Followup Visit
Subjective:
Patient has no major complaints, no issue with BM, no fever, chills
Pain is well controlled, no bleeding, no swelling/prolapse
Objective:
Vitals - Reviewed
HEENT - normal
ENT - normal
Lungs - breathing comfortably with no distress
Abdomen - soft, NT, ND, no peritonitis
Rectal exam showed healing hemorrhoidectomy
wound with no complication, no bleeding
Extremities - WNL
Skin/Integuments - WNL
Assessments and Plans:
Patient is status post hemorrhoidectomy
Wound is healing well with no bleeding
Pain is controlled
Recommend continue stool softener, bowel regimen, fluid
Gentle cleansing after each bowel movements, Sitz bath bid and prn
Light activity for few weeks
will see back in 3 weeks
will see back as needed