Dr Philip Simon
Star Health Hospital
5 July 2019
Dear Dr Simon,
Re: Mrs Jennifer Milton, ages 35
Mrs Jennifer Milton, who is 25 weeks pregnant and diagnosed with pregnancy induced hypertension as well as gestational diabetes mellitus, requires assessment for the need of insulin and increasing dose of thyroxin from you.
On 2 July 2019, Mrs Milton was admitted to our hospital. Generalized edema and palpitation were observed. Temperature 98 degree Celsius, Pulse rate 114 b/min, respiratory rate 20 b/min, blood pressure 160/100 mmhg and hemoglobin 6 mg /dl were recorded. Also, RBC 300mg/dl and TSH 6 MU/L were indicated. She has been suffering with hypothyroidism, for which is taking tablet thyroxin 50 mg . Tablet Labetalol 100 mg Once a day, tablet metformin 500 mg twice daily and tablet Qten 10 mg SoS has been taking for ongoing conditions.
In our care, blood and urine sugar levels were monitored and treated with anti- diabetic drugs. TSH 6.5 mU/L was recorded. Nutritional assessment was performed by the dietician. Education on dietery modification was provided.
Mrs Jennifer lives with her husband and prefers to eat cookies, chocolates, puddings and fruits. Family history of hypertension, diabetes mellitus and peptic ulcers were reported.
Based on the above information, assessment for the need of insulin would be highly appreciated. Blood sugar levels should be monitored. Dosage of tablet thyroxin needs to be increased.
Should you require further information, please feel free to contact me.