Other postoperative infection Abscess of anal and rectal regions Other specified surgical operations and procedures causing abnormal patient reaction or later complication without mention of misadventure at time of operation Condyloma acuminatum Dysthymic disorder
 
Name:  ___                 Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: SURGERY
 
Allergies: 
Patient recorded as having No Known Allergies to Drugs
 
Attending: ___
 
Chief Complaint:
Fevers, chills, perianal pain
 
Major Surgical or Invasive Procedure:
Incision and drainage of rectal abscess

 
History of Present Illness:
___ yo F s/p laser destruction of perineal and perianal
condyulomata on ___ by Dr. ___.  She had recovered well, 
and had returned both to work and school.  She now returns with 
complaints
of 3 days of intermittant fevers and chills, as well as some new 
L
perianal pain. She reports night sweats as well. She has had a
decreased appetite since the surgery and she has had some 
trouble
moving her bowels since then, with her last BM being 3 days ago.
She denies nausea or vomiting. She denies any melena or
hematochezia. She denies any drainage of bleeding from the
perianal region. Her L gluteus is tender when sitting, but she
does not note any increase in pain when she moves her bowels. 
She
does reports some dysuria and dark brown urine.

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

PSH: Microscopically-assisted biopsy and transanal
laser destruction of anal, perineal, vulvar, and vaginal
condylomata ___

 
Social History:
___
Family History:
Non-contributory.

 
Physical Exam:
On day of admission:
PE: 98.4   94   140/84   10   100RA
NAD. A&Ox3. 
Anicteric. MMM.
Supple. 
RRR.
CTAB.
Soft. NT. ND. +BS. 
Normal tone. No masses. No gross or occult blood. Erythema ~2
lateral to anal verge on L, occupying apex of gluteus. Tender to
palpation. No induration or fluctuance at area of erythema. No 
tenderness
in the anal canal. No masses, fullness or tenderness on digial 
rectal exam. No additional condylomata appreciated. 
Warm and well perfused. No peripheral edema. 

 
Pertinent Results:
___ 06:40AM BLOOD WBC-12.1* RBC-3.58* Hgb-11.4* Hct-32.9* 
MCV-92 MCH-31.8 MCHC-34.6 RDW-12.4 Plt ___
___ 06:25AM BLOOD WBC-19.5* RBC-3.55* Hgb-11.2* Hct-32.9* 
MCV-93 MCH-31.5 MCHC-33.9 RDW-12.6 Plt ___
___ 07:15AM BLOOD WBC-22.7* RBC-3.38* Hgb-10.9* Hct-31.1* 
MCV-92 MCH-32.3* MCHC-35.1* RDW-12.2 Plt ___
___ 10:20AM BLOOD WBC-31.3* RBC-4.03* Hgb-13.3 Hct-37.1 
MCV-92 MCH-33.1* MCHC-35.9* RDW-12.1 Plt ___
___ 06:20PM BLOOD Neuts-69 Bands-21* Lymphs-5* Monos-5 
Eos-0 Baso-0 ___ Myelos-0
___ 10:20AM BLOOD Glucose-115* UreaN-5* Creat-0.6 Na-137 
K-4.1 Cl-103 HCO3-21* AnGap-17
___ 10:20AM BLOOD Calcium-8.3* Phos-2.5* Mg-1.7
.
CT ABDOMEN W/CONTRAST Study Date of ___ 
IMPRESSION: Large anal fluid collection, which may represent 
multiple 
adjacent collections, or a single large collection with multiple 
compartments. It is highly suspicious for abscess in this 
clinical setting and would be amenable to percutaneous drainage. 


 
Brief Hospital Course:
The patient was admitted from the emergency room on ___.  She 
was empirically started on levo/flagyl.  

___ - the patient had a CT confirming a deep multiloculated 
___ abscess and was brought to the operating room for an 
incision and drainage of a ___ abscess.  A foley 
catheter was placed due to difficulty voiding.

___ - the patient underwent a dressing change and second look 
in the operating room which revealed no undrained or new areas, 
she continued on antibiotics.  The foley catheter was removed at 
midnight. Voiding adequate amounts.

___ - Tolerating a regular diet. Passing flatus. Ambulating 
independently. Perirectal wound packing changed at bedside. Two 
open sites, packed with kerlix gauze. Wound bed beefy red, no 
purulent exudate noted. Patient pre-medicated prior to dressing 
change. Tolerated well. WBC decreased 19.5 from 22.

___ - Discharge home with ___ for dressing changes. Continue 
with oral antibiotics for 7 more days.

 
Medications on Admission:
None
 
Discharge Medications:
1. Acetaminophen 500 mg Tablet Sig: ___ Tablets PO Q6H (every 6 
hours) as needed for pain: Do not exceed 4000mg in 24hours.  
2. Tums 500 mg Tablet, Chewable Sig: ___ Tablet, Chewables PO 
four times a day as needed for heartburn.  
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 
times a day) as needed for constipation for 1 months: Take with 
oxycodone.
Disp:*60 Capsule(s)* Refills:*0*
4. Ciprofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q12H 
(every 12 hours) for 7 days.
Disp:*42 Tablet(s)* Refills:*0*
5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 
times a day) for 7 days: Take with food.
Disp:*21 Tablet(s)* Refills:*0*
6. Oxycodone 5 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) 
as needed for pain for 2 weeks: Take 2 tabs 30 minutes prior to 
dressing change and as needed.
Disp:*45 Tablet(s)* Refills:*0*
7. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 
hours) as needed for pain for 2 weeks: Take with food  .
Disp:*45 Tablet(s)* Refills:*0*

 
Discharge Disposition:
Home With Service
 
Facility:
___
 
Discharge Diagnosis:
Primary:
___ abscess
.
Secondary:
perineal/perianal condylomas, Anxiety, depression 

 
Discharge Condition:
Stable
Tolerating a regular diet
Adequate pain control with oral medication
 
Discharge Instructions:
Please call your doctor or return to the ER for any of the 
following:
* Your pain is not improving within ___ hours or not gone 
within 24 hours. Call or return immediately if your pain is 
getting worse or is changing location or moving to your chest or 

back.
*Avoid driving or operating heavy machinery while taking pain 
medications.
* You have shaking chills, or a fever greater than 101.5 (F) 
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that 
concern you. 
* Please resume all regular home medications and take any new 
meds 
as ordered. 
* Continue to ambulate several times per day.
.
Perirectal Abscess wound care:
-Pre-medicate yourself with Pain pills about ___ minutes prior 
to dressing change per Visting nurse.
-___ should be changed once a day.
-You may shower. Avoid swimming and baths until your follow-up 
appointment.
-Please call the doctor if you have increased pain, swelling, 
redness, or drainage from the incision sites.

 
Followup Instructions:
___

{'fevers': ['Abscess of anal and rectal regions', 'Other postoperative infection'], 'chills': ['Abscess of anal and rectal regions', 'Other postoperative infection'], 'perianal pain': ['Abscess of anal and rectal regions', 'Other postoperative infection'], 'night sweats': ['Abscess of anal and rectal regions', 'Other postoperative infection'], 'decreased appetite': ['Abscess of anal and rectal regions', 'Other postoperative infection'], 'trouble moving bowels': ['Abscess of anal and rectal regions', 'Other postoperative infection'], 'tender gluteus': ['Abscess of anal and rectal regions', 'Other postoperative infection'], 'dysuria': ['Abscess of anal and rectal regions', 'Other postoperative infection'], 'dark brown urine': ['Abscess of anal and rectal regions', 'Other postoperative infection']}