100 Main Street
Re: Ms Patricia Styles, D.O.B: 27/04/1957
I am writing to refer a 62-year-old lady, Ms Styles, who has possible relapse or complication of pericarditis. Your immediate assessment and management would be greatly appreciated.
On her home visit on 30/08/2019, Ms Styles was stated complaints of chest pain which relieved with sitting up, shortness of the breath and fatigue. She found very frustrated and unsatisfied with poor recovery. On checking vital signs; the respiration rate and heart rate were recorded to be 28 per minute and 115 beats per minute respectively along with low-grade fever with 38.1°C.Her blood pressure was monitored to be normal than usual.
Last week Ms Styles was treated in hospital for fever, sharp and pleuritic chest pain, general weakness, malaise and tachycardia.Therefore, she was treated with intravenous saline and ibuprufen 600mg for 8 hourly.Few blood tests were carried out which revealed high levels of erythrocyte sedimentation rate, C-reactive protein and white blood cells. A viral influenza type B was confirmed by throat swab test and pericarditis was diagnosed on echocardiography.
Regarding her medication, Ms Styles has been taking quinapril 20mg twice a day for her uncontrolled blood pressure since 2013.She also has been taking metformin 500mg twice a day and gliclazide 30mg daily to manage her diabetes mellitus type 2 since 2014.
In view of the above, i would be grateful if you could urgently assess Ms Styles to provide her with management of pericarditis.
If you have any queries, please do not hesitate to contact me.