Wellington Case Report: MODERATE ANEAMIA IN A POST OP POSTERIOR LUMBER INTERANAL FIXATION AND DECOM

                                                                                                                                

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

 

 

16 Oct, 2023
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