MEDICAL REPORT
L.O/64YEARS/ MALE
DIAGNOSIS: MODERATE ANEAMIA IN A POST OP POSTERIOR LUMBER
INTERANAL FIXATION AND DECOMPRESSION PT.
BACKGROUND HISTORY AND
PRESENTATION:
The above
named patient is a known patient of this facility who presentenced with lower
back pain and was diagnosed as a case of advanced degenerative lumbar spine
disease at L4/L5 with severe canal stenosis. He subsequently had a posterior
lumbar decompression and internatal
fixation done.
He recently
presented with complains of dizziness and fever all of 2 days duration.
Symptoms have progressively gotten worse over time.
He is
being evaluated by a general surgeon on account of intra-abdominal mass.
INVESTIGATIONS
·
FBC: PCV- 27.38%,
·
EUCr- Na- 128, MANAGEMENT PLAN:
·
Admit
·
Transfuse
with 2 units of packed cells under lasix cover 29mg pre and post
Discharge medications/instructions
·
Tabs
exforge 10/160mg daily x 1/12
·
Tabs
metoprolol 50mg twice daily x 1/12
·
Tabs
biopentin 300mg bd x 2/52
·
Tabs
glucophage 1g bd x 1/12
·
Tabs
glimeperide 4mg daily x 1/12
·
Tabs
valsartan 160mg dly x 1/12
·
Avoid
strenuous activites
·
Eat
healthy diet
·
Continue
physiotherapy
Kindly
revert to us for clarifications where necessary.
Yours
Sincerely,
Dr. Oseni Somina
For Team Wellington Clinics Abuja