[Answered]: SEGER, SAMIPCase008Dr

SEGER, SAMIPCase008Dr. BILACKADMISsION DATE: 11/11 /YYYYSURGEON: Dr. HensonAdmission: 11/11/YYYYADMISSION DIAGNOSIS: Secondarily-infected right lower quadrant incision.DOB: 06/08/YYYYDISCHARGE DIAGNOSIS: Same, due to Escherichia coli and Bacteroides fragilis. Candidiasis,mouth.Continued on page 2DD: 11/22/YYYYROOM: 369OPERATION: Incision and drainage, with packing, of right lower quadrant subcutaneousWound infection.DT: 11/22/YYYYSEGER, SAMIPCase 008Dr. BLACKDISCHARGE DATE: 11/22 /YYYYSUMMARY: Patient is a 61-year-old male who recently had an appendectomy because theappendix had a fecalith in it, and he had had low anterior bowel resection, withradiotherapy, to the pelvis a year plus ago, and we were afraid the chance was high thathe might get acute appendicitis with abscess, that we decided to do an appendectomyelectively. The appendectomy was done, and the radiotherapied bowe l reacted and he endedup with a bowel obstruction which required further surgery, and nutritionally, while thiswas all healing, he went downhill and had to recover. He did recover slowly and wasdischarged. However, not many days after discharge, with his incisions both healing well,he began to get sore in the right lower quadrant appendectomy incision and was seen inthe Emergency Room with an obvious secondary wound infection in that incision. This wasopened in the Emergency Room and drained by Dr. Sizemore, and the patient was admittedand placed on IV antibiotics. This was over the weekend. When I saw him on Mondaymorning, I believed this still needed to be opened up more. There had been essentially nochange in the PMH and H&P from his last admission, except that he had some redness alongthe right flank and lateral wall, along with this obvious secondary wound infection, andit was felt at the time that he may have secondary cellulites in that area.Page two continuationDISCHARGE SUMMARYLaboratory work revealed normal hemoglobin, hematocrit, and white blood count, with aslight left shift. He was treated appropriately, and by the tine I saw him I felt itcould be opened up some more and drained further and packed and took him to the operatingroom and did this without problem under local anesthetic. Since that time, irrigationshave been with strong Betadine solution, and then with half-strength peroxide every 4hours. The redness in the flank went away. The incision still continues with somepurulent drainage in the morning mostly, but I suspect this was the night shift, fromwhat the patient says, was not really irrigating this as vigorously as I’d like them to,and it has been fine during the day. The packing was pulled 24 hours later, andirrigations were begun, and since then he is slowly recovering nutritionally; I put himon a high-calorie, high-protein-type diet, encouraged ambulation and moving around, withphysical therapy. He has done well, and I think he is ready to qo home at this point.Both he and his wife know how to irrigate this. His temperature went down, and the curvehas been down since; he has been afebrile for the past 48 hours. The Keflex has beenDATE: 11/15/YYYYCOMPLICATIONS: NonePhysician AuthenticationGLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234Admission: 11/11/YYYYDOB: 06/08/YYYYROOM: 369DisCHARGE SUMMARYstopped, and he really has done well from that standpoint. His abdominal incision looksgood. The staples were removed from that during this hospitalization, and the rest of theabdominal wall seems to be healing nicely. He is being discharged with adequateinstructions to see me next Tuesday and his family doctor sometime thereafter. With allthe antibiotics he has been on for this problem in the last month or two, he has been onbroad spectrum antibiotics at various periods of time, and he did develop what appearedto be oral candidiasis; this was treated and will continue to be treated unt il the e l4days, and this should be at least a week after the antibiotics are discontinued, so his assign ics 10 pcs code for the scenerio