Inguinal hernia with obstruction without mention of gangrene unilateral or unspecified (not specified as recurrent) Coronary atherosclerosis of unspecified type of vessel native or graft Unspecified essential hypertension Pure hypercholesterolemia Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS)
 
Name:  ___                   Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: SURGERY
 
Allergies: 
seasonal 
 
Attending: ___.
 
Chief Complaint:
left inguinal hernia
 
Major Surgical or Invasive Procedure:
___ Left Incarcerated recurrent Inguinal Hernia Repair 

 
History of Present Illness:
___ with history of L inguinal hernia repair presented with 
sudden onset of painful left groin buldge.  Patient awoke with 
bulge in left groin and constant pain.  Denies vomiting, some 
nausea, fevers/chills.  Last BM was 2 days prior. Last flatus 
was yesterday.  Denies sense of abdominal bloating.

 
Past Medical History:
1. CAD RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: 2 drug eluting stents: 
proximal and mid LAD (___)
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
-cluster headache (no terrible headaches for years)
-Left leg tibial/fibula ganglion cyst
-BPH

PSH
1. History of Left sided inguinal herniorraphy with mesh (___ 
___
2. Coronary stent placement
3. Left leg cyst excision

 
Social History:
___
Family History:
No family history of cancer, arrhythmia, cardiomyopathies, or 
sudden cardiac death. His uncle and cousin died of MIs in their 
___.
 
Physical Exam:
Vitals: 98  82  136/64  17  98%ra
Gen: no acute distress, alert and oriented, well appearing
Abd: hernia repair site in left inguinal region with dressing 
c/d/i, mild tenderness to palpation; abdomen nondistended, 
nontender, no rebound or guarding
Cardio: regular rate and rhythm
Pulm: nonlabored breathing, clear to ascultation
Ext: nonedematous, noncyanotic
 
Pertinent Results:
___ 10:15AM BLOOD WBC-6.6 RBC-4.30* Hgb-13.8* Hct-42.4 
MCV-99* MCH-32.2* MCHC-32.6 RDW-13.9 Plt ___
___ 10:15AM BLOOD Neuts-72.8* Lymphs-17.5* Monos-6.0 
Eos-3.2 Baso-0.5
___ 10:15AM BLOOD ___ PTT-29.4 ___
___ 10:15AM BLOOD Glucose-98 UreaN-22* Creat-0.7 Na-136 
K-4.4 Cl-103 HCO3-25 AnGap-12

CT ABD & PELVIS WITH CONTRAST Study Date of ___  
Abdomen:  The lung bases demonstrate minimal dependent 
atelectasis.  No pleural or pericardial effusion is seen. 
  
A subcentimeter hypodensity in segment 4A of the liver likely 
represents a cyst.  Calcification is again seen in the spleen.  
An accessory spleen is noted.  The gallbladder, pancreas, 
adrenal glands, stomach, and small bowel are within normal 
limits.  Bilateral renal hypodensities most likely represent 
cysts; the largest arises from the lower pole of the right 
kidney and measures 4.4 x 3.8 cm.  Neither kidney demonstrates 
hydronephrosis. Colonic diverticula do not demonstrate evidence 
for acute inflammation.  There is no free intraperitoneal air or 
ascites.  Major intra-abdominal vasculature appears patent and 
normal in caliber with dense calcified and non-calcified aortic 
atherosclerotic plaque. 
  
Pelvis:  The prostate, seminal vesicles, and rectum demonstrate 
no acute abnormalities.  The bladder is distended with layering 
contrast.  No free fluid is seen in the pelvis.  Fat containing 
right inguinal hernia is seen.  No left inguinal hernia is seen. 

  
No concerning lytic or sclerotic osseous lesions are detected. 
  
IMPRESSION: 
No CT evidence for acute intra-abdominal or pelvic process or 
incarcerated hernia.   

 
Brief Hospital Course:
The patient was admitted on ___ under the acute care 
surgery service for management of an incarcerated left inguinal 
hernia. Initial CT scan report said there was no hernia, but the 
clinical suspicion was high for an incarcerated inguinal hernia 
so he was taken to the operating room for open left inguinal 
hernia repair. Please see operative report for details of this 
procedure. He tolerated the procedure well and was extubated 
upon completion. He was subsequently taken to the PACU for 
recovery.

He was transferred to the surgical floor hemodynamically stable. 
His vital signs were routinely monitored and he remained 
afebrile and hemodynamically stable. He was initially given IV 
fluids postoperatively, which were discontinued when he was 
tolerating PO's. His diet was subsequently advanced and he 
tolerated it well.  

