DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
DISCHARGE DIAGNOSIS: Acute appendicitis with perforation.
PROCEDURE PERFORMED: The patient underwent exploratory laparotomy with right hemicolectomy and cystoscopy.
HISTORY OF PRESENT ILLNESS: This was the first hospital admission at this facility for this generally healthy (XX)-year-old Hispanic female, who presented to our office on the day prior to admission with a three-day history of nausea, vomiting and abdominal pain. The patient described the acute onset of nausea and vomiting three nights prior to admission with diffuse abdominal pain and anorexia. She had no diarrhea or hematemesis. She had had some chills but no fever. She was seen in our office on the day prior to admission. A CT scan was ordered, which showed apparent small bowel obstruction with distention of large and small bowel loops. The patient was admitted for further evaluation.
PHYSICAL EXAMINATION: On admission revealed an alert Hispanic female. Blood pressure 114/76, pulse 74 and regular, respirations 18. The skin was warm and dry without rash. HEENT examination was unremarkable. The neck was supple without mass or adenopathy. There was no JVD or bruits. The lungs were clear to auscultation and percussion. Heart had regular rate and rhythm without murmur or gallop. The abdomen was flat and diffusely tender. There was no significant guarding, but there was some rebound tenderness diffusely. There were no masses or hepatosplenomegaly. Bowel sounds were present in all quadrants. Extremities had no edema. Neurologic examination showed no focal deficits.
LABORATORY DATA: Initial CBC showed hemoglobin of 14.2, hematocrit 40.8, white blood cell count was 4600 with normal differential. Chemistries were remarkable for sodium 126, potassium 3.5, chloride 90, glucose 112, BUN 42, and creatinine 1.3. Albumin was low at 3. Liver enzymes were normal.
HOSPITAL COURSE: The patient was admitted to the medical-surgical bed. She was started on IV fluids and IV antibiotics with ciprofloxacin and metronidazole. GI consultation was requested. Abdominal MRA was obtained, which was a limited study, but showed no apparent vascular stenosis. The patient initially seemed to stabilize and improve with hydration but continued to have pain and anorexia. Surgical evaluation was obtained. She was seen by Dr. John Doe who preformed laparotomy revealing evidence of perforated appendicitis. A right hemicolectomy was performed. The patient tolerated the procedure very well. The patient remained stable with gradual improvement throughout the remainder of this admission. Her nasogastric tube was removed, and she was started on some clear liquids. Her diet was tolerated well and gradually advanced.
The patient was discharged home on MM/DD/YYYY. At the time of discharge, she was afebrile. Blood pressure and pulse were stable. Her appetite remained poor, but she was tolerating small amounts of solid foods.
DISCHARGE PHYSICAL EXAMINATION: Lungs: Clear. Heart: Regular rate and rhythm without murmur. Abdomen: Soft with decreased bowel sounds.
DISCHARGE MEDICATIONS:
1. Vytorin 10/40 mg daily.
2. Evista 60 mg daily.
DISPOSITION: The patient was discharged home. She is to follow up with us in one to two weeks. The patient is to follow up with Dr. John Doe.
