Followup Visit
Subjective:
Patient has no complaints, no nausea, vomit, constipation, diarrhea, fever, chills
Pain is well controlled
Tolerating current diet, no issues with voiding or BM
Objective:
Vitals - Reviewed
General - no acute distress
Lungs - no resp distress
Abdomen - soft, NT, ND, no peritonitis
Incisions are clean, clear and intact with no evidence of infection
no complication
Drain output min serosang
Extremities - WNL
Skin/Integuments - WNL
Path: Appendicitis
Assessments and Plans:
Patient is status post laparoscopic appendectomy for appendicitis
Doing well, stable, tolerating diet with good bowel function
Incisions are healing well
Drain removed
May shower, no tub bath/pool/swimming or soaking for four weeks
No heaving lifting/pulling/pushing over 15lb for 4 weeks as well
Bowel regimen, encourage fluid, low fat diet
Will see back as needed and instructed pt to notify us if issues
Patient is to maintain routine medical visit with his/her PCP