Derek Romano
Dr Fransiska Hutahaean
87 George Town Road NEWNHAM, TAS 7248
30-04-1991
The Registrar
Emergency Department
Launceston General Hospital
LAUNCESTON, TAS 7250
Dear Sir/ Madam,
I am referring Mr. Derek Romano, a 46-year-old insurance clerk, with acute myocardial infarction. The patient initially presented on 20-03-1991 for a general medical check up. On examination, he was overweight and had a high blood pressure. I advised him to lose weight and stop smoking that I would review him in a month.
Two weeks later he came to see me again. He was still smoking and had no improvement in exercise. I assessed him as having hypertension and commenced him on Nifedipin 20 mg daily.
Eleven days later he presented again with the major complaint of epigastric pain. The pain was radiating retrosternally and occurred after eating and walking. I assessed him as having gastric reflux and added Mylanta 30 mls four times daily. I also increased Nifedipin to 20 mg twice daily.
His father died of acute myocardial infarction at aged 48. He had no allergies.
Today he presented again with the major complaint of crushing retrosternal chest pain which lasted for an hour. On examination, he was in obvious distress. His blood pressure was 160/100 mmHg and there were few crepitations at his lung bases. Electrocardigram confirmed acute myocardial infarction. I administered Oxygen, Morphine 2,5 mg and Maxolon 10 mg intravenously immediately.I also gave him Anginine sublingually.
I would appreciate your assessment and further treatment of this patient’s condition.
Yours faithfully,
Dr Fransiska Hutahaean
General Practitioner
Correction by Ruth
http://adrive.com/public/8f02890fd29f10af8b20c4506c20965a474467c61e9dd47e76df513ab04f5800.html
