Updated: Aug 2, 2021
Mr. Paul Ferris
Manager of Summerseat Nursing Home
16 June 2018
Dear Mr. Ferris
Re: Mrs. Anne Ellis, aged 76
I am writing thisletter to you, Mrs. Anne Ellis, who has diagnosed Renal Cdic, dilation of L collectibg system; obstructing Pelviureteric Junction ( PUJ) Calculus was admitted on 12 June 2018 at Berry town Public Hospital. She requires continuing care. She is being discharge today.
On admission 12 June 2018, she presented with severe pain attack on left unilateral coin, groin extending to lower back and vomiting. On assessment she experinced restless, sweating, and grimacing expression were noted. Blood pressure, 140/90, urine test was ordered which decker haematuria, but no infection . Computerized tomography scan had been order which was showed bilateral multi renal calculi, moderate bilateral hydronephrosis dilation of left collecting system and 4 mm obatructing pelvi ureteric junction (PUJ) calculus.
Intravenous Diclofenac 75 mg had administered and repeated after 35 minutes for reducing pain, intravenous metoclopramide long had given to shop vomiting rehydrating therapy was continue fkr two days encouraged to increase intake fluid medium 200 ml in a day.
On 13 June 2018 Tamsolusin 8 mg was started twice a day for support spontaneouspassage of calculus, paracetamol was commenced every 4-6 hours for relief pain. Therefore after treatment her condition had improp vital sign were stable base on urologist consultation. She is fit for discharge appointment of urology OPD has been arranged for followup on 20 July 2018.
In additional base ln above mentation information, she requires continuity of care monitoring complaince medicine observe pain encourage for intake fluid maximum 2-3 litres per a day monitoring urine output. Surprise to use sieve encourage and monitor low salt intake maximum 3g per a day, instruct to avoid excessive intake oxalaterich food and minimize animal protein.
If you have any queries donot hesitate to contact me.
Berrytown Public Hospital
24 Beech Road