The Surgical Nurse Surgical Unit
Ones Hospital
29 October 2021
Dear Nurse,
Re: Mrs Guana Ferrocia, DOB: 01 June 1964
Mrs Guana Ferrocia, who has been diagnosed with grade 4 hemorrhoids is ready for the surgery tomorrow.
She lives with her boyfriend since last five years in rural area. Apart from that, she has a history of type 2 diabetes mellitus and inflammed bowel syndrome. She underwent colonoscopy in 2018, and treated for appendix inflammation in January 2020. She is allergic to Penicillin and Aspirin.
Today, she presented with rectal bleeding with burning pain. On physical examination, prolapse and slight tenderness were noticed. Pathology investigation and pre - procedure assessment has been recommended. Therefore, information regarding post-surgery management has been provided. On observation, temperature was 37.1° C, pulse 83, blood pressure 135/90, respiration 17, weight 70 kg and height 172 cm.
In addition, she has kept nil per orally and commenced on intravenous fluids. Enema has been given. Dosage of anaesthesia level has been explained and consent form is signed for hemorrhoidectomy. Pathology reports are still awaited.
Should you have further queries, please do not hesitate to contact me.
Yours faithfully,
Mary Mouse
Ward Nurse
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