CC: I have a hernia that needs to be repaired

Subjective:

63-year-old obese male with PMHx includes HLD, HTN, DM, diverticulosis, former cigarette smoker (recently quit), shingles. Presents to PAT prior to scheduled Open Incisional Hernia Repair with Ovitex Mesh Dr. Denoto on 9/28/2020. Patient is s/p colon resection with colostomy (2012), reversed colostomy and diverting loop ileostomy (2013), ileostomy reversed 3 months later. Patient reports he has a mass protruding through the abdomen over the abdominal incision. He reports the hernia has gotten larger over the last several months. He wears a belt to keep the mass from popping out. He reports it is reducible and nontender. He denies fevers, chills, chest pain, palpitations, light headedness, dizziness, chronic cough, difficulty urinating or constipation. Patient had a CT of the abdomen on 1/24/2019 which revealed “large supraumbilical midline anterior hernia containing nonobstructive bowel and mesenteric fat.” Patient was recently evaluated by Dr. Denoto and the above surgery was recommended.

Objectives:

Allergies: Penicillin– rash

Current Medication:

• Aspirin 325 mg tablet PO once per day
• Atorvastatin 40 mg tablet once per day
• Chlorthalidone 25 mg tablet 1T PO QD
• Diazepam 5 mg tablet PO Q6H as needed for anxiety
• Metformin 1000 mg tablet PO once daily

Vitals:

• BP: 165/76, sitting, left arm
• HR: 72 bpm, regular
• RR: 18 breaths per minute, regular
• O2 Sat: 98%, RA
• T: 98.0 oral
• Ht: 68 in Wt: 230 lbs     BMI: 34.97 kg/m2

Physical Exam

• Gen – Obese male, well nourished, well developed resting in chair, no apparent distress
• ENT – NC/AT, no JVD noted
• Thorax – Symmetric, no retractions
• Lung – CTA b/l, no rhonchi, rales or wheezes noted
• CV – S1S2 distinct, no M/R/G, RRR. No carotid bruits
• Abdomen – Mild distended, a visible mass is present in the ventral area. It was non-tender, approximately 3 cm in diameter, soft in consistency and reducible. Bowel sounds normoactive in all four quadrants, no hepatosplenomegaly.
• Extremities –No clubbing, cyanosis, or edema, radial/DP pulses +2 bilaterally
• MS –Full range of motion throughout, strength 5/5 bilaterally throughout
• Neuro – A&O x 3, no gross motor or sensory deficits, CN II-XII grossly intact

 

Assessment

63-year-old obese male with PMHx includes HLD, HTN, DM, diverticulosis, former cigarette smoker, shingles, presents for Open Incisional Hernia Repair. Findings consistent with incisional hernia without obstruction or gangrene.

Plan

• Medical clearance with Dr. Bergman.
• Open Incisional Hernia Repair with Ovitex Mesh with Muscle And Skin Flap Technique with Dr. George Denoto on 9/28/2020
• Enhanced Recovery Protocol Patient Guide given to patient. Two Ensure clears given to patient with instructions. Reviewed clear liquid diet the day prior to surgery with patient. Patient instructed to remain NPO four hours prior to surgery per ERP protocol. Patient verbalized a good understanding of discussed material.
• Hibiclens given to patient with instructions on use.
• “A Patient’s Guide to Managing Pain” educational pamphlet was given to patient and reviewed with patient.
• COVID-19 nasopharyngeal swab performed today as part of the preadmission testing process. Patient denies exposure to someone diagnosed with COVID-19 in the past 14 days.  Pt denies returning from any of the states listed in the NYS travel advisory in the last 14 days. Advised patient to self-quarantine prior to surgery/procedure and to contact doctor’s office if he develops febrile illness, chills, cough, dyspnea, sore throat, myalgias, headache, and or loss of taste or smell prior to surgery