Discharge Summary

Discharge Summary

Patient Name: Benjamin Engelhart
Patient ID: 112592 DOB: 10/05/---- Age: 46 Sex: M
Date of Admission: 11/14/----
Date of Discharge: 11/17/----
Admitting Physician: Bernard Kester, MD, General Surgery
Procedure Preformed: Laparoscopic appendectomy with placement of right lower quadrant drain on 14 November.
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 gentlemen 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.


Patient Name: Benjamin Engelhart
Patient ID: 112592
Date of Discharge: 11/17/----
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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 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....

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