Woodland Memorial Hospital
225 Main Street, Anywhere AL 12345
Office: (555) 123-4567
DISCHARGE SUMMARY
Patient Name: Benjamin Engelhart
Patient ID: 112592
DOB: 10/05/1968
Age: 46
Sex: Male
Date of Admission: 11/14/2014
Date of Discharge: 11/17/2014
Admitting Physician: Bernard Kester, MD, General Surgery
Procedure Performed: Laparoscopic appendectomy with placement of right lower quadrant drain on
November 14, 2014.
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 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.
(Continued)
Woodland Memorial Hospital
225 Main Street, Anywhere AL 12345
Office: (555) 123-4567
DISCHARGE SUMMARY
Patient Name: Benjamin Engelhart
Patient ID: 112592
Date of Discharge: 11/17/2014
Page 2
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 November 24, 2014, 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 and agreement
with the above plan.
_________________________
Bernard Kester, MD, General Surgery
BK:vw
D: 11/17/2014
T: 11/17/2014
CC: Max L. Hirsch, MD, Orthopedics