Updated: Jul 29, 2021
The Community Health Health Nurse
23 July 2018
Re. Albert Disauzer, aged 45
I am referring Mr. Albert Dsouza, who was diagnosed with myocardial infarction (MI). He requires continued care for regular monitoring and complainice of anti-biotic and other medication. He is being discharged today.
He has had hypertension since 2010 and diabetes source 2014. He has been on amlodipine 5mg once -day respector, cellulities on the right foot.
Mr Albert Dsouza presented at Carolinc toriage on 18 July 2018 with Chest Pain radiated to Smaller, breathless ness and sweating. He was facing abolomen pain from last week. ECG (electroc coligram) which was taken revealed MI (Mycardial infarction, haemoglobin was 78, Using Was unremarkable, bland Sugar was remarkable ultrasonoghraphy USG was done which was done revealed store in right kidney
Upon admission thrombolysis therapy was given with Streptokinase, oxygen therapy was commenceal via nasal. Carmela. Kept head end elevate, pain reduced vital sings were within normal limit, low Sodium and low segar diet Was recommened.
Based on all above mentation circumstance uf Dsouza, renfuires Continued nursing care, regullar monitoring Complaince of antibiotic and other medication , maintain blood pressure chart on daily bases. Blood sugar to be checked on attenative day. Advised reffernce to dietician revisit schedule has been arranged after three weeks in cardiology OPD at 10Am. In case of any complain contact to local GP.
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