20th july 2024
Dr. Marry Elsworth
General Practitioner
New Century Medical Surgery
94 Clemency Road
East Melbourne.
Dear Dr Elsworth,
Re: Ms.Bisma Saleem, 17 years old
I am writing to update you regarding Ms.Saleen who is undergoing treatment for SLE. She requires regular monitoring and assessment.
On 14/07/2022, Ms.Saleem was referred to me and she reported facial rash, tiredness, and forthy foul smelling urine, and two episodes of seizures. Her examination revealed BP, 97/74mmHg, Temperature,100F and BMI, 18kg/m2. Additionally, temporal alopecia, butterfly rash on cheeks and oral ulcers along with cold extremities and tenderness of multiple joints were found. Furthermore, her blood reports showed platelets 102,000/mm3, positive Coombs, creatinine,1.3 mg/dl,+ ANA and anti dsDNA along with WBC casts in urine sample.
Ms. Saleem was diagnosed with SLE. Therefore, tab hydrochloroquine, Ibuprofen and prednisolone were suggested. In addition to this, MR1 brain, ECG are awaited. Please note, arthrocentesis, ECHO, and Lumbar puncture will also be arranged.
In view of the above, Ms Saleem’s clinical response will be assessed after seven days and her electrolytes and seizures will be monitored.
Should you require any further information, please do not hesitate to contact me.
Yours sincerely,
Doctor
TRANSFER LETTER
20th July 2024
Mr. Edward Collins
The Director
Physical Rehabilitation Centre
Mary Curie
Dear Mr. Collins,
Re: Mr. Peter Berry, DOB: 26/03/1991
I am writing to transfer Mr. Berry who underwent the craniotomy and repairment of femur fracture. He is vitally stable now and he requires further care in the physical rehabilitation centre.
Mr. Berry smokes and drinks moderately. Additionally, he takes marijuana occasionally.
He has a frequent history of overspeeding fine.
Mr. Berry was admitted with subdural hematoma and the right femur fracture after a vehicle accident on 26/06/2021. Consequently, the craniotomy and repairment of femur fracture were done. His procedures went Successfull, however he was in coma state. Subsequently, he gained consciousness on 11/10/2021.
Today, Mr. Berry has had symptoms of depression . In addition, he has a problem with speech. Therefore ,In your care, please continue his speech therapy and physical rehabilitation. He also needs psychological assessment for his depression and counselling session for his social behaviour regarding speeding issue, Alcohol and smoking habits.Notably, he will also need wheel chair assistance
In view of the above, Mr. Berry is being transferred to you on his mother’s request.
Should you require any further information, please do not hesitate to contact me.
Yours sincerely,
Doctor