Attention to ileostomy
 
Name:  ___                    Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: SURGERY
 
Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___.
 
Chief Complaint:
Diverting loop ileostomy
 
Major Surgical or Invasive Procedure:
Ileostomy Takedown

 
History of Present Illness:
___ with history of medically refractory UC s/p laparoscopic
proctocolectomy, J-pouch loop ileostomy last month with course 
c/b SIRS reaction with spontaneous resolution now presenting for 
follow-up and discussion for ileostomy take-down. He has been 
doing well, eating well with a good appetite. He denies fevers 
or chills. He underwent routine pouch study last week, which did 
not demonstrate a leak.
 
Past Medical History:
PMH: Ulcerative colitis

PSH: ___- Laparoscopic proctocolectomy and mobilization of
splenic flexure, ileal pouch anal anastomosis with diverting
loop ileostomy.

 
Social History:
___
Family History:
He has 2 maternal cousins with underlying inflammatory bowel 
disease. He has one twin brother and one sister who are in good 
health. Maternal GF pancreatic cancer 56. Maternal GM breast 
post menopausal age ___. Paternal GF ? lung ca.

 
Physical Exam:
Upon discharge:

VS: Afebrile, VSS
General: young white Caucasian male, in no acute distress
HEENT: mucus membranes moist
CV: regular rate, rhythm
P: CTAB
Abd: former ileostomy site clean, dry, intact without active 
drainage. Minimal expected post-operative erythema. Soft, 
appropriately tender.
MSK: warm, well perfused 
 
Pertinent Results:
___ 06:00AM BLOOD WBC-6.6 RBC-4.42* Hgb-11.8* Hct-36.4* 
MCV-82 MCH-26.8* MCHC-32.5 RDW-17.3* Plt ___
___ 06:00AM BLOOD Glucose-90 UreaN-7 Creat-0.7 Na-140 K-3.5 
Cl-104 HCO3-26 AnGap-14
___ 06:00AM BLOOD Calcium-8.8 Phos-4.2 Mg-1.7
 
Brief Hospital Course:
___ was admitted to the inpatient Colorectal Surgery 
Service after ileostomy takedown. The patient was stable into 
post-operative day one. He did not have a foley catheter and was 
voiding without issue.

He was advanced to clears, then to a regular diet the next day 
without issue. He was transitioned to oral pain medication with 
effective pain control.

The day of discharge, the patient remained afebrile, with stable 
vital signs. He was ambulating without assistance, had return of 
bowel function and was tolerating a regular diet without issue. 
He verbalized understanding of his discharge instructions and 
was discharged home in good condition with follow-up.
 
Medications on Admission:
HYDROCODONE-ACETAMINOPHEN - hydrocodone 5 mg-acetaminophen 300 
mg
tablet. ___ tablet(s) by mouth every ___ hours as needed for 
pain
LIDOCAINE - lidocaine 5 % Topical Ointment. Apply to affected
area three to four per day as needed
Medications - ___
FERROUS SULFATE [FERROUSUL] - FerrouSul 325 mg (65 mg iron)
tablet. 1 tablet(s) by mouth twice a day -  (Prescribed by Other
Provider; ___)

 
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H 
do not take more than 3000mg of tylenol in 24hrs, do not drink 
alcohol 
RX *acetaminophen 325 mg ___ tablet(s) by mouth every six (6) 
hours Disp #*45 Tablet Refills:*0
2. OxycoDONE (Immediate Release)  ___ mg PO Q4H:PRN pain 
do not drink alcohol or drive a car while taking this medication 

RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours 
Disp #*50 Tablet Refills:*0
3. Ferrous Sulfate 325 mg PO BID 
home regimen 

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
Ileostomy after surgical managment of Ulcerative Colitis

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

 
Discharge Instructions:
You were admitted to the hospital after an ileostomy takedown. 
You have recovered from this procedure well and you are now 
ready to return home. You have tolerated a regular diet, passing 

gas and your pain is controlled with pain medications by mouth. 
You may return home to finish your recovery

Please monitor your bowel function closely. Have had a bowel 
movement prior to your discharge.  It is not uncommon after an 
ileostomy takedown to have frequent loose stool until you are 
taking more regular food however this should improve. The 
muscles of the sphincters have not been used in quite some time 
and you may experience urgency or small amounts of incontinence 
however this should improve. If you do not show improvement in 
these symptoms within ___ days please call the office for 
advice. You previously were taking imodium to slow your stool 
output with the ileostomy. If you find that you are having more 
than ___ bowel movements daily you can try a wafer also. Please 
call the Colorectal Surgery Office for advice. 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 
constipation. 

You have a small wound where the old ileostomy once was. This 
should be covered with a dry sterile gauze dressing. The wound 
no longer requires packing with gauze packing strip. Please 
monitor the incision for signs and symptoms of infection 
including: increasing redness at the incision, opening of the 
incision, increased pain at the incision line, draining of 
white/green/yellow/foul smelling drainage, or if you develop a 
fever. The staples will be removed at your follow-up 
appointment. 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 wound line and pat the 
area dry with a towel, do not rub. Please apply a new gauze 
dressing after showering.

No heavy lifting for at least 6 weeks after surgery unless 
instructed otherwise by Dr. ___. You may 
gradually increase your activity as tolerated but clear heavy 
exercise with Dr. ___. 

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 4000mg 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:
___

{'fevers or chills': ['Ulcerative colitis'], 'good appetite': [], 'no acute distress': [], 'mucus membranes moist': [], 'regular rate, rhythm': [], 'CTAB': [], 'soft, appropriately tender': [], 'warm, well perfused': [], 'stable vital signs': [], 'ambulating without assistance': [], 'return of bowel function': [], 'tolerating a regular diet': [], 'pain controlled': ['Ulcerative colitis'], 'afebrile': ['Ulcerative colitis'], 'voiding without issue': []}