DIAGNOSIS: MODERATE ANEAMIA IN A POST OP POSTERIOR LUMBER INTERANAL FIXATION AND DECOMPRESSION PT.
BACKGROUND HISTORY AND PRESENTATION:
The above named patient is a known patient of this facility who presentenced with lower back pain and was diagnosed as a case of advanced degenerative lumbar spine disease at L4/L5 with severe canal stenosis. He subsequently had a posterior lumbar decompression and internatal fixation done.
He recently presented with complains of dizziness and fever all of 2 days duration. Symptoms have progressively gotten worse over time.
He is being evaluated by a general surgeon on account of intra-abdominal mass.
· FBC: PCV- 27.38%,
· EUCr- Na- 128, MANAGEMENT PLAN:
· Transfuse with 2 units of packed cells under lasix cover 29mg pre and post
· Tabs exforge 10/160mg daily x 1/12
· Tabs metoprolol 50mg twice daily x 1/12
· Tabs biopentin 300mg bd x 2/52
· Tabs glucophage 1g bd x 1/12
· Tabs glimeperide 4mg daily x 1/12
· Tabs valsartan 160mg dly x 1/12
· Avoid strenuous activites
· Eat healthy diet
· Continue physiotherapy
Kindly revert to us for clarifications where necessary.
Dr. Oseni Somina
For Team Wellington Clinics Abuja