Patient Details
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Medications |
Perindopril 5mg PO mane Atorvastatin 40mg nocte Ferrous Fumarate 200mg PO mane Clexane 40mg S/C nocte Paracetamol 1g PO QID Targin 10/5mg PO BD Endone 5-10mg PO Q4H PRN |
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HPC |
Mr Cunningham had a CT to chest, abdo, pelvis prior to having his lower anterior resection with temporary ileostomy 5 days ago. The CT scan showed no obvious distal metastasis but there are conspicuous pelvic lymph nodes. The patient had a morphine PCA for post-operative analgesia, an IDC and a bellovac drain insitu initially. The PCA and IDC were removed on day 2 and the bellovac drain on day 3 as there was only scant output. There has been no output into the ileostomy bag since operation so likely a post-operative ileus. Patient refuses to be mobilised due to abdominal discomfort and has no cough nor breathing difficulties. Urine output – satisfactory. |
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PSxHx |
Cholecystectomy |
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PMHx |
Hypertension Dyslipidaemia |
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Allergies |
Penicillin |
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FHx |
Mother died from myocardial infarction 15 years ago. Father died 50 years ago from a farm accident with no relevant medical history. Patient believes his maternal grandfather had bowel cancer, as did a maternal aunty. |
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SHx |
Patient and his wife recently sold their farm and moved into town for retirement. They have the support of a local daughter and son-in-law. Has a 25-pack-per-year smoking history but stopped 35 years ago. Has about 4-5 schooners of beer a week. |