Followup Visit
Subjective:
Patient has no complaints
Pain is well controlled, ambulating with no difficulties
Tolerating current diet, enies any nausea, vomiting, constipation, diarrhea, fever, or chills
Objective:
Vitals - Reviewed
General - patient is in no acute distress, comfortable
Chest - normal respiratory effort
Abdomen - soft, nontender, nondistended, good bowel sounds, no peritonitis
Incisions are clean, clear and intact
Drain in place, minimal serosanguineous output
Assessments and Plans:
Patient is status post abdominal exploration
Doing well, stable, nontoxic, with no peritonitis
Staples and drain was removed during this office visit
Diet as tolerate, bowel regimen
May shower; no tub bath, pool, lifting, pulling, or pushing over 10 # for 4 weeks
Encourage ambulation, okay to drive
Follow up in 4 weeks
Maintain routine medical visit with PCP