12 November 2018
Iam referring Juanita Ferreira who has to undergo haemorrhoidectomy tomorrow in your surgical unit. Pre-procedure explained to her and she is ready for the procedure tomorrow.
Ms Ferreira came to hospital today with the complainys of rectal bleeding with burning pain. On assessment, hemorrhoids grade 4 have been noticed, with prolapse and slightly tender. In addition, she was passing fresh blood when defeating few days ago. During consultation with doctor, she was complaining of constipation and hard stools. However, doctor advised her haemorrhoidectomy for which pathology has been ordered and pre procedure assessment explained.
In view of her medical and social history, she lives with her boyfriend since 2 years and have four sons who all are in navy. Moreover, she underwent Colonoscopy in 2015 and treated appendix inflammation with antibiotics in 2018.
Pre-operatively, vitals are normal with weight of 73 kg. In addition, enema has performed, administered IV fluids and NPO have to start six hours prior to surgery. She has been explained about dosage of anaesthesia and it's level of sedation. She has given sign for consent form regarding her procedure. Ms Ferreira is a diabetic and she has received information about pre and post surgery as well as pain management.
Pertaining to the above details, if you require further details please do not hesitate to contact me.