Emergency Consultant
Emergency Department
Holy Spirit Hospital
15 July 2019
Dear Doctor
Re: Ms Helen Marshal, DOB: 29 Jan 1968
I am referring Ms Helen Marshal, who has suspected to acute myocardial infarction, requires emergency evaluation and management at your facility
Today, tiredness, feeling weak and blood pressure 180/95 is recorded. Buscopan and Panadol for indigestion and shoulder pain are commenced respectively, On the prescription of general practitioner. After 15 minutes, loss of appetite and problem with sleep are noticed. Severe anxiety is experienced related to wish to meet son. Half an hour later, distress, pale,sweat, tightness and chest pain as 8/10 on pain scale are noted. Severe pain radiating towards shoulder and neck, not relieved by Nitroderm transdermal patch. Two litre of oxygen is administered via nasal prongs.
On 13 July, complains related to sleep disturbance and shoulder pain were experienced. Two Panadol and Diclofenac 75mg intramuscular were commanced for pain. Vaccination for flu and influence type B prophylaxis were given on 28 June. Hypertension and glaucoma for last ten and nine years respectively and also allergy to codeine. Ms Marshal has habit of drink alcohol two glass daily at night.
Ms Marshal, independent with walking frame and wears contact lens. Continence noted and requires continence pads. She is fully alert, oriented and reading, watching television regularely.
In case of any additional information is required, please do not hesitate to contact me.
Yours faithfully
Registered Nurse
Wellness Retirement Village
Waterford st
Berkely
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