Patient Name: ENGELHART, Benjamin
Patient ID: 112592 DOB: 10/5/1967 Age: 46 Sex: Male
Date of Admission: 11/14/2012
Date of Discharge: 11/17/2012
Admitting Physician: Bernard Kester, MD, General Surgery
Procedures Performed: Laparoscopic appendectomy, with placemat of right lower quadrant drain 11/14/2012
Discharge Diagnosis: Acute suppurative appendicitis, perforated.
DIAGNOSTIC LAB/IMAGING: Lab results at the time of admission showed a WBC count of 13. CT scan done in the ED revealed an acute appendicitis with phlegmon.
HOSPITAL COURSE: This 46 year old Caucasian gentleman presented to the ED with a 3 day history of abdominal pain; however, over the past 24 hours it had radiated and migrated to the right lower quadrant causing a significant amount of anorexia with some guarding. With an elevated white blood cell count of 13 and a CT scan consistent with appendicitis, the patient was taken to the operating room w here he underwent a laparoscopic appendectomy that revealed perforation of the appendix with a phlegmon. The appendix was removed in total with an intact stable line. A drain was placed in the right lower quadrant due to the phlegmonous material.
Patient did well over the success of 2 to 3 days post operatively with resumption of oral diet, having passed flatus and having had bowel movements with minimal pain and minimal drain output. However, his white blood cell count lowered to 6. His drain has been left intact.
Patient is being discharged on post operative day 3 on a one week course of gentimcin with the drain being left in place. The drain will be removed on my office on 24 November 2012, should the drain output be minimal. Patient is on a P.O. diet. He was given a prescription for both antibiotics and p.o. narcotics.
PLAN: Post operative visit in my office in one week for evaluation and possible removal of JP drain. No heavy lifting for 4 weeks...