Calculus of gallbladder without mention of cholecystitis without mention of obstruction Hemorrhage complicating a procedure Precipitous drop in hematocrit Other pulmonary insufficiency not elsewhere classified Incisional hernia without mention of obstruction or gangrene Other specified surgical operations and procedures causing abnormal patient reaction or later complication without mention of misadventure at time of operation Other iatrogenic hypotension Altered mental status Esophageal reflux Gout unspecified
 
Name:  ___                Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: SURGERY
 
Allergies: 
Patient recorded as having No Known Allergies to Drugs
 
Attending: ___.
 
Chief Complaint:
Cholelithiasis and incisional
hernia.

 
Major Surgical or Invasive Procedure:
___:
1. Open cholecystectomy.
2. Repair of incisional hernia with AlloDerm
.
___:
Evacuation of hematoma from the subcutaneous space with washout 
and reclosure of the abdominal wound.

 
Past Medical History:
PMHx: Duodenal ulcer s/p bleed
.
PSHx: Ex lap/repair of duodenal ulcer > ___ yrs ago (unclear as
to what type of surgery patient had - whether pyloroplasty vs.
reconstruction), repair of L hand tendon, pilonadial cyst and
sinus tract excision.

 
Physical Exam:
On dischage:
afvss
Gen:nad aox3
___: reg
Pulm:no resp disteress
Abd: soft, approp tender, mild distension, JP in place: 
serosanguinous drainage midline incsion healing, sutures in 
place
___: no LLE
 
Pertinent Results:
___ 01:07PM BLOOD Hct-39.6*
___ 07:35AM BLOOD WBC-10.4 RBC-4.01* Hgb-12.8* Hct-38.1* 
MCV-95 MCH-32.0 MCHC-33.6 RDW-12.5 Plt ___
___ 04:30PM BLOOD Hct-32.5*
___ 09:41PM BLOOD WBC-9.7 RBC-3.47* Hgb-11.1* Hct-31.2* 
MCV-90 MCH-31.9 MCHC-35.4* RDW-13.9 Plt ___
___ 03:06AM BLOOD Hct-29.3*
___ 06:42AM BLOOD Hct-27.2*
___ 10:13AM BLOOD Hct-29.0*
___ 06:07PM BLOOD WBC-8.8 RBC-3.26* Hgb-10.2* Hct-29.2* 
MCV-89 MCH-31.2 MCHC-34.8 RDW-13.7 Plt ___
___ 02:17AM BLOOD WBC-8.2 RBC-3.03* Hgb-9.5* Hct-27.1* 
MCV-89 MCH-31.1 MCHC-34.9 RDW-13.5 Plt ___
___ 01:20PM BLOOD WBC-9.1 RBC-3.13* Hgb-9.7* Hct-28.1* 
MCV-90 MCH-31.1 MCHC-34.6 RDW-13.7 Plt ___
___ 04:24AM BLOOD WBC-7.1 RBC-3.09* Hgb-9.6* Hct-27.5* 
MCV-89 MCH-31.0 MCHC-34.8 RDW-13.6 Plt ___
___ 04:24AM BLOOD ___ PTT-19.8* ___
___ 04:24AM BLOOD Glucose-106* UreaN-6 Creat-0.8 Na-141 
K-3.4 Cl-106 HCO3-27 AnGap-11
___ 04:24AM BLOOD Calcium-8.0* Phos-2.6* Mg-1.9
___ 06:15PM BLOOD Type-ART pO2-333* pCO2-29* pH-7.43 
calTCO2-20* Base XS--3
___ 06:15PM BLOOD Lactate-1.___ s/p CCY, ventral hernia repair w/ Alloderm ___.  Patient 
postoperatively was triggered on the floor x2 for hypotension 
and AMS. Patient transferred to trauma sicu.  Receiving two 
units of PRBCs on arrival to the ___ SBP fluid responsive and 
stable in TSICU, pt with O2sat 100% on RA. There was a 
complication of abdominal wall hematoma with decreasing Hct and 
patient was returned to OR on ___ for evacuation of hematoma 
from the subcutaneous space with washout and reclosure of the 
abdominal wound.   Post operatively the patient did well, his 
hct remained stable and after bowel function returned his diet 
was advance.  He had 2 drains left to bulb suction.  One drain 
was removed on POD 7.  By discharge he was tolerating regular 
diet and his pain was controlled on PO pain meds.  He is being 
discharged with ___ with one JP in place.

 
Medications on Admission:
Meds: vitD, tylenol, loratadine, guaifenesin 
 
Discharge Medications:
1. Oxycodone 5 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) 
as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
3. Acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6 
hours) as needed for fever or pain.  
4. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).  

5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) 
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
6. Loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day as 
needed for allergy symptoms.  
7. Vitamin D  Oral
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as 
needed for constipation: Over-the-counter.  

 
Discharge Disposition:
Home With Service
 
Facility:
___
 
Discharge Diagnosis:
1. Cholelithiasis and incisional hernia.
2. Postoperative bleeding, status post open cholecystectomy and 
incisional hernia repair with AlloDerm.

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

 
Discharge Instructions:
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.

*Your pain in not improving within ___ hours or is not gone 
within 24 hours. Call or return immediately if your pain is 
getting worse or changes location or moving to your chest or 
back.

*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.

JP Drain Care:

*Please look at the site every day for signs of infection 
(increased redness or pain, swelling, odor, yellow or bloody 
discharge, warm to touch, fever).

*Maintain suction of the bulb.

*Note color, consistency, and amount of fluid in the drain. Call 
the doctor, ___, or ___ nurse if the amount 
increases significantly or changes in character.

*Be sure to empty the drain frequently. Record the output, if 
instructed to do so.

*You may shower; wash the area gently with warm, soapy water.

*Keep the insertion site clean and dry otherwise.

*Avoid swimming, baths, hot tubs; do not submerge yourself in 
water.

*Make sure to keep the drain attached securely to your body to 
prevent pulling or dislocation.
 
Followup Instructions:
___

{'Cholelithiasis': ['Calculus of gallbladder without mention of cholecystitis'], 'Incisional hernia': ['Incisional hernia without mention of obstruction or gangrene'], 'Postoperative bleeding': ['Hemorrhage complicating a procedure'], 'Precipitous drop in hematocrit': ['Precipitous drop in hematocrit'], 'Pulmonary insufficiency': ['Other pulmonary insufficiency'], 'Surgical operation complication': ['Other specified surgical operations and procedures causing abnormal patient reaction'], 'Iatrogenic hypotension': ['Other iatrogenic hypotension'], 'Altered mental status': ['Altered mental status'], 'Esophageal reflux': ['Esophageal reflux'], 'Gout': ['Gout']}