Dr Luey Peter
Gynocologist and obstetrieian
st Luke city hospital
16 August 2019
Dear Dr peter,
Re: Mrs clara Jones , aged 25
I am referring mrs clara jones who is 6 weeks pregnant , and left ruptured fallopian tube . she requires emergency management and surgical intervention.
ms jones was presented to hospital on 15 august 2019 with the complaints of lower pain, work in right illiae fasse. on assesment non specific abdosmen pain was noticed . vaginal examination revealed tenderness in right fornix she was adviced to return back next morning for blood test and reassessment.
on 16 august 2019 she rushed to the hospital due to severe constant pain and vaginal bleeding with presence of clots. she was fainted while waiting in reception . on evaluasion, she Was severe tonsernex in the right illiac dosa, with guarding and rehoued tenderness . Vital signs reported aferbrile, pulse 58 /minute and blood pressure 50/30 mm Hg. Blood investigation shows haemoglobin 4 gm and beta heg is 2800 . Ultrasound revealed a heavy mass of clot measuring 38 mm.
Ma Jones was socially active . She is deaf and dumb . She stay away from home. She has habit of alcohol and smoke heavily she has family history of hypertension and four absorptions.
Based on above mentioned circumstances, urgent assessment and appropriate treatment would be greatly beneficial, if you read any additional information please do not hesitate to contact me.
St luke city hospital