Clinical note · #55
Hospital & observation
Patient Name: Emily Davis
MRN: 43219876
Date of Admission: 09/18/2024
Date of Discharge: 09/21/2024
Attending Surgeon: Dr. Melissa Brown
Primary Diagnosis: Status post-laparoscopic appendectomy (99490 - post op period is 90 days)
Secondary Diagnosis: None
Hospital Course:
Emily Davis underwent successful laparoscopic appendectomy following a diagnosis of acute appendicitis. She recovered well post-operatively, resuming oral intake and ambulation by day 2. Surgery was performed on 9/19/2024.
Final Physical Exam:
- Vitals: BP 112/70, HR 75
- Abdomen: Soft, non-tender, laparoscopic incisions healing well
Discharge Medications:
- Acetaminophen 500 mg as needed for pain
- Ondansetron 4 mg as needed for nausea
Discharge Instructions:
- Avoid heavy lifting for 4 weeks
- Monitor for signs of infection at incision sites
- Follow up with surgeon in 2 weeks
Discharge Condition:
Stable, healing well post-operatively.
Discharge Time: 20 minutes
Disposition: Discharged home in good condition.