Surgical Progress Notes

s/p Appendectomy 3 days Subjective: - Patient reports mild abdominal pain and tenderness at the incision site. - No significant past medical history. Previous appendectomy 3 days ago. - Currently taking paracetamol for pain management. - No known allergies. - Two bowel movements since surgery, normal consistency. Objective: - Vital signs: BP 120/80 mmHg, HR 78 bpm, Temp 37°C, RR 16 breaths/min. - Physical examination: Mild tenderness around the incision site, no signs of infection. - Wound assessment: Incision site clean, dry, and intact with minimal erythema. - Drain output: No drains present. - Laboratory results: WBC count within normal range. - Urine output: Adequate, approximately 1500 ml/day. Assessment: - Postoperative diagnosis: Uncomplicated appendicitis. - No complications noted. - Progress since surgery: Healing well, pain is manageable with medication. Plan: - Continue paracetamol as needed for pain. - Wound care: Keep incision site clean and dry, change dressing daily. - Activity restrictions: Avoid heavy lifting for 2 weeks. - Follow-up appointment in 1 week. - No additional tests or consultations required at this time.