Congestive Cardiac Failure | My Assignment Tutor

GP LETTERDr Jones49 Bligh StreetNew town6525 6594Date: YesterdayRE: Mr Clive Jenkins. DOB 5/3/1942To whom it may concern,Mr Jenkins has been a patient at my rooms for several years. His main pasthistory includes Myocardial infarction two years ago, Congestive Cardiac Failure. He lives alone andtells me he is distressed by the loss of several friends recently. He has been regularly taking Ramipril5mg BD, Spironolactone 25mg daily and carvedilol 6.25mg daily, which seem to manage hissymptoms well, but he has displayed a tendency to not renew his scripts in a timely fashion once theprevious scripts are exhausted. This has led to previous admissions in the past and I suspect it is thesame issue this time evidenced by his current cardiac picture and his weight gain. From what I cangather during my appointment with him today, he has not taken his cardiac medication for threedays.Whilst I have been in communication with Mr Jenkin’s cardiologist, I understand Mr Jenkins has notattended his recent appointments.If you required any further information, please do not hesitate to contact my rooms.Kind regards,Signed Dr JonesProgress notesYesterday: 1830Emergency departmentMr Jenkins, history of CCF, admitted to department via GP referral for clinical investigation after nottaking cardiac medications for 3 days. Awaiting cardiology review. Obs as charted. Commenced on IVfluids as nil by mouth due to anticipated trans-oesophageal echo (TOE).Signed: R. Jones. Registered Nurse.Yesterday: 2300Cardiology reviewMedications recharted with increase in ramipril and addition of furosemide for next 48 hours untiloedema resolves. ECG shows sinus tachycardia with no new evident ischaemic changes. Will notproceed with TOE at this time – can recommence diet and oral fluids. Will review tomorrowafternoon.Signed: Dr. T Smith. CardiologistToday: 0600Emergency departmentPatient awake most of the night as uncomfortable and confused. Easy to orientate and compliantwith instructions. For transfer to ward.Signed: W. Fielding. Registered Nurse.–i–i– –=a-r-1i;� “=0Oz0zG�):z00z�::=m0URN/HCIALLERGIES & ADVERSE REACTIONS (ADR)SURNAME……………………………………………………….. D.0.B. …………………….DDrug NII Known (or other) Reaction/ypeDateInitials D Unknown (tick appropriate box or complete details below) OTHER NAMES……………………………… .. �……. ‘……………………………….. SEXMARITALADDRESS ………………… …… ……………………………………………. STATUS……………………………………… …………………………………………….. REL.1 st Prescriber to print patient name and check label correctWard/nit………………………………………………………………………….Sign…………………………………..Print……………………………………..Date …………….Estimated Creatinine Clearance………………………………mlminREGULAR MEDICATIONS Patient Weight (kg) ………………………….Height (cm) ………………..0 O��YEAR 20 DATE & MONTH—— � �.;::1;;VRAlBALE�O;O$;EaM;E;O;Ic”A”T”Io”_ _�:.:� N D,ru:g .tev_e,1 —+—-+—-1–+—Date M edication (Print Generic Name) nm e level taken Dose-��Rou-te —-�F’requ_ _ency – ————–,P rescriber“1 Date Medication (P rint Generic Name)Route Dose Frequency and NOWenter tim es IndicationVTE prophylaxisIPharmacyP resc rib er signatu re I Print your nam e Contact/Pager�Mechanical prophylaxisI I——-.——� 5

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