~Teachingcenter的醫學筆記~

腹腔鏡、疝氣手術、乳房手術、甲狀腺

Laparoscopic appendectomy
 Hemodynamic status: Stable
 HEENT:
   Pink conjunctiva
 Chest:
   Bilateral clear breath sound
 Abdomen:
   Soft
   Mild hypoactive bowel sound
   Small abdominal wound *three: (0.5cm, 0.5cm, 1.2cm)
   little discharge, no hematoma
Plan:
    1. sip water --> regular diet if tolerable
    2. Empiric antibiotics use
    3. Pain control: Analgesics use
    4. Wound care
    5. Monitor abdominal condition

Inguinal hernia
 Hemodynamic status: Stable
 Urination: voiding smoothly

HEENT:
   Pink conjunctiva
 Chest:
   Bilateral clear breath sound
 Abdomen:
   Soft
   Normoactive bowel sound
   Small abdominal wound 5cm at groin
   little discharge, no hematoma
Plan:
    1. Sip water --> regular diet, if tolerable
    2. Pain control: Analgesics use
    3. Apply ice pack to reduce the pain and swelling
   (Cover with a towel and apply for only 15 minute at a time)
    4. Wound care
    5. Avoid constipation
    6. Monitor abdominal condition

Laparoscopic hernioplasty
Hemodynamic status: Stable
 Urination: voiding smoothly

HEENT:
   Pink conjunctiva
 Chest:
   Bilateral clear breath sound
 Abdomen:
   Soft
   Normoactive bowel sound
   Small abdominal wound * three: (0.5, 1cm, 1.1cm) at lower abdomen)
   little discharge, no hematoma
Plan:
    1. Sip water --> regular diet, if tolerable
    2. Pain control: Analgesics use
    3. Apply ice pack to reduce the pain and swelling
   (Cover with a towel and apply for only 15 minute at a time)
    4. Wound care
    5. Avoid constipation
    6. Monitor abdominal condition
 

Laparoscopic cholecystectomy
 Hemodynamic status: Stable
 Moderate abdominal wound pain
 HEENT:
  Pink conjunctiva, anicteric sclera
 Chest:
  Bilateral clear breathing sound
 Abdomen:
  Soft
  Mild hypoactive bowel sound
  Small abdominal wound *three:(0.5cm, 1.1cm, 1.1cm) at RUQ abdomen
  little discharge, no hematoma
 Drain: Nil
Plan:
    1. sip water --> regular diet if tolerable
    2. Prophylactic antibiotics use
    3. Pain control: Analgesics use
    4. Wound care
    5. Monitor abdominal condition

Conventional cholecystectomy
 Hemodynamic status: Stable
 Moderate abdominal wound pain
 HEENT:
  Pink conjunctiva, anicteric sclera
 Chest:
  Bilateral coarse breathing sound with basal rales
 Abdomen:
  Soft
  Mild hypoactive bowel sound
  Abdominal wound at right subcostal area
  little discharge, no hematoma
  Drain: V-B: pinkish fluid without bile stain
Plan:
    1. NPO with NG decompression
    2. Empiric antibiotics use
    3. Pain control: Analgesics use
    4. Wound care
    5. Chest care with IPPB
    6. Monitor abdominal condition and I/O

Breast
 Hemodynamic status: Stable
 Mild ~ Moderate breast wound pain
 HEENT:
  Pink conjunctiva, anicteric sclera
 Chest:
  Bilateral clear breath sound
 Breast:
  Wound at right/left side +/- axillary region
  Loose gauze + elastic bandage compression
  Drains: V-B*two: light reddish fluid output
  no hematoma found
Plan:
    1. Sip water --> regular diet if tolerable
    2. Pain control: Analgesics use
    3. keep loose gauze + elastic bandage compression for breast wound
    4. Monitor vital signs and drains output

Thyroid
 Hemodynamic status: Stable
 Respiration: smooth
 Sore throat and Neck wound pain
 Voice sound: normal
 HEENT: Pink conjunctiva
 Neck:
  Wound at anterior lower neck
  dry & clean, not swollen
  no hematoma found
 Drain: V-B/penrose: light reddish fluid
 Chest: Bilateral clear breath sound
Plan:
    1. Sip water --> regular diet if tolerable
    2. Pain control: Analgesics use
    3. Apply ice pack to reduce the pain and swelling
   (Cover with a towel and apply for only 15 minute at a time)
    4. Wound care
    5. Monitor vital signs, esp. respiratory condition

Laparoscopic abdominal surgery
 Hemodynamic status: Stable
 Mild ~ Moderate abdominal wound pain
 HEENT:
  Pink conjunctiva, anicteric sclera
 Chest:
  Mild coarse breath sound without basal rales
 Abdomen:
  Soft and mild distended
  Mild hypoactive bowel sound
  Small abdominal wounds * 4 :0.5~1.2cm
  little discharge, no hematoma
 Drains: V-B: light reddish fluid without bile stain
Plan:
    1. NPO with NG decompression
    2. Empiric antibiotics use
    3. Pain control: Analgesics use
    4. Wound care
    5. Chest care
    6. Monitor vital signs, abdominal condition and I/O