General Surgery Morning Ward Round

**General Surgery Ward Round:** Context of admission: The patient, a 67-year-old male, presented with acute cholecystitis and underwent an emergency laparoscopic cholecystectomy on 29 October 2024. This is day 3 post-operation. Assessment of post-operative recovery: The patient is recovering well, with good pain control and minimal nausea. He is tolerating oral intake and ambulating independently. **Current Status:** Current patient status: The patient reports mild incisional pain, otherwise feeling well. Nursing staff report no concerns. Significant events: No significant events since admission. **Nutrition Status:** - Fluids: 2000ml IV Hartmann's overnight, now PO. - Oral intake: Tolerating a regular diet. - Output: Urine output 1500, no stoma or drains. - Total fluid balance: +500 **Mobility:** - Ambulating independently. **Today's Observations and Vitals:** - BP 130/80 - HR 78 - SpO2 98% on room air - Temp 37.1 **Pain Status:** - Pain level 2/10, well controlled with PRN paracetamol 1g PO. **Escalation Status:** - Full. **Symptoms:** - Mild incisional pain. **Current Medication:** - Continue: Paracetamol 1g PO QDS, Ondansetron 4mg PRN, Clexane 40mg SC daily. - Stopped: IVABx. **Multidisciplinary Team Input:** - Physiotherapy reviewed and advised on mobility exercises. **Today's Ward Plan:** - Continue regular diet. - Encourage ambulation. - Monitor pain and administer PRN analgesia. - Review blood results. **Discharge Plan:** - Plan for discharge tomorrow if pain is controlled and tolerating diet. - Provide patient with discharge medications and instructions. **Follow-up Plan:** - GP follow-up in 2 weeks. **Jobs:** - Arrange discharge summary. - Review blood results. **Patient and Doctor Conversation:** - Discussed the patient's progress and discharge plan. The patient expressed satisfaction with his care and understanding of the plan. The patient's wife was present and also understood the plan.