Mr. Paul Ferris
Manager of Summerseat Nursing Home
16 June 2018
Re: Mrs.Anne Ellis, DOB 6 January 42
Mrs. Anne Ellis, has been diagnosed with bilateral multiple renal calculi, now been discharged today , even so require your ongoing care and facilitation.
Initially on the 12th of June, presented with intense radiating pain to the lower back including vomiting, restlessness, sweating and frowning pain, subsequently, computer tomography and urine test were performed. On report above mentioned diagnosis was confirmed and haematuria was noticed.
In addition to, intravenous Diclofenac 75mg, intravenous Metoclopramide 10mg, intravenous rehydration therapy for 48 hrs were commenced. Also advised to increase adequate amount of fluid intake to 2 lit/day.
On the 13th of June, Ellis vitals were normal and general health condition was improved. Pain was subsided and tablet paracetamol 500 mg every four to six hours was prescribed for ongoing pain management. Additionally, urologist consultation was done and tablet Tamsolusin 8mg twice in a day prescribed. As per Urologist assessment stone will be removed spontaneously within 1-2 weeks, in such case passage stone to be send to laboratory for further investigation.
Based on the above mentioned circumstances; continue monitoring of medication and intake of fluid level 2-3 lit/day is required. Any increase of pain to be assessed. Also excess intake of salt ( maximum 3mg/day ) rich tools like nuts, soy products, wheat bran, limited animal, protein intake 1.0g?kg body weight need to be monitored by dietician. The follow-up programme is scheduled for 20 July.
Incase you require any additional information please do not hesitate to contact me.
Berrytown Public Hospital
24 Beech Road