Mr Paul Ferris
Manager of summer seat nursing home
16 June 2018,
Dear Mr Ferris,
Re: Mrs Anne Ellis,aged 76,
Mrs Ellis,who was diagnosed with renal colic needs ongoing care and evolution from your facility, following the discharge.
On 12 June 2018, Mrs Ellis admitted with abrupt onset of intense, unilateral left lain, along with grain pain radiating to lower back. In addition,had vomiting, restless, sweating and grimacing with pain. On examination,vital signs were deranged and observed hematuria in urine test. Computerised tomography report revealed bilateral multiple renal calculi and moderate hydronephrosis along with a 4mm calculus obstructed in pelvicuretic junction. Dehydration was observed and unable to consume oral fluids due to vomiting.
Mrs Ellis,was administered with intravenous fluids for 48 hours and suggested to increase the intake of fluid to 2 litres daily. Consequently, diclofenac,75mg, metoclopramide,10mg and paracetamol,500mg were commenced for ongoing symptoms every 4-6 hours. His vitals are stable within 36 hours and observed minimal pain. As per the suggestion of urologist,stone likely to pass spontaneously within 1-2 weeks,for which tamsolusin ,8mg, was commenced and advised to continue until next follow-up. On 20 July, urologist review has been suggested. Monitoring medication compliance and urine output would be beneficial.
Based on the above mentioned circumstances,usage of siave to check passage of stone has been advised. Avoid excessive intake of oxalate rich foods and to decrease salt intake food has been suggested.
If any additional information is required, please do not hesitate to contact me.
Berrytown public hospital
24 beech road
2. Anne Ellis - Reena Vineesh