The Emergency Department
Consultant on Duty
100 Main Street
30 August 2019
Dear Sir/ Madam,
Re: Ms Patricia Styles, aged 62
Ms Styles, who has been assessed with a possible relapse of pericarditis, requires urgent assessment and appropriate management from your facility.
Today, Ms Styles reports chest pain, which gets better with sitting up. In addition, shortness of breath and fatigue have been described. Excellent medication compliance has been observed. Also, she has low grade fever (38.1 degree C), elevated respiratory rate (28b/min), heart rate (115b/min) and blood pressure is 125/78mmhg, lower then her usual (140/90mmhg).
On 23 August 2019, she was admitted to Green Valley Hospital with fever, sharp chest pain, which got worsed while breathing. General weakness, malaise and tachycardia have been noticed. Throat swab revealed type B viral influenza and an echocardiogram indicated pericarditis. Chest X-ray was normal. Intravenous saline along with ibuprofen 600mg thrice daily was commenced to manage her condition.
On 25 August 2019, Ms Styles was discharged. A Nurse follow- up visit was arranged for today. Current medications include Accupril 40mg twice day for hypertension, Diabex 500mg twice daily and APo- Gliclazide MR 30mg daily for diabetes mellitus.
In the above mentioned circumstances, an urgent assessment and appropriate management would be highly recommended.
In case any additional information, please do not hesitate to contact me.
Green Valley Hospital