DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
ADMITTING DIAGNOSES:
1. Diverticulitis.
2. Possible acute appendicitis.
3. Diabetes, non-insulin-dependent.
4. Ovarian cyst.
DISCHARGE DIAGNOSES:
1. Acute diverticulitis.
2. Non-insulin-dependent diabetes.
3. Ovarian cyst.
4. Hypokalemia.
HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE: This patient was admitted from the emergency room with complaints of lower abdominal pain preceding two days prior to admission and worsening on the day of admission. The patient also complained of some emesis and nausea. The patient was diagnosed in the emergency room with acute diverticulitis and, as per CT scan, showed inflammation of a segment of the colon and possible early appendicitis with appendix being in the upper limits of normal. The patient was admitted, placed on antibiotics, Levaquin 500 mg IV and Flagyl 500 mg IV b.i.d. The patient began to improve on the second day of admission. Her pain markedly decreased and her WBCs, which were slightly elevated at 12,500 upon admission, began to normalize. The patient was seen by Surgery to rule out possible early appendicitis, and a repeat scan showed no appendicitis but improvement of her diverticular disease.
On MM/DD/YYYY, the patient was discharged in stable condition. The patient was instructed to follow up with Dr. John Doe in one week. The patient was instructed to be on the following take-home medications, Avandia 4 mg p.o. daily. The patient was instructed to hold Glucophage 500 mg p.o. daily at this time for 48 hours due to her contrast injection for her CT scan. After that, the patient was instructed to go ahead and resume her Glucophage. The patient was also placed on Levaquin 750 mg p.o. daily, Flagyl 500 mg p.o. b.i.d. The patient was instructed to be on an ADA, low-residue, no seeds, no popcorn diet, and to advance it very slowly. The patient was instructed to call if there is any change in her condition with increasing pain or any nausea or vomiting.
At this point, there was no need for any pain medication since the patient does state that she had very minimal abdominal pain only occasionally. The patient was instructed not to return to work for at least a week. The patient was again discharged in stable condition.
