Community Health Nurse
23 July 2018
Dear Ms Alexandria,
Re: Mr Albert Dsouza, aged 45
I am writing to update you the current health status of Mr Dsouza who has been recovering from myocardial infarction. He requires continuing care and appropriate management following the discharge today.
Mr Dsouza presented to the hospital on 18 July with complaints of chest pain which was radiating to the right shoulder associated with weakness breathlessness and abdominal pain since one week. Therefore, various investigations were carried out. The blood investigation revealed anemia and the red blood cell count was 2 lakh. Despite of normal routine test, renal calculi was noted in the ultrasound. In addition, cardiac markers were positive and the electrocardiogram confirmed the diagnosis.
During hospitalization, oxygen was administered to easen his symptoms and was commenced on thrombolysis with streptokinase. Consequently was referred to the nephrologist for the management of renal calculi. Apart from that he was also seen by the dietician nd low salt, low sugar diet has been advised. His pain is decreased; however he needs to maintain the blood pressure chart for recording.
Based on the above mentioned circumstances requesting you to monitor his blood sugar thrice a week, continue wound dressing and antibiotics. Ensure complaince to diet and medication. An appointment has been scheduled for Mr Dsouza with the cardiologist after a week in the outpatient clinic at 10am. If he develops any complication kindly contact the local physician.
Incase any additional information is required, please do not hesitate to contact me.