ID: “Mr. X is a 64 year-old man who is now postoperative day one from an open right hemicolectomy for cecal adenocarcinoma.”
S: “Mr. X’s pain has been well-controlled overnight. His urine output was low but responsive to a one liter bolus.”
“On focused exam his abdomen is minimally distended, appropriately tender to palpation, and his surgical dressing remains in place.”
PLAN: Today we will continue Mr. X’s PCA for pain control. We will encourage him to use his IS and get out of bed and ambulate. We can discontinue his NG tube as the output has been low. We will monitor his urine output closely and keep his foley given the low urine output overnight. We will change his IV fluids to maintenance (D5 0.45 NS + 20 KCl). We will continue his SQH and SCDs for prophylaxis.