14 April, 2018
Re:Ms Patricia : aged 63
Dear sir / Madam,
I am writing to introduce Ms styles who has been suffering with pericardits.she requires an urgent assessment and management from your facility.
On today's home visit, Ms Styles felt tired and had pain along with shortness of breath and fatigue; however, chest pain was less while sitting .Her vital signs were temp - 38, HR - 122, RR - 28 and BP - 180/90.
Medically, she has had hypertension since 2012 ,for which she takes carpinel medicine and type 2 diabetes mellitus was diagnosed in 2009 and, she takes metformin 500mg two times daily and glipizide 10mh once daily.
During hospitalisation, her glucose level was monitored regularly and the blood test revealed high level of ESR and creat platelets. The oral throat swab confirmed type B influenza and pericardium was diagnosed by echocardiogram.she was commenced on intravenous saline and antibiotics .she was discharged on 09/04/2018 and was advised on further follow-up home visits. She was on self-care after discharge .
It would be greatly appreciated if you could assess and treat her as deemed appropriate.
Should you require further information, please do not hesitate to contact me.