Fictitious University Hospital
Department of Internal Medicine
Prof. Malala Miller
Re: Medical History and Clinical Course of Patient Ashley Park
Dear Dr. General Practitioner,
I am writing to provide a comprehensive summary of the medical history, diagnoses, and
clinical course of our patient, Ashley Park, who was recently diagnosed and treated for a lung
embolism.
Patient Information: Ashley Park, Date of Birth: 12/24/1996
Age: 28
Gender: Female
Medical Record Number: 9874562
Medical History:
• Recent pregnancy (6 weeks postpartum)
• Cesarean section delivery
• History of preeclampsia
Presenting Symptoms: Ashley Park presented with sudden shortness of breath, chest pain
radiating to the shoulder, palpitations, and swelling and tenderness in the left calf.
Initial Assessment and Diagnosis: Diagnostic tests revealed elevated D-dimer levels, a
Doppler ultrasound confirming left calf DVT, and a CTPA demonstrating embolism in the left
pulmonary artery.
Clinical Course: Ashley Park was admitted to the obstetrics and gynecology ward for
specialized postpartum care. She was initially managed with LMWH therapy and
supplemental oxygen as needed. After stabilization, she transitioned to oral anticoagulants
(rivaroxaban) and received postpartum care and support, including breastfeeding
consultation. She experienced mild postpartum hemorrhage, which was managed
conservatively. Regular follow-ups were scheduled to monitor coagulation and postpartum
recovery, and she was educated on thromboembolism risks and preventive measures.
Current Status: Ashley Park is recovering well, continues anticoagulation therapy, and
receives support for postpartum care.
Recommendations: Continued anticoagulation with routine monitoring, follow-ups with
obstetrics and hematology specialists, and education on postpartum care and
thromboembolism prevention.
Sincerely,
Fictitious University Hospital
Department of Internal Medicine
Prof. Malala Miller
Dr. Fictitious Finch