Gastroesophageal Reflux Discharge Summary Sample
DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
ADMITTING PHYSICIAN: John Doe, MD
ADMISSION DIAGNOSES:
1. Longstanding gastroesophageal reflux.
2. Esophagitis.
DISCHARGE DIAGNOSES:
1. Longstanding gastroesophageal reflux.
2. Esophagitis.
OPERATION PERFORMED: Laparoscopic Nissen fundoplication.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old female in general good health, who presents now with a 9-year history of requiring medication and treatment for gastroesophageal reflux disease. She had progressed through various anti-H2 and proton pump inhibitor agents and was dependent upon them for symptom relief. She was requiring increasing doses of those medications for relief. She did have an EGD, which documented presence of esophagitis and early changes of columnar epithelium but no evidence of metaplasia or malignancy. She was found to have hiatal hernia with reflux on preoperative testing. On the basis of her prolonged symptoms and need for medication and documented pathology, surgical intervention was offered and undertaken.
ADMISSION PHYSICAL EXAMINATION: Remarkable for abdomen, which is soft, flat and nontender. Bowel sounds are normal. No abnormal masses or hepatosplenomegaly. No umbilical or groin bulges. She had some laparoscopic scars from previous laparoscopic cholecystectomy and appendectomy.
ADMISSION LABORATORY DATA: Overall, unremarkable.
HOSPITAL COURSE: The patient was admitted and on the day of admission was taken to the main operating room. Under general anesthesia, she had a diagnostic laparoscopy with laparoscopic Nissen fundoplication. She was found to have moderate-sized hiatal hernia, which was repaired. She was noted to have healing of the previous operative sites in the subhepatic space and in the right lower quadrant. There was no evidence of other significant pathology. The patient tolerated the procedure well and recovered without incident.
DISPOSITION: Home.
DISCHARGE CONDITION: The patient is ambulating and tolerating p.o. without emesis with only mild discomfort. She has been afebrile with stable vital signs since surgery. Her abdomen was soft and nontender. Her wounds are healing with no erythema or drainage.
DISCHARGE INSTRUCTIONS: Diet: Regular and mechanical soft. Activity: Ad lib.
MEDICATIONS: Percocet 1-2 p.o. q. 4-6 hours p.r.n. pain.
FOLLOWUP: The patient is to follow up with us routinely in three weeks. She will call sooner for severe pain, wound redness or drainage, temperature of 101 degrees Fahrenheit, persistent emesis or diarrhea.
