Community Health Nurse
23 July 2018
Re: Albert Disouza, aged 45
Thank you for seeing, aforementioned patient as, he require continued care following admission in the hospital due to radiating chest pain, which is due to myocardial infarction.
Difficulty in breathing has been observed. As well as had pain in the abdomen a week ago. Apart from these general weakness and excessive sweating has been noticed.
Positive cardiac triage has been noted. And the level of hemoglobin and Red blood cells subsequently found at: 7.8, 2 lakhs. Apart from this, has stone in right kidney.
He has been prescribed with: O2 therapy, thrombolysis and streptokinase, and low Sodium and sugar diet, as je has had hypertension since 2010. Likewise diabetes since 2014. Also has cellulitis on the right foot.
Sedentary lifestyle has been observed, as usually eat junk food and has habit of smoking.
Please provide wound care frequently, as well as monitor medication chart, Likewise blood pressure chart. Apart from this blood sugar level 3 times a week recommended. If suspect any complication inform the GP.
If you have any further query, please let me know.