Post-Op Note Template

Laparoscopic appendectomy on November 9, 2026, 17:10 to 18:05, Dr. Hana Okafor. Postoperative day 1. Inflamed appendix, not perforated, no pus or abscess. Base stapled. No drain. Estimated blood loss 10 mL. Cefazolin 2 g and metronidazole 500 mg IV before incision. Seen at 07:15 by the surgical resident.

34-year-old woman, a primary school teacher. Overnight: nauseated once at 22:30, settled with ondansetron 4 mg IV. One dose of oxycodone 5 mg at 02:00 for a right shoulder ache, which she now calls “much better.” Pain 2 out of 10 at rest and 4 out of 10 walking, around the ports. Clear fluids last night; ate toast and yogurt this morning without nausea. Passed gas at 05:00; no bowel movement yet. Voiding without difficulty. Walked the hallway 3 times on her own. Asks when she can go back to work.

T max 37.4 °C (99.3 °F); HR 72 to 90; BP 108 to 124/64 to 76; RR 14 to 16; SpO2 96 to 98% on room air. Intake: 1,000 mL lactated Ringer’s and 900 mL by mouth. Urine 1,150 mL in the 13 hours since surgery, about 1.4 mL per kg per hour at 62 kg. Drains: none. Sitting in the chair, comfortable. Chest clear. Abdomen soft, not distended, tender only around the ports, no guarding; bowel sounds present. Three port sites dry, glue intact, no redness. Calves soft, not tender. One peripheral IV, day 1, saline-locked.

Labs: none today; not needed after an uncomplicated course. Preoperative white count 13.4, hemoglobin 128 g/L (12.8 g/dL). Pathology: appendix sent November 9, pending. Pain relief: acetaminophen 1 g every 6 hours and ibuprofen 400 mg every 8 hours with food; oxycodone used once in 24 hours. VTE prophylaxis: Caprini score 2, so walking, with compression devices while in bed; no anticoagulant. Antibiotics: none after surgery, as the appendicitis was uncomplicated. Home medicines: none.

34-year-old woman, day 1 after laparoscopic appendectomy for uncomplicated acute appendicitis, on track. 1. Recovery: all discharge criteria met: pain controlled on acetaminophen and ibuprofen, eating without vomiting, passing gas, voiding, walking on her own, afebrile, wounds clean. Home today; IV out. 2. Shoulder ache from the gas used in surgery: expected, settling. 3. Pain relief at home: acetaminophen and ibuprofen on a schedule for 3 to 5 days. No opioid prescription, agreed with her, as she has needed none since 02:00. 4. Activity: shower from tomorrow; the glue peels off on its own; no heavy lifting for 2 weeks; back to teaching in 1 to 2 weeks; drive once she can brake hard without pain. 5. Follow-up: the team will phone with the pathology in 2 weeks; no routine clinic visit. Come back or call if she has a fever of 38.5 °C (101.3 °F) or more, pain that gets worse instead of better, vomiting, or redness or discharge at a wound. Discharge instructions given; discharge letter to her family doctor today.

Entered the evening before, November 9 at 21:40, 3 hours after she left the operating room. Awake and oriented. Pain 4 out of 10 at the ports and right shoulder; nauseated once, ondansetron given. T 37.2 °C (99.0 °F); HR 92; BP 116/70; RR 16; SpO2 96% on room air. Voided 280 mL at 21:15. Port dressings dry. Abdomen soft, tender only at the ports. Orders checked against the operative note: diet as tolerated, acetaminophen and ibuprofen on a schedule, compression devices, no further antibiotics, walk tonight with the nurse. No change.

Emergency laparotomy, sigmoid colectomy, and end colostomy, a Hartmann’s procedure, on November 7, 2026, Dr. Marco Bellini, for perforated sigmoid diverticulitis with purulent peritonitis, Hinchey III. No feculent contamination. Pelvis washed out; 19 Fr drain in the pelvis. Estimated blood loss 250 mL. Postoperative day 3. Seen at 07:40 by the surgical resident and the attending.

66-year-old man. Nasogastric tube removed on day 1 by the enhanced recovery protocol; clear fluids started on day 2. Overnight: vomited about 400 mL of green fluid at 03:00, with hiccups and a bloated feeling. No gas or stool from the stoma yet. Pain 3 out of 10 at rest, 6 out of 10 on coughing, at the wound. Used the hydromorphone pump 14 times in 24 hours. Catheter in place. Walked to the nursing station twice yesterday, not since the vomiting. Worried that “the bowel isn’t working.”

