Community Health Nurse
Date: 23 June 18,
Ref: Mr Albert Dsouza, aged 45,
Mr Alberr Dsouza, who has been diagnosed with Myocardial infraction, is being referred for ongoing care, regular monitoring and appropriate management following the discharge back to your facility.
Mr Dsouza was admitted to our facility on 18 July 18 with the complaints of chest pain radiated to shoulder, and breathlessness along with abdominal pain fast one week ago, and also he was experienced, weakness and severe sweating. According to ECG and laboratory reports, haemoglobiline was 7.8 and cardiac triage report positive, which confirmed the diagnosis Myocardial infarction has been ruled out. Renal stone in right kidney were revealed by ultrasonography respectively. He was commenced thrombolysis with streptokinase, pain was controlled, provided head elevated positions and administered oxygen via nasal cannula, breathing pattern maintain normally. Hence vital signs haemodynamically stable. Therefore, diet advised to low sodium and diabetic diet.
Mr DSouza, has had HTN since 2010, which was managed with amlodipine 5mg once daily. Although diabetics since 2014 its managing observent. Along with that, daily dressing on right foot case of cellulities. He lives alone, was widower. He has had habit of smoking in excess 10 cigarettes a day.
Based on the aforementioned circumstances, commenced continue antibiotics and other medications. Therefore, monitor the blood sugar level 3 times a week, as well as blood pressure chart maintenance, consequently recommended dietician consultation. Follow-up visit after 3 weeks with cardiologist OPD at 10 AM. Further any complication contact local GP.
In case any additional information is required, please do not hesitate to contact me.