder and right Side paralyses following Stroke.

Following discharge, it would be greatly appreciated if you could do further assessment and treatment. Thyroidectomy has been recommended; however, Mrs Maria requested for the medical management only. Physiotherapy and regular exercises should be advised. Dietary modification should be recommended. After each meal walking needs to be monitored. kindly limit her dairy products. Medication chart has been enclosed with this.

Should you require further information please feel free to contact me.

yours sincerely

charge nurse

shelly Kate

Blue well Hospital



 

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