Discharge summary



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Woodland Memorial Hospital

225 Main Street, Anywhere AL 12345

Office: (555) 123-4567



DISCHARGE SUMMARY
Patient Name: Benjamin Engelhart
Patient ID: 112592 DOB: 10/05/1968 Age: 46 Sex: Male
Date of Admission: 11/14/2014
Date of Discharge: 11/17/2014
Admitting Physician: Bernard Kester, MD, General Surgery
Procedure Performed: Laparoscopic appendectomy with placement of right lower quadrant drain on November 14, 2014.
Complications: None.
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 where he underwent a laparoscopic appendectomy that revealed perforation of the appendix with a phlegmon. The appendix was removed in toto with an intact stable line. A drain was placed in the right lower quadrant due to the phlegmonous material.
Patient did well over the successive 2 to 3 days postoperatively 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.
(Continued)

DISCHARGE SUMMARY


Patient Name: Benjamin Engelhart

Patient ID: 112592

Date of Discharge: 11/17/2014

Page 2
Patient is being discharged on postoperative day 3 on a 1-week course of p.o. gentamicin with the drain being left in place. The drain will be removed in my office on November 24, 2014, 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: Postoperative visit in my office in 1 week for evaluation and possible removal of JP drain. No heavy lifting for 4 weeks following surgery. Patient is to complete his full course of postop antibiotics. Patient is to report to the ED or to my office earlier for any redness or foul-smelling drainage at the wound site, any swelling, fever, pain, or any other concerns. The patient and his wife verbalized understanding of and agreement with the above plan.

_________________________

Bernard Kester, MD, General Surgery
BK:vw
D: 11/17/2014

T: 11/17/2014


CC: Max L. Hirsch, MD, Orthopedics


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