Discharge Synopsis Essay

RELEASE SUMMARY

Patient Name: ENGELHART, Benjamin

Sufferer ID: 112592 DOB: 10/5/1967 Age: 46 Sex: Men

Particular date of Entrance: 11/14/2012

Particular date of Discharge: 11/17/2012

Acknowledging Physician: Bernard Kester, MARYLAND, General Surgical procedure

Procedures Performed: Laparoscopic appendectomy, with placemat of right lower quadrant drain 11/14/2012

Difficulties: None

Release Diagnosis: Severe suppurative appendicitis, perforated.

DIAGNOSTIC LAB/IMAGING: Lab benefits at the time of admission showed a WBC depend of 13. CT search within done in the ED revealed an severe appendicitis with phlegmon.

HOSPITAL COURSE: This 46 year old Caucasian gentleman provided to the ED with a three or more day great abdominal discomfort; however , within the last 24 hours it had radiated and migrated to the right lower quadrant leading to a significant amount of anorexic with some guarding. With an elevated white blood cell depend of 13 and a CT check out consistent with appendicitis, the patient was taken to the operating place w right here he went through a laparoscopic appendectomy that revealed perforation of the appendix with a phlegmon. The appendix was eliminated in total with an undamaged stable series. A drain was put into the right lower quadrant because of the phlegmonous material.

Affected person did well over the success of 2 to 3 days content operatively with resumption of oral diet, having exceeded flatus and having had bowel movements with minimal discomfort and little drain outcome. However , his white bloodstream cell count number lowered to 6. His drain has been still left intact.

Patient will be discharged in post practical, effectual day a few on a seven days course of gentimcin with the drain being left in place. The drain will probably be removed on my office upon 24 The fall of 2012, if the drain output be nominal. Patient is usually on a P. O. diet. He was given a pharmaceutical for both equally antibiotics and p. um. narcotics.

PLAN: Post operative go to in my office in one week for analysis and feasible removal of JP drain. Zero heavy training for four weeks...



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