Incisional ventral hernia with obstruction
 
Name:  ___                  Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: SURGERY
 
Allergies: 
Amoxicillin / Nitrofurantoin / Augmentin / Cipro
 
Attending: ___
 
Chief Complaint:
incisional hernia 
 
Major Surgical or Invasive Procedure:
Open mesh incisional hernia repair.

 
History of Present Illness:
___ woman who is status post a laparoscopic 
cholecystectomy and she has
developed an incisional hernia at the umbilical port site. It 
has grown slowly, but surely grown to a massive size, and she 
now has entrapped omentum and a large hernia sac and needs this 
repaired.  She has no evidence of bowel obstruction.

 
Past Medical History:
OA, obesity, umbilical hernia
 
Social History:
___
Family History:
n/c
 
Physical Exam:
AVSS
Gen: NAD, cooperative
Chest: no resp distress
CV: RRR
Abd: soft, tender ___, incision - c/d/i, abdominal 
binder in place. JP drain in place, sero-sang output.
Extrem: warm, well perfused
 
Pertinent Results:
___ 08:15PM URINE RBC-9* WBC-35* Bacteri-MANY Yeast-NONE 
Epi-16 TransE-<1
___ 08:15PM URINE Blood-TR Nitrite-NEG Protein-NEG 
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG
___ 08:15PM URINE Color-Straw Appear-Hazy Sp ___

___ - Urine Cx pending
 
Brief Hospital Course:
  The patient was admitted to the Colorectal Surgical Service 
after operative repair. After a brief, uneventful stay in the 
PACU, the patient arrived on the floor with a regular diet, on 
IV fluids and antibiotics, and Dilaudid PCA for pain control. 
The patient was hemodynamically stable.
Neuro: The patient received IV Dilaudid with good effect and 
adequate pain control. When tolerating oral intake, the patient 
was transitioned to oral pain medications.
CV: The patient remained stable from a cardiovascular 
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary 
standpoint; vital signs were routinely monitored. Good pulmonary 
toilet, early ambulation and incentive spirrometry were 
encouraged throughout hospitalization.
GI/GU/FEN: Patient's intake and output were closely monitored, 
and IV fluid was adjusted when necessary. UA was sent on POD1 as 
patient was having urinary frequency. The result appeared 
consistent with contaminated specimen and patient denied having 
any buring or dysuria. Urine culture was pending at time of 
discharge. JP drain was left in place and patient received 
adequate teaching on drain management. 
Prophylaxis: The patient received subcutaneous heparin and 
venodyne boots were used during this stay; was encouraged to get 
up and ambulate as early as possible.

 At the time of discharge, the patient was doing well, afebrile 
with stable vital signs. The patient was tolerating a regular 
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:
1. citalopram 20 mg Tablet Sig: Four (4) Tablet PO DAILY 
(Daily).  
2. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 
hours) as needed for Anxiety.  

 
Discharge Medications:
1. citalopram 20 mg Tablet Sig: Four (4) Tablet PO DAILY 
(Daily).  
2. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 
hours) as needed for Anxiety.  
3. hydrocodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO 
Q6H (every 6 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 
times a day).
Disp:*60 Capsule(s)* Refills:*2*

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
incisional hernia

 
Discharge Condition:
Stable, Alert and Oriented.
Ambulating safely.

 
Discharge Instructions:
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 or operating heavy machinery while taking pain 
medications. You may keep the binder on as you wish for comfort.
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.
JP Drain Care:
*Please look at the site every day for signs of infection 
(increased redness or pain, swelling, odor, yellow or bloody 
discharge, warm to touch, fever).
*Maintain suction of the bulb.
*Note color, consistency, and amount of fluid in the drain.  
Call the doctor, ___, or ___ nurse if the amount 
increases significantly or changes in character.
*Be sure to empty the drain frequently.  Record the output, and 
bring these recordings to your follow up appointment. 
*You may shower; wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in 
water.
*Make sure to keep the drain attached securely to your body to 
prevent pulling or dislocation.

 
Followup Instructions:
___

{'tender ___, incision - c/d/i': ['Incisional ventral hernia with obstruction'], 'Abd: soft': ['Incisional ventral hernia with obstruction'], 'JP drain in place, sero-sang output': ['Incisional ventral hernia with obstruction']}