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Discharge Summary Essay Sample

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Discharge Summary Essay Sample

DIAGNOSTIC LAB/IMAGING: Lab results at time of admission showed a WBC count of 13. CT scan done in the ED revealed acute appendicitis with a phlegmon. HOSPITAL COURSE: This 46-year old Caucasian gentleman presented ED with a three day history of abdominal pain. However, in the past 24 hours it radiated and migrated to the RLQ causing a significant amount of anorexia with some guarding. With and elevated WBC 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 and intact stable line. A drain was placed in the RLQ due to the phlegmonous material.

Patient did well over the success of two to three days of postoperatively with resumption of oral diet, having passed flatus and having 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 postoperative day three and a one week course of p.o. gentamicin with the drain being left in place. The drain will be removed in my office on 24 November should the drain output be minimal. Patient is on a p.o. diet. He was given a prescription for both antibiotics and p.o. necrotics. PLAN: Postoperative visit in my office in one week for evaluation and possible removal for JP drain. No heavy lifting for 4 weeks following surgery. Patient is to complete his full course of postoperative antibiotics. Patient is to report to the ED or to my office earlier for any redness.

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