COURSE IN THE WARD

2ND HOSPITAL DAY

S:
O:
Patient was irritable, in pain and crying, tachycardic with other vital signs normal.
Head and neck findings revealed no head lesions, anicteric sclerae, pink
palpebral conjunctivae, with intact NGT open to bed side bottle, moist lips
and moist buccal mucosa.
Abdominal findings revealed globular, non distended, well coaptated wound,
intact non soaked dressing, with Pavanac drain draining 2cc of
bloody liquid.
Genitalia was grossly male with an intact IFC draining to a urine bag with
adequate output. Patients diet was non per orem temporarily.

P:
Paracetamol 200mg IV, Tramadol 10mg IV, Ibuprofen 200/5, 1.5ml once
Paracetamol IV, Ceftriaxone 500mg IV
1ST POST-OP DAY
S:
there was no noted flatus and bowel movement
O:
patient was awake, calm, not irritable and not in pain.
Patient was tachycardic with other vital signs normal.
Abdominal findings revealed globular, non distended, well coaptated
wound, intact non soaked dressing, with drain draining 4cc of
bloody liquid, soft, tympanitic and non tender
P:
NGT was removed inadvertently by the patient.
IFC was also removed, with noted spontaneous adequate urine voiding.
Medications were continued but Cefixime was put on hold.
Patient was monitored closely and wound care was done
2ND POST-OP DAY
S:
there was no noted flatus and bowel movement
O:
patient was awake, calm, not irritable and not in pain.
Patient was tachycardic with other vital signs normal.
Abdominal findings revealed globular, non distended, well coaptated
wound, intact non soaked dressing, with drain draining 0cc of
bloody liquid, soft, tympanitic and non tender
P:
NGT was removed inadvertently by the patient.
IFC was also removed, with noted spontaneous adequate urine voiding.
Medications were continued but Ceftriaxone was put on hold.
Patient was monitored closely and wound care was done
3RD POST-OP DAY
S:
no complaints of pain and had flatus and bowel
movement
O:
Patient was tachycardic with other vital signs normal.
P:
Drain was removed.
Diet was changed to diet as tolerated
Medications were continued.
Patient was monitored closely and wound care was done.
4TH - 6THPOST-OP DAY

S:
no subjective complaints of abdominal pain
O:
Patient was tachycardic with other vital signs normal.
P:
Medications were continued.
Patient was monitored closely and wound care was done.
Patient was then deemed fit improved and was discharged
with instructions and home medications.
FINAL DIAGNOSIS

WILMS TUMOR, STAGE IIIB