Name: Emer Joy T.

Vale Year Level & Block No:4B

Date and Time: February 15, 2022 10:00 AM
Department: OBGYNE

PROGRESS NOTES

POST-OP DAY 1

SUBJECTIVE FINDINGS

Patient reported throbbing pain on the incision site with a pain score of 6-7/10 during sitting up
on bed and walking. It was relieved with IV pain reliever and rest. No nausea, no vomiting, no
dizziness, no fever, no cough, no dyspnea, and no itchiness at surgical site. She was able to
tolerate last night meal of crackers and breakfast of rice and viand. She was able to drink 3-4
liters of water since post op yesterday. She has not passed stool, only flatus last night. She was
able to sit up on bed with assistance.

OBJECTIVE FINDINGS

The patient is generally coherent, conscious, and not in respiratory distress.

Contraptions include IV line at left arm attached to D5 LR I Liter and she still has an FBC to
urobag with clear yellowish urine.

Vital Signs:

Temp: 37 C
HR: 99bpm
RR: 20cpm
BP: 130/80mmHg
O2 Sat: 98%

Physical Examination

Skin: Good turgor, no pallor and no cyanosis. Warm to touch.

HEENT: pinkish palpebral conjunctivae and anicteric sclerae. No nasal discharge. Eyeball not
sunken.
Chest and Lungs: equal chest expansion, equal tactile fremitus, clear breath sounds
Breast: symmetrically engorged breast
Cardiovascular: Distinct heart sounds, normal rate and rhythm and no murmur
Abdomen: Symmetric post gravid abdomen. Intact and dry dressing over 4-5 inches lower
transverse incision 2-3 cm above pubic symphysis. Patient refused from palpation and
auscultation.
GUT: Refused from examination.
Anus and Rectum: Refused from examination.
Peripheral vascular: Warm and without edema. Calves supple, nontender. 2+ Brachial, 2+ radial,
2+ popliteal, 2+ dorsalis pedis, and symmetric. Capillary refill time <2 seconds.
ASSESSMENT

1) G2P2 (2002) Pregnancy Uterine 38 weeks AOG, cephalic, not in labor, delivered via first
repeat low segment transverse Cesarean Section under CSEA (2/14/2022) , a live female
neonate, AS 4,9 BS 38 weeks AOG, BW 2761 gms AGA
2) Gestational Diabetes Mellitus- Insulin requiring- controlled
3) S/P LTCS (2017) for non reassuring Fetal Heart Rate Pattern
She is recovering well with good postpartal adaptation. Surgical site pain during movements
is adequately relieved with pain medications.

PLAN

1. Continue Diet as Tolerated.

2. Discontinue IVF.
3. Continue Cephalexin 500 mg tab 1 tab q 8 hrs for 3 more doses.
4. Continue Metronidazole 500 mg tab 1 tab q 8 hrs for 3 more doses.
5. Discontinue Tramadol IV shift to Tramadol+ PCM tab TID PO for pain
6. Bladder training for FBC removal.
7. Monitor vaginal discharge and count number of perineal pads consumed.
8. Continue daily wound care with betadine swab then do dressing.
9. Encourage NICU visit for breast feeding.
10. Continue CBS monitoring. Sliding scale with regular insulin as indicated.
11. Continue comanagement with endocrinologist.
12. Monitor vital signs and, I and O.
13. Monitor for any unusualities such as heavy vaginal bleeding, soft and boggy uterus,
inadequate pain relief, dyspnea and signs of infection.
14. Possible discharge after 24 hours. For family planning education prior to discharge.
15. Refer to Hospital Diabetes Group. If ok with the endocrinologist.

EMER JOY T. VALE

OB Clerk