Dr Elvira Sternberg
2nd February 2007
Dear Dr Sternberg
Re:Mrs Larissa Zaneeta,aged 38
Mrs Zaneeta who presents with complaints of infertility ,would requires your expert evaluation and further advice.
Initially she presents on 11/7/2005 with stress related anxiety and mild hypertension due to insomnia and pressure at work place.she was recommended on relaxation techniques and physical exercises.moreover sedatives was prescribe and advice was giving on adequate rest by reducing hours of work.
On 15/8/2006 presents with sleeping difficulty with growing anxiety as a result of failure to conceive despite quitting contraceptive pills 4months ago.she was educated on ovulatory period by monitoring of body temperature. also nature and frequency of sexual intercourse was discussed.
One year After she came with the initial complains,she was seen crying and appears anxious.on assessment vital signs,general exam,pelvic exam and pap smear reveals no any abnormality. She was prescribed 1-2 tabs of Valium twice a day to enhance sleeping, also Mrs Zaneeta was adviced to come after 1 week with husband.
Presently she appears with husband Mr Zaneeta,he was assessed and sperm count was done and sperm was normal.
Base on this circumstances it would be profoundly beneficial if you could provide further advice and suggestion as Mrs Zaneeta is eager to have a child.