4865 ‫الرقم‬

Health Care No
‫الصحي‬

Name ‫سعد الصانع‬ ‫االسم‬

Age 60 ‫العمر‬ Sex ‫ذكر‬ ‫الجنس‬

Eradh Complex of Mental Health Nationality ‫سعودي‬ ‫الجنسية‬

Medical Referral Center Consultant In- ‫االستشاري‬
Department of Eligibility for Treatment Omaima abd al moneem
charge ‫المسئول‬
and Medical Coordination Center of
Internal
.Dept ‫القسم‬ Unit Social ‫الوحدة‬
Medicine Fraternization
REFERRAL FORM ‫نـمــوذج تـحـــــويـــــــل‬
TO DR ER DEPT ER
DESIGNATION HOSPITAL / PHC
FROM DR MAZEN HAJ AHMAD DEPT Center of Social Fraternization
DESIGNATION RISEDENT HOSPITAL / PHC ERADAH COMPLEX IN Riyadh
Clinical history: Known patient with past history of chronic schizophrenia on : clozapine 200 mg bid,valproat sodium
. cronic 500 mg bid, amlodipine tab 5 mg od,aspirine 75-100 mg od

The patient complained of shiver and dizziness ,pt conscious ,v/s : bp 100/70 , pulse 100/min, Temp 39.3

RBS 111

Refferal the pt to ER FOR EVALOATION AND TREATMENT

DIAGNOSIS
Provisional diagnosis : BPH ,OBSTUCTIVE UROPATHY ,CKD4.
PATIENT'S CONDITION : Stable  Critical  Conscious  Unconscious
REASON FOR REFERRAL :  Consultion AND treatment  Admission /Treatment
… Further Investigation Other : urgent case
TRANSPORTATION :  Ambulance  Helicopter Air Other:…patient herself…….
ESCORT : None Doctor  Nure Relative Other:…………..
DOCUMENTS SENT : Med.Report Lab.Result X_ray  Other:…………..
Dr.'s Name MAZEN HAJ AHMAD
Date : 27/09/2021
Mobile # 0595603653
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