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CORRECTED LETTERS

Dr Steph Sandy

General Practitioner

Phoenix Care Clinic

Melbourne

VIC 3876


13  March, 2011


Dear Dr Sandy,


Re: Mr Eusalyn Phelan

DOB: 13 March, 1976


I am writing to update the current health status of Mr Phelan who requires further follow-up care and management following his discharge today.He has been recuperating from a myocardial Infarction.

  • Regular follow up visits and drug dosage adjustments are the purposes. 

  • Although he has history of myocardial infarction, currently he has been diagnosed with heart failure secondary to recurrent myocardial infarction. 

Mr Phelan was admitted to the  hospital on 03 March, 2011 due to breathlessness.On assessment, his blood pressure was elevated to 160/100mmHg along with weak pulse.In addition, he had mild piting ankle edema and inaudible heart sounds.Therefore,he was suspected to have congestive heart failure due to recurrent infraction forwhich ( two word) fruoemide 10mg, morphine and glyceryle nitrate 600mgb was were administered along with oxygen.


In addition, blood investigations along with eletrocardiogram and an x-ray were performed for him which revealed significant elevation in serum electrolyte and glucose.Moreover, cardiomegaly and pulmoy edema were identified .Based on the investigations ,he has been confirmed with the diagnosis.


Mr Phelan was then transferred to the coronary unit and was started with isosorbride dinitrite , heparin intravenously along with digoxin orally.On subsequent days, he improved considerably and cardiac medications has been stopped.


Today, Mr Phelan has attained a significant recovery and he is able to ambulate without any breathing difficulty.Please note, his heart , lungs and kidney functions are stable though he has moderate impairment in mitral regurgitation.

  • Significant recovery is not same as gradual recovery.

It would be greatly appreciated if you could take over the case of Mr Phelan  and provide proper follow-up and management.Currently, he is on furesmide, aspirin ,digoxin,warfarin and insulin which need to be changed into tablets as deemed appropriate.


Kindly contact me if you have any queries.


Yours sincerely,


Registered Nurse


  • Don't use judgemental language 

  • Read the casenote properly and plan accordingly.

  • make sure your introduction is perfect.

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