Community Health Nurse West Line
12 October 2018
Dear Ms Catherine
Re: Ms Grace William, aged 55
I am writing regarding Ms Grace William ,who successfully underwent panhystrectomy surgery, requires follow-up care and management from your service. She is being discharged today.
On 5 October 2018 Ms William was admitted to hospital with the complaints of vaginal bleeding ,fatigue and persistent abdominal pain. Multiple investigation was done and her vitals were deranged. USG shows multiple fibroidin uterus and ovaries ,for which surgery was recommended and alsotwo units of PRBC was transfused, Since her haemoglobin level is low (Hb_ 7mg/dl) surgery was done on 6 October 2018 and connected with IV Fluids, analgesics and antibiotics. In addition two units of PRBC was transfused.
On 8th October 2018 noticed pus in the wound area, it was drained and dressing has been done, and also noticed anxiety and stress. Haemoglobin level was checked on 9 October it was 8 mg/dl, for which reviewed by dietitian and started iron supplements. Now she has been walking with assistance.
Ms William is a widow. she has had diabetes since 2000, which was under control and also hypertension since 2008.
It would be appreciated if you could follow- up wound care, medication monitoring ,mobilization and pain management. Daily wound dressing has been adviced. In addition provide her with some dietary modification- iron rich food to increase hemoglobin level. Please note that she has a follow up on 18 October 2018 also she has to come to check her hemoglobin level after 2 days from discharge.
If you require any further information , kindly do not hesitate to contact me.