On ___ the patient's pain was under control; he was 
tolerating a regular diet and functioning independently so he 
was discharged home.  At the time of discharge the patient 
understood the recommendation for follow up and instructions for 
no heavy lifting for minimum of 6 weeks after the surgery.  
 
Medications on Admission:
1. Verapamil
2. Plavix 75 daily
3. Lisinopril 
4. Simvastatin  40

 
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H RX *acetaminophen 650 mg 1 
tablet(s) by mouth q8hrs Disp #*60 Tablet Refills:*2
2. OxycoDONE (Immediate Release)  5 mg PO Q4H:PRN pain do not 
drive or use alcohol while taking this medicaiton RX *oxycodone 
5 mg 1 tablet(s) by mouth q4hrs prn Disp #*40 Tablet Refills:*0
3. Verapamil SR 240 mg PO Q24H 
4. Clopidogrel 75 mg PO DAILY 
5. Lisinopril 5 mg PO DAILY 
6. Simvastatin 40 mg PO DAILY 
7. Docusate Sodium 100 mg PO BID RX *docusate sodium [Colace] 
100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule 
Refills:*2

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
left inguinal hernia

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 
Discharge Instructions:
You were seen and evaluated by the Acute Care Surgery Service at 
___ for your left inguinal hernia.  We took you to the 
operating room and repaired the hernia.  You are now in better 
condition and are safe to return home and continue your recovery 
there.  

You will need to avoid heavy lifting for at least 6 weeks.  You 
will have some pain and swelling at the surgical site, but these 
will improve with time.  

Please take the pain medication as prescribed; also take the 
stool softener while taking narcotic pain medications to prevent 
constipation.  

You will need to follow up with us in clinic in 2 weeks so we 
can monitor your recovery.  

**You can take off your dressing on ___, ___.  
Until then, do not get the area wet (take a sponge bath if 
necessary).  After taking the bandage off you can shower, 
allowing warm water to run over the wound but do not scrub the 
wound; pat dry with a clean towel; leave the steristrips (white 
bandages) in place; these will fall off on their own (or you can 
remove them ___ days after your surgery).  

Please call your doctor or nurse practitioner or return to the 
Emergency Department for any of the following:

*You experience new chest pain, pressure, squeezing or 
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your 
medications.
*You are getting dehydrated due to continued vomiting, diarrhea, 
or other reasons. Signs of dehydration include dry mouth, rapid 
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a 
bowel movement.
*You experience burning when you urinate, have blood in your 
urine, or experience a discharge.
*You have shaking chills, or fever greater than 101.5 degrees 
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern 
you.

Please resume all regular home medications , unless specifically 
advised not to take a particular medication. Also, please take 
any new medications as prescribed.

Please get plenty of rest, continue to ambulate several times 
per day, and drink adequate amounts of fluids. Avoid lifting 
weights greater than ___ lbs until you follow-up with your 
surgeon.

Avoid driving or operating heavy machinery while taking pain 
medications.

Incision Care:
*Please call your doctor or nurse practitioner if you have 
increased pain, swelling, redness, or drainage from the incision 
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap 
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up 
appointment.
*If you have steri-strips, they will fall off on their own. 
Please remove any remaining strips ___ days after surgery.

 
Followup Instructions:
___

{'painful left groin bulge': ['Inguinal hernia'], 'constant pain': ['Inguinal hernia'], 'nausea': ['Inguinal hernia'], 'fevers/chills': ['Inguinal hernia'], 'cluster headache': ['Pure hypercholesterolemia'], 'left leg tibial/fibula ganglion cyst': ['Pure hypercholesterolemia'], 'BPH': ['Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS)'], 'CAD RISK FACTORS': ['Coronary atherosclerosis of unspecified type of vessel, native or graft', 'Unspecified essential hypertension'], 'vomiting': ['Inguinal hernia'], 'no rebound or guarding': ['Inguinal hernia'], 'mild tenderness': ['Inguinal hernia'], 'nontender': ['Inguinal hernia'], 'nonedematous': ['Inguinal hernia'], 'nontender, no rebound or guarding': ['Inguinal hernia'], 'nonlabored breathing': ['Inguinal hernia'], 'clear to ascultation': ['Inguinal hernia'], 'noncyanotic': ['Inguinal hernia'], 'no acute distress': ['Inguinal hernia'], 'alert and oriented': ['Inguinal hernia'], 'well appearing': ['Inguinal hernia'], 'no acute abnormalities': ['Inguinal hernia'], 'no concerning lytic or sclerotic osseous lesions': ['Inguinal hernia'], 'no free intraperitoneal air or ascites': ['Inguinal hernia'], 'no CT evidence for acute intra-abdominal or pelvic process or incarcerated hernia': ['Inguinal hernia']}