Abscess of anal and rectal regions Irritable bowel syndrome Bipolar disorder unspecified
 
Name:  ___                 Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: SURGERY
 
Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___
 
Chief Complaint:
Rectal Pain
 
Major Surgical or Invasive Procedure:
Incision and Drainage with ___ Placement for treatment of 
Perirectal Abscess

 
History of Present Illness:
HPI: ___ with IBS and prior I&D of ___ and ischiorectal
abscesses in ___ and ___ now p/w worsening rectal pain over 
the
past several days. She was recently seen in ED on ___ with 2
days of worsening rectal pain after anal sex, examination at 
that
time exam was unremarkable and pt was instructed to avoid anal
intercourse and discharged home. Patient states that since that
time she has had increased rectal pain and swelling,
fevers/chills, and night sweats. Feels that this is consistent
with her prior presentations of perianal abscesses. She has
refrained from all sexual contact since her last ED visit. She
also reports some nausea and bloating, but denies vomiting,
hematochezia or black stools. She has no pain with defecation 
and
her last BM was yesterday.

 
Past Medical History:
PMH: Depression, anxiety, perineal/perianal condylomata

PSH:
# Microscopically-assisted biopsy and transanal laser 
destruction of anal, perineal, vulvar, and vaginal condylomata 
___
# perirectal abscess drainage in ___
# perirectal abscess drainage ___
 
Social History:
___
Family History:
Maternal grandmother with skin cancer.  Paternal aunt with 
breast cancer. 
 
Physical Exam:
General: Doing well, pain controlled, tolerating medications by 
mouth, minimal pain
A&OX3
No chest pain or shortness of breath
Abd: soft, nondistended
 
Pertinent Results:
___ 05:40AM BLOOD WBC-19.3* RBC-3.63* Hgb-11.8* Hct-34.9* 
MCV-96 MCH-32.6* MCHC-33.8 RDW-11.8 Plt ___
___ 02:17PM BLOOD WBC-20.3* RBC-4.22 Hgb-13.5 Hct-41.3 
MCV-98 MCH-32.0 MCHC-32.7 RDW-11.5 Plt ___
___ 02:17PM BLOOD Neuts-89.3* Lymphs-6.9* Monos-3.5 Eos-0.1 
Baso-0.2
___ 05:40AM BLOOD Glucose-103* UreaN-6 Creat-0.5 Na-139 
K-3.5 Cl-105 HCO3-24 AnGap-14
___ 02:17PM BLOOD Glucose-84 UreaN-7 Creat-0.7 Na-138 K-3.8 
Cl-103 HCO3-26 AnGap-13
___ 05:40AM BLOOD Calcium-8.0* Phos-3.5 Mg-1.5*

CT ABD & PELVIS WITH CONTRAST Study Date of ___ 5:36 ___ 
IMPRESSION: 
IMPRESSION: 
  
A large perianal fluid collection consistent with abscess does 
not definitely involve the anal sphincter, but is not well 
evaluated on CT. If definite determinent of sphincter 
involvement is required, MR can help with further evaluation.
 
Brief Hospital Course:
Ms. ___ was admitted overnight after I&D of a perirectal 
abscess. She was doing well on post-operative day one. Her wbs 
was 19 however, the abscess was drained. She was seen by the 
surgical attending and discharged home. She was given a week of 
Augmentin by mouth and pain mediacation. She tolerated a regular 
diet without issue.
 
Medications on Admission:
None
 
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H 
do not take more than 3000mg of tylenol in 24 hours or drink 
alcohol while taking 
2. Docusate Sodium 100 mg PO BID 
3. OxycoDONE (Immediate Release)  ___ mg PO Q3H:PRN pain 
do not drink alcohol or drive a car while taking this 
medications 
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours 
Disp #*35 Tablet Refills:*0
4. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 7 Days 
Please take entire prescription, start first dose evening of 
___ 
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 Tablet by mouth 
every twelve (12) hours Disp #*14 Tablet Refills:*0

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
Perirectal Abscess

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

 
Discharge Instructions:
You were admitted to the inpatient Colorectal Surgery Service 
after I&D of horseshoe perirectal abscess with ___ placement.

Please monitor your bowel function closely. You may or may not 
have had a bowel movement prior to your discharge which is 
acceptable, however it is important that you have a bowel 
movement in the next ___ days. If you are taking narcotic pain 
medications there is a risk that you will have some 
constipation. Please take an over the counter stool softener 
such as Colace, and if the symptoms do not improve call the 
office. If you have any of the following symptoms please call 
the office for advice or go to the emergency room if severe: 
increasing abdominal distension, increasing abdominal pain, 
nausea, vomiting, inability to tolerate food or liquids, 
prolonged loose stool, or extended constipation. You can shower, 
let the warm soapy water run over the area and keep as clean and 
dry as possible. You may preform ___ baths ___ times daily as 
needed. Please preform these as instructed by the nursing staff. 
Please eat foods that promote bowel motility such as: prunes, 
oat meal, apple juice, etc. Please avoid constipation.
 
You have ___ which has been incerted into the abscess and this 
will help keep the abscess draining and allow it to heal. This 
can be left open to air and a gauze dressing o pad may be worn 
in your underwear collect drianage. The ___ will stay in place 
until your first clinic visit and Dr. ___ will decide if the 
abscess has resolved enough for it to be removed. Please monitor 
or rectal area for signs and symptoms of worsening infection 
including: increasing redness, increased pain, increased 
draining of white/green/yellow/foul smelling drainage, or if you 
develop a fever. Please call the office if you develop these 
symptoms or go to the emergency room if the symptoms are severe. 
You may shower, let the warm water run over the incision line 
and pat the area dry with a towel, do not rub.

Avoid intercourse until your follow-up with Dr. ___. 

You may gradually increase your activity as tolerated but clear 
heavy exercise with your surgeon.
 
You will be prescribed a small amount of the pain medication 
Oxycodone. Please take this medication exactly as prescribed. 
You may take Tylenol as recommended for pain. Please do not take 
more than 3000mg of Tylenol daily. Do not drink alcohol while 
taking narcotic pain medication or Tylenol. Please do not drive 
a car while taking narcotic pain medication.
 
Thank you for allowing us to participate in your care! Our hope 
is that you will have a quick return to your life and usual 
activities. Good luck!
  

 
Followup Instructions:
___

{'Rectal Pain': ['Abscess of anal and rectal regions'], 'Worsening rectal pain': ['Abscess of anal and rectal regions'], 'Fevers/chills': ['Abscess of anal and rectal regions'], 'Night sweats': ['Abscess of anal and rectal regions'], 'Nausea': ['Abscess of anal and rectal regions'], 'Bloating': ['Abscess of anal and rectal regions'], 'Perirectal abscess': ['Abscess of anal and rectal regions']}