57 Sand Lane
10th June 2019
Re: Ivan Thompson, DOB 01/08/1984
Thank you for seeing Mr Thompson, who was admitted on the 8th June 2018, due to a perianal abscess. He will require wound care following an incision and drainage yesterday and will be discharged today.
Post operatively, Mr Thompson is observationally stable. The incision site, slightly to the right of the anus, is currently 2cm(length) x 1.5cm(width) and has been cleaned daily with prontosan, packed with kaltostat and sealed with a tegaderm. On discharge, nil signs of infection were noted.
The patient has been advised to take pain killers before dressing changes for the next few days and has been warned against long term use of ibuprofen. In addition, Metronidazole (500mg PO, q8hrs) was prescribed for one week as prophylactic cover. Please ensure Mr Thompson finishes his course.
I would be grateful if you could continue to dress the wound daily as it is producing a lot of exudate. Please monitor for any signs of infection and do not hesitate to refer Mr Thompson back to the hospital should you have any concerns. He has an OPD appointment in 6 weeks.
Please note we have advised that he uses a stool softner as when needed for short term use to reduce any discomfort.
If you have any queries, please do not hesitate to contact me.