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AD.18. Amal Mariya - Ms Helen Marshal


 

The Emergency Consultant

Emergency Department

Holy Spirit Hospital


15 July 2019


Dear Consultant


Re: Ms Helen Marshal, who was performing signs and symptoms of acute myocardial infraction, referred into your facility for definitive diagnosis and further management.


In the observation of 15 July, tiredness and weekness was reported. Evening meals was refused and difficulty to sleep was noticed, therefore tablet buscopan and tablet panadol was administered. After sometime a severe chest pain occurs, meanwhile pain radiating to the shoulder and neck, associated with chest tightness, distressed and sweating was noticed. Vital signs are unremarkable.


Through nasal cannula two litre oxygen per minute was given and nitroderm patch has been administered, but the pain not subsided. She has had hypertension and glucoma since 2009 and 2010 respectively. Because of arthritis walking is possible with the support of walking frame.


Ms Marshal wears contact lenses for which timoptol eye drops one drop in each eye morning and evening has been prescribed. To prevent continence of urine continence pad has been provided. She has immunized with influenza type B prophylaxis to prevent the flu. The list of ongoing medications is attached with this letter for your knowledge.


Based on these circumstances, your assessment and emergency management is required for Ms Marshal for her recovery. If you require further information, please do not hesitate to contact me.


Yours faithfully



Registered Nurse



 

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