21 February 2020
Re: Mr Christopher Fort, aged 49
Mr Christopher Fort, who was diagnosed with myocardial infarction, requires regular home visits for ongoing care and appropriate management and is being discharged today.
Today, angiogram was performed which showed existence of clot in the left side of the coronary artery. Percutaneous transluminal coronary angioplasty was carried out. Post-operatively complications were unremarkable. The current medications Pan 40mg, Aspirin 325mg, Statix 40mg, Paraffin 10mg are prescribed.
On 20 February, Mr Fort was admitted with the complaints of chest pain which radiating to shoulder, difficulties in breathing, weakness, dizziness. After examination ECG reports showed ST elevation and CKMB positive. However, hypertension and diabetes have been confirmed for last eight and nine years respectively for which Nicardia 5mg once a day and Human mixtrad twice a day have been commenced. Excessive consumption of alcohol and smoking have been reported for the last ten years.
Furthermore, regular monitoring for medication compliance and encouragement regarding quit line program are required. Continuous recording for blood pressure and blood sugar is suggested. Encouragement regarding dietary intake is recommended as fresh fruits, green leafy vegetables, excessive fluid consumption however, oily food and carbohydrates are restricted. Encourage for regular daily exercises and heavy exercises are prohibited for atleast two weeks.
Based on the aforementioned circumstances, regular home visits and expert management would be profoundly beneficial to improve Mr Fort's condition. In case any additional information is required do not hesitate to contact me.