T max 37.7 °C (99.9 °F); HR 86 to 98, steady over 48 hours; BP 118 to 134/66 to 78; RR 16 to 20; SpO2 94 to 96% on room air. Intake: 2,100 mL IV, about 300 mL by mouth. Output: urine 1,600 mL by catheter, 0.8 mL per kg per hour at 82 kg; vomit 400 mL. Pelvic drain: 45 mL in 24 hours, serosanguinous, down from 130 mL on day 1 and 90 mL on day 2. Alert, uncomfortable, hiccuping. Reduced air entry at both bases. Abdomen distended and tympanic, tender at the wound only, no guarding or rebound; bowel sounds quiet. Midline wound: staples, dressing dry, edges together, no redness or discharge. Stoma: left lower quadrant, pink and moist, mildly swollen, no gas or stool in the bag. Calves soft, not tender. Lines: 2 peripheral IVs, day 3; urinary catheter, day 3. Nasogastric tube placed at 07:55: 700 mL of bilious fluid on placement.

Potassium 3.2 mmol/L, from 3.8. Magnesium 0.61 mmol/L (1.5 mg/dL). Phosphate 0.9 mmol/L (2.8 mg/dL). Sodium 136 mmol/L. Creatinine 88 µmol/L (1.0 mg/dL); baseline 80 µmol/L (0.9 mg/dL). White count 12.4, from 16.8 yesterday. CRP 168 mg/L, from 224. Hemoglobin 118 g/L (11.8 g/dL), from 124 g/L (12.4 g/dL). Abdominal X-ray this morning: dilated small and large bowel loops with gas up to the stoma, in keeping with ileus, no transition point seen; nasogastric tube tip in the stomach. Pathology: sigmoid colon sent November 7, pending. Pain relief: hydromorphone pump, 4.2 mg in 24 hours; acetaminophen 1 g by mouth every 6 hours. VTE prophylaxis: enoxaparin 40 mg subcutaneously daily since the morning of day 1, with compression devices. Antibiotics: ceftriaxone 2 g IV daily and metronidazole 500 mg IV every 8 hours, day 3 of 4 after source control. Home medicines: amlodipine continued by mouth until today.

66-year-old man, day 3 after a Hartmann’s procedure for purulent peritonitis, with a postoperative ileus; no clinical signs of a rectal stump leak or pelvic collection. 1. Ileus: vomiting, distension, and hiccups with no stoma output, so nasogastric tube to free drainage, nothing by mouth except sips for mouth comfort. Falling CRP and white count, a steady heart rate, a soft abdomen without peritonism, and a small serosanguinous drain output make a leak less likely. Remove the tube once the stoma passes gas and the output falls, then restart clear fluids. 2. Low potassium and magnesium, worsening the ileus: potassium chloride 40 mmol (40 mEq) IV at 10 mmol per hour, and magnesium sulfate 2 g IV over 2 hours; recheck at 18:00 and in the morning, aiming for potassium 4.0 mmol/L or more and magnesium 0.8 mmol/L (2.0 mg/dL) or more. Maintenance IV fluid with potassium chloride 20 mmol per litre at 90 mL/h; replace nasogastric output mL for mL with 0.9% saline every 6 hours. 3. Pain relief: stop the hydromorphone pump to cut opioid use; acetaminophen 1 g IV every 6 hours while the tube is in, hydromorphone 0.4 mg IV every 3 hours as needed. 4. Antibiotics: last doses tomorrow, November 11, if he stays afebrile. 5. Drain: serosanguinous and falling; remove today. 6. Catheter out today; bladder scan if he hasn’t voided in 6 hours. 7. Chest: incentive spirometer 10 times an hour while awake; walk 4 times a day with the nurse. 8. Nutrition: dietitian review today; if he can’t eat by day 7, discuss parenteral nutrition with the nutrition team. 9. Amlodipine held while nothing by mouth; BP each shift. 10. Stoma nurse visit today. Discharge criteria: none met yet; expected discharge not before day 7. CT abdomen and pelvis with IV contrast if T 38.5 °C (101.3 °F) or more, HR over 110, new peritonism, a rising CRP, feculent or purulent drain fluid, or no stoma output by day 5. Patient and his wife updated at the bedside.