Holy Spirit Hospital
15 July 2019
Re: Ms Helen Marshal, aged 29
I am referring Ms Helen Marshal, whose signs and symptoms are suggestive of myocardial infarction is being referred to you for an emergency evaluation and expert management.
Today, Ms Marshal felt tiredness, general body weakness and her blood pressure 180/95 are reported. Buscopan ingection and Panadol tablets for indigestion and pain relief are commenced respectively, on prescription of her general practitioner. Dysphasia and sleep disturbance are identified. Half an hour later, excruciating chest pain, tightness, distress, paleness and sweats were observed. Two litres per minute oxygen via nasal pronges is administered.
subsequently, complaints regarding sleep disturbance and shoulder aches were experienced for the first time. Two Panadol orally and Diclofenac 75 mg intramuscular were prescribed for pain management. Vaccination for flu and influenza type B prophylaxis was provided on 28 June. Regarding her medical history, hypertension is recorded from past ten years. Also, she has had glaucoma since 2010 and is allergic to codeine. Moreover Ms Marshal has a habit of alcohol consumption, daily takes two glasses of wine at night.
Additionally, she independently walks with walking frame and wears contact lens. Incontinence of bowel and bladder is reported. Therefore, she requires incontinence pad. Ms Marshal is mentally fit, watches television and also reads newspapers as well. The current medications record is attached to this letter for your kind perusal.
Based on the aforementioned circumstances, your immediate observation and appropriate management of Ms Marshal’s health condition would be profoundly beneficial. In case any additional information is required, please do not hesitate to contact me.
Wellness Retirement Village