Subjective:

41 y/o F, G2P1011, s/p total abdominal hysterectomy and bilateral salpingectomy and cystoscopy for abnormal uterine bleeding and fibroids POD #2. Patient reports no overnight events and offers no complaints. She states she is ambulating with mild pain but is able to get out of bed and ambulate. Patient states the pain is improving and is managed well with the pain medication. However, patient requests to stop the Percocet and have another medication for pain because she did not like the way the Percocet made her feel. She also reports voiding without difficulty. Patient admits to flatus but denies having a bowel movement. She denies fever, chills, chest pain, shortness of breath, nausea, vomiting, abdominal pain, leg pain/swelling, dizziness or vaginal bleeding. She reports to tolerating her current diet.

Objective:

Vital Signs:

• BP: 92/58
• HR: 82 bpm
• RR: 18
• Temp: 98.4 F orally
• O2: 97% on room air
• Ht: 5’35”
• Wt: 179 lbs
• BMI: 29.58 kg/m²

Physical Exam:

• General: alert, oriented and cooperative
• Heart: Regular rate and rhythm
• Lungs: Clear to auscultation bilaterally
• Abdomen: Soft, positive bowel sounds. Incision clean, dry and intact with steri strips in place
• Extremities: Lower extremities symmetrical, nontender with no discolorations bilaterally

Assessment:

41 y/o F, G2P1011, s/p total abdominal hysterectomy and bilateral salpingectomy for abnormal uterine bleeding and fibroids with acute blood loss anemia secondary to chronic anemia.

Plan:

• Continue postop care
  • Continue Maalox 30 mL TID PRN, Lovenox 40 mg SC daily, Ferrous Sulfate 325 mg BID, Ibuprofen 800 mg q8h PRN, Zofran 4 mg IV q6h PRN, Simethicone 80 mg 4x daily PRN
• Pain management will be switched from Percocet to Tylenol #3
• Continue to get out of bed and ambulate
• Regular diet
• Encourage use of incentive spirometer 10 times every hour
• Anticipate discharge tomorrow