Re:Guana Ferrocia, DOB: 1 June 1964
Iam writing to refer Ms Guana Ferrocia, who has been diagnosed with haemorrhoids grade 4 and she requires to undergo haemorrhoidectomy tomorrow in your surgical unit.
Ms Ferrrocia admitted to hospital today with the complaints of rectal bleeding with burning pain. On examination, prolapse and slightly tender of rectum has been noticed. Based on this, pathology has been sent.
Regarding medical history, passing if fresh blood while defecating and severe perianal itching has been reported. In addition, she has a history of bowel complaints specifically constipation and has treated for appendix inflammation in January 2020.Besides this, she has been advised to soak the rectal area in warm water and to maintain fiber rich diet. Apart from this, she is suffering from type 2 diabetes mellitus.
In terms of pre-procedure management, information has been given regarding pre-procedure assessment and post-procedure care as well as consent taken. In addition, NPO have to start prior 6 hours to surgery, administered IV fluids, dosage of anaesthesia and sedation level has been explained. Moret, pathology results are awaited and she has been educated regarding hospital policies.
In case of additional queries, please do not hesitate to contact me.