Home Health Nurse
Millhouse Visiting Nurses Association
25 March 2018
Re: Mrs Sally Fletcher, DOB: 3 March 1993
Mrs Sally Fletcher, who is recovering from laparoscopic following endometriosis, requires ongoing care and adequate monitoring of her activities of daily living upon discharge.
Today, Mrs Fletcher presented with complaints of sudden menstrual pain and occasional constipation, for which over the counter drugs were ineffective. Assessment revealed a localised pain at the left lower side of her abdomen, and trans- vaginal ultrasound revealed a 6cm cyst with possible endometrial origin, and the aforementioned diagnosis was confirmed.She was operated same day with good outcome, evidenced by orientation in person, place, time and situation, and her discharged was discussed.
Post operatively, his pain was managed with painkillers. Consumption of fluid orally and regular diet were encouraged, Including ambulating of short distance independently.
Regarding her medical and social history, she reported episodes of painful menstruations for the past three years. Additionally, she consumes Western food.
It would be greatly appreciated if you could continue the management of Mrs Fletcher, encourage her to attend to her self-care and can resume driving after two. Please note that someone should convey her home.
Please contact me if you have any queries.