Hank Babcockk
DISCHARGE SUMMARY
Patient Name: Hank Babcock
Patient ID: 652277
Admitted: 0l/14/----
Discharged: 01/18/----
Consultations: Jose Medina, MD, Surgeon
Procedures: Appendectomy.
Complications: None.
Admitting Diagnosis: Rule out acute appendicitis.
This is a 45-year-old man seen in my office on January 14 with the onset of acute abdominal pain at 10 a.m. that day. He was admitted directly to the hospital with a diagnosis of probable acute appendicitis.
DIAGNOSTIC DATA: Serum amylase was normal at 64. Cultures of peritoneal fluid at the time of discharge showed no growth. CBC performed as a follow-up on January 16 showed a white count of 12,400 (decreased from 21,000 on January 14). Hemoglobin today is 12 (decreased from 15.5 on January 14). Preop diagnostic data was performed in the office prior to admission. The remainder of the values were within the reference range for our facility.
HOSPITAL COURSE: The patient was admitted and surgical consultation was obtained from Dr. Medina. The patient was taken to surgery the evening of admission where acute appendicitis with a small perforation was found. Pathology confirmed acute appendicitis. The patient convalesced without difficulty; although, he did have a low-grade fever of 99.9 0F until January 17.
He was discharged on the following medications: Darvocet-N 100 one q. 6 h. p.r.n. pain and Keflex 500 mg p.o.q. 6 h. for three days. Diet and activities at the time of discharge as tolerated.
DISCHARGE DIAGNOSIS: Acute suppurative appendicitis.
DISPOSITION: He will be seen by Dr. Medina in 5 days. He will be seen in my office in 6 weeks to be evaluated for possible hypercholesterolemia and possible hypothyroidism.
_________________________
Ruth Ellis, MD
RE: xx
D: 01/20/----
T: 01/22/----
Patient Name: Hank Babcock
Patient ID: 652277
Admitted: 0l/14/----
Discharged: 01/18/----
Consultations: Jose Medina, MD, Surgeon
Procedures: Appendectomy.
Complications: None.
Admitting Diagnosis: Rule out acute appendicitis.
This is a 45-year-old man seen in my office on January 14 with the onset of acute abdominal pain at 10 a.m. that day. He was admitted directly to the hospital with a diagnosis of probable acute appendicitis.
DIAGNOSTIC DATA: Serum amylase was normal at 64. Cultures of peritoneal fluid at the time of discharge showed no growth. CBC performed as a follow-up on January 16 showed a white count of 12,400 (decreased from 21,000 on January 14). Hemoglobin today is 12 (decreased from 15.5 on January 14). Preop diagnostic data was performed in the office prior to admission. The remainder of the values were within the reference range for our facility.
HOSPITAL COURSE: The patient was admitted and surgical consultation was obtained from Dr. Medina. The patient was taken to surgery the evening of admission where acute appendicitis with a small perforation was found. Pathology confirmed acute appendicitis. The patient convalesced without difficulty; although, he did have a low-grade fever of 99.9 0F until January 17.
He was discharged on the following medications: Darvocet-N 100 one q. 6 h. p.r.n. pain and Keflex 500 mg p.o.q. 6 h. for three days. Diet and activities at the time of discharge as tolerated.
DISCHARGE DIAGNOSIS: Acute suppurative appendicitis.
DISPOSITION: He will be seen by Dr. Medina in 5 days. He will be seen in my office in 6 weeks to be evaluated for possible hypercholesterolemia and possible hypothyroidism.
_________________________
Ruth Ellis, MD
RE: xx
D: 01/20/----
T: 01/22/----