i 2 3 a & t University Hospitals Birmingham Wa NHS Foundation Trust wurwuhb.nhs.uk 0121 627 2000 Burns Surgery - Discharge Letter GP Copy Unknown GP Hospital No: k691813/4 Unknown address NHS number: Unavailable Patient's name: Anton STANICU Dos: 20/12/1978 Patient's Address: Rookrow Farm Moorend Cross Mathon ‘Malvern WR13 5PR 28 October 2019 Dear Unknown GP Re: Anton STANICU Consultant: Mr A. Farroha Admitted: 23 October 2018 Ward: Burs Unit (QEHB) Discharged: 26 October 2019 Destination: Home Presenting Problem + Bum infection + Bum <5% Clinical Details Category of Injury: Accidental, Unspecified Type of Injury. Contact PSU S/SD%: 0 PSU DDIFT%: 1 Discharge Dressing Acticoat Diagnoses Primary: ‘Acute Bums ‘Secondary: - Principal Disability Aesthetic Complications + None Coexisting Medical Conditions + Senile dementia (disorder) + Depressive disorder (disorder) Generated Sat 26 Oct 2019 17:13 Page 1 of 3i i ‘Anton STANICU Hospital No: Ke91813/4 + Epilepsy (disorder) Procedures Performed: Procedure: Result: 25.10.2019 Spl skin graft 25.10.2018 Excision of burn Allergies No recorded allergies Medication on Discharge For precise instructions of when and how to take your medication please (eclaCok Urea see eue ts Lees Meera Lets) Drug Name Route Form Dose Frequency Duration Codeine Phosphate Oral Tablet 30-60mg —-FourTimes a To continue Day (07-00, 1200, 17:00, 22:00) Flucioxaciia| Oral Capsule 500g Every SixHours 1 week (07:00, 12:0, 17:00, 22:00) ‘Mitazapine Oral ‘Tablet 159 Once aDay To continue (22.00) Paracatamal Oral Tablet ‘9 FourTimes a To continue Day (07:00, 42:00, 17:00, 22:00) Sodium Valproate Oral Gastro 500mg Twice @ Day To continue Resistant (07.00, 17:00) Tablet Latest Laboratory Results Date_[_Na | K | Urea | Croat] ca | Ab | ei | AMP] AST] AUT [Hb(@i)] WeC fesororel taal tof sala 3 a_i 156) 1053 [aers072076] oy tas] 703] Dato | Plat] Folate | Bia izsrioreors| 177] ieeniozora] 167] Date] TSH | Date | Chol Date [ABATo™ Wo Resuls "No Ress Woe = [esrtoora] 23 Date [WS] 1S Date [INR Warfarin Date | cK | GRP | Glue trop | Trop! may | [RarI07079 7 Fess [earOnOTe] 77 Admission Details 23/10/18: 40M Right Flank FT Burn with surrounding cellulitis TBSA 1% Sdays ago, fell from bed, 7in contact with radiator/Heater, Noticed pain around right flank Tuesday, went to local GP then showed it to employer who took him to Malvern Community hospital : referred to us via phone. PMH: ?Alcohol excess, Epilepsy, Depression, senile dementia. Admitted under Burns team, Full thickness bums excised & skin graft. Discharged post-op when well with oral antibiotics. Generated Sat 26 Oct 2019 17:13 Page 2 of 3os procera —rm ‘Anton STANICU lospital No: K691819/4 Information Given to Patient As above. After Hospital admission, you are at increased risk of blood clots (thrombosis). For further information about the symptoms of Deep Vein Thrombosis (OVT) and Pulmonary Embolism (PE) and what you can do to reduce your risk, please see the video and information leaflets on our website (https:/www.uhb.nhs.ukidvt) Recommendations for GP Please inform AnticoagulantTeam@uhb.nhs.uk if this patient develops a deep vein thrombosis or pulmonary embolism within 90 days of discharge. Other Services Arranged Risk of falls The latest Falls assessment suggests that the patient is at risk of falls. Follow Up Follow up: OP Appointment Follow up details: PDC 30/10/19 Yours sincerely, Dr Stephen Frost QoF data During this episode of care it was also noted that this patient has a BMI of 24.45 (estimated) Other data collected during this episode: FOL Cholesterol ‘Systolic BP Diastolic BP Tania TBAT 108 60 HATCIFCC | Microalbuminurea ent Weight Height Creatinine FEA (eal) Big (est) em Albumin Gamma oT We Result Generated Sat 26 Oct 2019 17:13 Page 3 of3