Emergency Department Consultant On Duty
100 Main Street
30 August 2019
Re: Ms Patricia styles, DOB: 27 April 1957
Ms Patricia styles, who requires urgent assessment and management of suspected complications of pericarditis.
On observation, Ms Styles reports chest pain, shortness of breath and fatigue. Regular blood glucose monitoring and medication comply have been noticed. she has a low grade fever 38.1°C, blood pressure 125/78 mmHg, respiratory rate 28 and heart rate 115 was elevated.
On 23 August, Ms Styles visited sister house for weekend, who lives away from Newton in green valley. She was admitted to green valley Hospital with the complaints of fever, sharp chest pain, generalized weakness, malaise and tachycardia. Subsequently, blood examination showed inflammation, throat swab test confirmed viral influenzae type B and and an echocardiogram revealed pericarditis. Ms Styles was managed with IV saline and ibuprofen. On 25th August, she was discharged to home.
Ms Styles has a history of hypertension, diabetes mellitus type 2 and depression which was manage with quinapril 40 mg twice daily, metformin 500 mg twice daily and gliciazide 30 mg daily.
In view of the above, required daily monitoring of her medication and proper observation.
Please do not hesitate to contact me if you require any further information.