DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
DISCHARGE DIAGNOSES:
1. Morbid obesity, status post laparoscopic Roux-en-Y gastric bypass surgery.
2. Chronic depression.
OPERATION PERFORMED: The patient underwent elective laparoscopic Roux-en-Y gastric bypass.
CONSULTATIONS: None.
ALLERGIES: No known drug allergies.
DISCHARGE MEDICATIONS:
1. Prevacid 30 mg cap once daily. The patient is to open capsule and place granules in food.
2. Roxicet elixir 5-10 mL by mouth every 4 hours as needed for pain.
3. Effexor 150 mg by mouth at bedtime. The patient is to open capsule and put in food.
4. Elavil 40 mg by mouth daily, to be crushed.
5. Topamax sprinkles 200 mg by mouth daily.
REASON FOR ADMISSION: The patient is a (XX)-year-old female with a history of morbid obesity. The patient was seen in the outpatient surgery clinic and evaluated for gastric bypass surgery and felt to be an adequate candidate. Following extensive counseling and discussion of risks and benefits, the patient was scheduled for surgery.
HOSPITAL COURSE: The patient was admitted to the floor following laparoscopic gastric bypass surgery and did well. Overnight, following surgery, the patient was mildly tachycardic, however, remained afebrile. On postoperative day number one, a swallow study was performed and demonstrated no evidence of leak. The patient had mild leukocytosis of 12,000 at that time. This was felt to be postoperative demargination. She was, therefore, started on a clear liquid diet at 30 mL an hour, which she tolerated well. On postoperative day number two, the patient remained stable. Repeat white count was 8000. The patient did remain mildly tachycardic into the low 100s; however, given her benign physical exam and stable white count, she was started on a bariatric pureed diet. This was advanced from 1 ounce an hour to 2 ounces an hour on postoperative day number three. On postoperative day number four, the patient was tolerating a diet, and pain was well controlled on oral pain regimen. The patient remained afebrile with stable vital signs. The patient’s abdominal exam remained benign.
CONDITION ON DISCHARGE: Stable.
DISCHARGE INSTRUCTIONS:
1. Diet: The patient is to take a bariatric pureed diet at 2 ounces an hour.
2. Activity: The patient is to restrict heavy lifting to less than 10 pounds. The patient was instructed to shower and not bathe or soak wounds. The patient was instructed to not drive while taking narcotics.
3. Followup: The patient is to call Dr. John Doe’s clinic for an appointment in two weeks. The patient was instructed to call or return for increase in fever, intractable nausea, vomiting, or abdominal pain.
