Unilateral inguinal hernia with obstruction without gangrene not specified as recurrent Unspecified viral hepatitis C without hepatic coma Opioid abuse uncomplicated Alcohol abuse uncomplicated Nicotine dependence cigarettes uncomplicated
 
Name:  ___             Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: SURGERY
 
Allergies: 
vancomycin / Thorazine / contact metal agent
 
Attending: ___.
 
Chief Complaint:
Inguinal hernia
 
Major Surgical or Invasive Procedure:
___: right-sided inguinal hernia repair

 
History of Present Illness:
Per resident: ___ active IVDA, ETOH abuse  with Hep C, on 
methadone program who presented to the clinic with Rt inguinal 
hernia.  the patient niticed the hernia ___ m ago and had a few ER 
visit  for symoptomatic hernia , it was never incarcerated and 
was not operated on. Denies trauma, or heavy lifting. He also 
denies fevers, chills, nausea, of decreased PO intake. Pt 
requesting the hernia to be repaired.

 
Past Medical History:
HCV, 
Bipolar disorder
Active IVDU heroin sometimes sniffs 
ETOH active drinker came to the clinic 
s/p car accident with Lt tibial Fx and shoulder injuries on ___ for which he had surgery and plating in both sites Per
patient (probably at ___)

Past Surgical History:
Incision, drainage, and packing of left forearm abscess. ___
Lt tibial and Rt shoulder Fixation ___ ___

 
Social History:
___
Family History:
NC
 
Physical Exam:
VS:T99.3 P45 (pt states baseline ___ BP 166/82 RR 18 02 
100%RA
General: no acute distress, alert and oriented x 3
Cardiac: regular rhythm, bradycardia, NL S1,S2
Resp: clear to auscultation, bilaterally
Abdomen: soft, non-tender, non-distended, no rebound 
tenderness/guarding
Wounds: abdominal lap sites with primary dgs, slight 
serosanguinous staining x 1; no periwound erythema or ecchymosis
Ext: no lower extremity edema or tenderness
 
Pertinent Results:
LABS:
___ 05:00AM BLOOD Hct-37.2*
___ 04:39PM BLOOD Hct-36.5*

 
Brief Hospital Course:
The patient presented to pre-op on ___ . Pt was 
evaluated by anaesthesia and was taken to the operating room 
where he underwent a laparoscopic right inguinal hernia repair.  
There were no adverse events in the operating room; please see 
the operative note for details.  Pt was extubated, taken to the 
PACU until stable, then transferred to the ward for observation. 

Neuro: The patient was alert and oriented throughout 
hospitalization; pain was managed with the patient's home 
methadone dose and prn oxycodone.  He was transitioned to oral 
oxycodone-acetaminophen upon discharge. 
CV: The patient remained stable from a cardiovascular 
standpoint; vital signs were routinely monitored. He was noted 
to have bradycardia during the hospitalization, which was 
asymptomatic and the baseline heart rate, per patient. 
Pulmonary: The patient remained stable from a pulmonary 
standpoint; vital signs were routinely monitored. Good pulmonary 
toilet, early ambulation and incentive spirometry were 
encouraged throughout hospitalization. 
GI/GU/FEN: The patient tolerated a Regular diet 
post-operatively; intake and output were closely monitored
ID: The patient's fever curves were closely watched for signs of 
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs 
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___ 
dyne boots were used during this stay and was encouraged to get 
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile 
and hemodynamically stable.  The patient was tolerating a diet, 
ambulating, voiding without assistance, and pain was well 
controlled.  The patient received discharge teaching and 
follow-up instructions with understanding verbalized and 
agreement with the discharge plan.

 
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires 
futher investigation.
1. Methadone (Concentrated Oral Solution) 10 mg/1 mL 73 mg PO 
DAILY 

 
Discharge Medications:
1.  Docusate Sodium 100 mg PO BID:PRN constipation 
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day 
Disp #*30 Capsule Refills:*0 
2.  OxyCODONE--Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN Pain 
- Mild 
RX *oxycodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth q 
4 hours Disp #*40 Tablet Refills:*0 
3.  Methadone (Concentrated Oral Solution) 10 mg/1 mL 73 mg PO 
AS DIRECTED BY PRESCRIBING PROVIDER  

 
___:
Home
 
Discharge Diagnosis:
Right-sided inguinal hernia 

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

 
Discharge Instructions:
Dear Mr. ___, 

You have undergone repair of your right sided inguinal hernia, 
recovered in the hospital and are now preparing for discharge 
with the following 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, operating heavy machinery or consuming alcohol 
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:
___

{'Inguinal hernia': ['Unilateral inguinal hernia'], 'Hep C': ['Unspecified viral hepatitis C without hepatic coma'], 'IVDA': ['Opioid abuse'], 'ETOH abuse': ['Alcohol abuse'], 'Bipolar disorder': [], 'Lt tibial Fx': [], 'Rt shoulder injuries': [], 'Bradycardia': []}