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Ms Sandrine David-Discharge Back

Ms. Sandrine David was admitted to the hospital due to symptoms of possible acute coronary syndrome, gastritis, and gallbladder stones. She presented with abdominal pain, vomiting, agitation, and fear of dying. Diagnostic tests confirmed acute coronary syndrome and she was treated in the intensive care unit. Her condition stabilized with medication and she no longer reported pain. She is being discharged into the care of her general practitioner, Dr. Ali Maali, who is asked to provide continuous prescribed medication and advise her to quit smoking, limit alcohol, and exercise daily.

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213 views1 page

Ms Sandrine David-Discharge Back

Ms. Sandrine David was admitted to the hospital due to symptoms of possible acute coronary syndrome, gastritis, and gallbladder stones. She presented with abdominal pain, vomiting, agitation, and fear of dying. Diagnostic tests confirmed acute coronary syndrome and she was treated in the intensive care unit. Her condition stabilized with medication and she no longer reported pain. She is being discharged into the care of her general practitioner, Dr. Ali Maali, who is asked to provide continuous prescribed medication and advise her to quit smoking, limit alcohol, and exercise daily.

Uploaded by

Gretchen
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Dr Ali Maali

General Practitioner
Private Practice
Newtown

10 September 2022

Re: Ms Sandrine David, DOB : 22/01/1960


Dear Dr Maali,

I am writing to discharge Ms Sandrine David back into your care, who was admitted to St Mary
NHS Trust due to features possible of acute coronary syndrome, gastritis, and gallbladder
stones. Your continuous care and management would be appreciated.

On 02/09/2020 at 10 am, Ms David presented with complaints of abdominal pain radiating to


back and bilateral shoulders, vomiting, appeared agitated and thought of possible dying. On
assessment, she mainly reported epigastric pain with no abdominal tenderness noted. In
addition, her PR was 110, oxygen saturation was 92%, temperature of 37 celcius, RR 20 and BP
was 120/90. She was commenced on morphine intravenously for pain and hooked to fifteen
liters of oxygen inhalation. Consequently, she was immediately transferred to intensive care
unit for admission due to a confirmed ACS diagnosis following her diagnostic procedures
ordered for which reported a suspicious ischemic change in her ECG, noted elevation in cardiac
enzymes and NAD in ultrasound.

During ICU admission, Ms David was managed with continuous oxygenation and recommended
medications like Aspirin 250mg, Clopidogrel, morphine and alteplase infusion. Given that, she
was ordered for a repeated ECG and Echo.

In line with this, Ms David’s condition stabilized well with normal diagnostic results and no pain
reported. It would be appreciated if you could provide her a continuous prescribed medication
and kindly advise to quit smoking and alcohol intake. Please render education regarding her
current condition and a 30 min daily exercise might be beneficial.

If you have any queries, please do not hesitate to contact me.

Yours sincerely,

Nurse

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