Consultant On Duty
The Emergency Department
100 Main Street
30 August 2019
Re: Ms Patricia Styles , aged 62
I am writing to refer Ms Patricia Styles, who is suspected to have relapse complications of pericarditis, requires your urgent assessment and management.She is being transferred today.
On 23 August 2019 Ms Styles was admitted to the greenvalley Hospital with complaints of chest pain, shortness of breath and tiredness. She underwent multiple investigations such as echocardiogram and throat swab, which confirmed pericarditis and viral type b influenza. Her condition was managed well with intravenous normal saline and antibiotics. She was discharged on 25 August 2019 with follow up home visit.
Today during home visit Ms styles was unwell and she complains of chest pain shortness of breath and fatigue. However chest pain relieved while sitting up and she was frustrated with progress of recovery. On examination vital signs were deranged, temperature 38.1C; respiratory rate -28;heart rate _115 :blood pressure 125/ 78 ( usually 140/ 90).She has been adherence with medication and regular blood monitoring.
Ms Styles lives alone,she has had hypertension and diabetes mellitus type 2 since 2011 and 2013 accordingly, for which she has been taking Queen April 40 mg twice a day orally; tablet metformin 500 mg twice daily and tablet gliciazide 30mg once a day. In addition she has been diagnosed with depression since June 2016 and it's triggered after her husband demice and she attend counsellings for mood swings and diabetic management.
In view of the above ,it would be appreciated if you would provide an urgent assessment and management .
If you need further information, please do not hesitate to contact me.