Abscess of anal and rectal regions Depressive disorder not elsewhere classified Anxiety state 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:
perirectal abscess
 
Major Surgical or Invasive Procedure:
Exam under anesthesia
Incision and drainage of complex ___ abscess

 
History of Present Illness:
Ms. ___ is a ___ woman who underwent incision and 
drainage of a perirectal abscess approximately ___ years ago.  She 
now presents with recurrent
perirectal abscess and on a CAT scan that was obtained in the 
emergency room before surgery consult; the patient was found to 
have a horseshoe type of perirectal abscess extending from the 
patient's left side and around the rectum on the dorsal aspect.  
The patient was then taken to the OR for examination
under anesthesia and incision and drainage of the perirectal 
abscess.

 
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:
Discharge Physical Exam
VS: 98.9  73  115/76  18  100%ra
Gen: alert and oriented x3 NAD
CV: RRR 
Pulm: CTAB
Abd: Soft NT ND
Rectal: opened abscess cavity with some purulent drainage, 
packed loosely with plain packing material
 
Pertinent Results:
___ 04:21PM   LACTATE-0.9
___ 02:25PM   WBC-19.1*# RBC-3.82* HGB-11.7* HCT-36.0 
MCV-94 MCH-30.6 MCHC-32.5 RDW-11.9
___ 04:45AM BLOOD WBC-13.7* RBC-3.59* Hgb-11.2* Hct-33.4* 
MCV-93 MCH-31.1 MCHC-33.5 RDW-11.6 Plt ___
 
Brief Hospital Course:
Ms. ___ has a history of prior perirectal abscesses, and 
presented to the ED with symptoms of a recurrent abscess. She 
was taken to the OR for incision and drainage of this large 
horseshoe type abscess; for full details please see the dictated 
operative summary. She tolerated the procedure well; a shortened 
chest tube was left in the cavity to allow for irrigation 
overnight.

She was brought back to the floor in good condition. She was 
advanced to a regular diet and pain was controlled on oral 
medications. She ambulated and voided appropriately. She 
remained on cipro/flagyl for the duration of her hospital 
course. Prior to discharge, the tube was removed from the cavity 
and a loose packing was placed. She will remove the packing in 
one day and follow up with Dr. ___ in clinic later this 
week. She is discharged home in good condition on hospital day 
2, POD#1.
 
Medications on Admission:
lamictal 100', dicyclomine 10'

 
Discharge Medications:
1. lamotrigine 100 mg Tablet Sig: One (1) Tablet PO DAILY 
(Daily).  
2. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) 
as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 
6 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
4. dicyclomine 10 mg Capsule Sig: One (1) Capsule PO once a day. 
 
5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*0*

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
___ 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 colorectal surgery service after 
drainage of a complex ___ abscess. You have done well 
postoperatively and you are now ready to go home.

You will have a small wick inside the abscess. This should be 
removed tomorrow. After it is removed, please start taking ___ 
baths daily and after bowel movements. Continue to take pain 
medication as needed and also take stool softeners to prevent 
constipation.
 
Followup Instructions:
___

{'perirectal abscess': ['Abscess of anal and rectal regions'], 'Depression': ['Depressive disorder'], 'Anxiety': ['Anxiety state']}