discharge

Topics: Surgery, Appendicitis, Vermiform appendix Pages: 3 (369 words) Published: November 10, 2013
DISCHARGE SUMMARY

Patient Name: Benjamin Engelhart

Patient ID: 112592DOB:10/05/1967Age: 46Sex: M

Date of Admission: 11/14/2013

Date of Discharge: 11/17/2013

Admitting Physician: Bernard Kester, MD General Surgery

Consultations:

Procedures Performed: Laparoscopic Appendectomy with placement of RLQ drain 11/14/2013

Complications: None

Discharge Diagnosis: Acute Superative 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 three day history of abdominal pain. However over the past 24 hours it had radiated and migrated to the RLQ causing a significant amount of anorexia with some guarding. With an elevated WBC of 13 and a CT scan consistent with appendicitis, the patient was taken to the operating room where he underwent a laparoscopic appendectomy that revealed perforation of the appendix with phlegmon. The appendix was removed in to with an intact stable line. A drain was placed in the RLQ due to the phlegmonous material.

Patient did well over the successive two to three days postoperatively with resumption of oral diet. Having past flatus and having had bowel movements with minimal pain and minimal drain output. However his WBC count lowered to 6. His drain has been left intact.

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DISCHARGE SUMMARY

Patient Name: Benjamin Engelhart

Patient ID: 112592

page 2

Hospital Course Continued:

Patient is being discharged on postoperative day three on a one week course of p.o. Gentamicin with the drain being left in place. The drain will be removed in my office on 11/24/13 should the drain output be minimal. The patient is on a p.o. diet. He was given a prescription for both antibiotics and p.o. narcotics.

Plan: Postoperative visit in my office in one week for evaluation and possible...
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