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    Discharge Summary

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    Jaslynn White
    Benjamin Engelhart, a 46-year-old male, underwent a laparoscopic appendectomy for a perforated appendix. He recovered well with decreasing white blood cell count and minimal drain output. He was discharged on antibiotics with a follow-up appointment in one week to remove the drain if output remained low.

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    Discharge Summary

    Uploaded by

    Jaslynn White
    2K views2 pages
    Benjamin Engelhart, a 46-year-old male, underwent a laparoscopic appendectomy for a perforated appendix. He recovered well with decreasing white blood cell count and minimal drain output. He was discharged on antibiotics with a follow-up appointment in one week to remove the drain if output remained low.

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    Benjamin Engelhart, a 46-year-old male, underwent a laparoscopic appendectomy for a perforated appendix. He recovered well with decreasing white blood cell count and minimal drain output. He was discharged on antibiotics with a follow-up appointment in one week to remove the drain if output remained low.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    2K views2 pages

    Discharge Summary

    Uploaded by

    Jaslynn White
    Benjamin Engelhart, a 46-year-old male, underwent a laparoscopic appendectomy for a perforated appendix. He recovered well with decreasing white blood cell count and minimal drain output. He was discharged on antibiotics with a follow-up appointment in one week to remove the drain if output remained low.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 2

    DISCHARGE SUMMARY

    Patient Name: Benjamin Engelhart

    Patient ID: 112592 DOB: 10/05/1973 Age: 46 Sex: M

    Date of Admission: 11/14/2019

    Date of Discharge: 11/17/2019

    Admitting Physician: Bernard Kester, MD, General Surgery

    Procedure Performed: 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 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 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 to 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 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 2019, 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 any agreement with the above plan.

    (Continued)
    DISCHARGE SUMMARY

    Patient Name: Benjamin Engelhart


    Patient ID: 112592
    Date of Discharge: 11/17/2019
    Page 2

    ____________________________
    Bernard Kester,MD,
    General Surgery

    BK:jw
    D: 11/17/2019
    T: 11/20/2019

    C: Max L. Hirch, MD, Orthopedics

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