Progress Notes January 7, 2013 9:35 am BP= 100/79 CR= 88 RR= 19 T= 36.

5 LMP = December 24, 2012 BMI : 26.6 LNMP : November 2012 Pelvic Exam

Doctors Order NPO post midnight IVF : D5 LR 1L X 8 hours once on NPO Give cefoxitin 2 grams IV ( ) ANST 1 hour prior to OR Give phosphosoda 45cc +1 glass of clear soda to be given 12 hours and 6 hours prior to OR For total abdominal hysterectomy bilateral salphingo- oophorectomy tom. (January 8, 2013) at 1pm to OR at 12pm Secure consent for the procedure Inform OR/AOD Please attach all laboratory results at the chart Secure billing clearance Prepare 2 units FWB properly typed and cross matched May have full bath prior to procedure Give Bisacodyl (Dulcolax) suppository 1 tablet per rectum before bedtime Bisacodyl (Dulcolax) tablet, 2 tablets per orem at bedtime Refer to medicine for comanagement (Re: HPN and Nodular non- toxic goiter) Complete data base c/o OBIIC/OBCIIC Monitor VS every four hours Daily perineal hygiene Will inform AP Refer For Anes Pre- Op evaluation

Rationale

Nxg. Responsibilities

January 7, 2013 6pm

Pre- Op Evaluation Orders ( Anasthesia) S>

O> BP = 130/90 PR = 89 RR = 21 A > PS II P > CSEA NPO post midnight Insert IVF: D5 LR 1L x 8 hours once patient on NPO Vital signs every 4 hours Oral body hygiene Medication: 1) Ranitidine 150mg/ tab, 1 tab at bedtime AO 2) Diphenhydramine 25mg +Naltraphine 5mg TIV ___ 3) 30 ____prior wheeling patient to OR 4) Dipenhydramine 25mg + Naltraphine 5mg TIV at OR Avoid ambulation once patient on pre meds Secure 3 u FWB properly typed and cross matched for _____ ____Take anti HPN meds ____with sips of water (30cc) Refer accordingly January 7, 2013 10: 40pm Stable Vital signs No hypogastric pain No vaginal bleeding

NPO Continue IVF Continue meds as ordered Give phosphosoda 45cc in 1 glass of clear soda at 1am and 7am tomorrow (January 8, 2013)

 Cefoxitin 2 grams IV ( ) ANST as loading dose 1 hour prior to OR Carry out all order of anesthesiologist Standby 3 units FWB properly typed and cross matched for possible OR use For TAHBSO tomorrow at 1 pm To OR at 12pm Secure consent and billing clearance Full bath prior to OR Follow up referral with IM re- comanagement of NNTG and HPN Inform OR/ AOD/ MROD of OR schedule Monitor VS every 4 hours Refer Moderate risk for perioperative cardiopulmonary complication for contemplated procedure Attach NTG 5mg/ patch OACW 30 mins. Prior to OR, and wipe off after OR for BP < 90/ 60 May start Nicardipine drip for BP > 160/ 110 10mg Nicardipine + 90 ml D5 W at 10 ugtts/ min to maintain SBP 120140mmHg, D_____ for BP < 100/ 80 AP updated Will follow up patient May resume Amlodipine 10mg/ tab tablet OD

January 8,2013 12: 45pm BP = 120/ 80 CR = 80 Clear breath sounds Normal rate Regular rhythm

January 8, 2013

2am

once with diet NPO Continue IVF: D5 LR 1L X 8 hours IVF to follow: D5 LR 1L X 8 hours For Exlap, TAHBSO today at 1pm To OR at 12pm Inform OR/ AOD/ MROD Facilitate billing clearance and inform OBROD Give Cefoxitin 2 grams IV ( ) ANST 1 hour prior to OR Carry out order of IM and anesthesioogist Standby 3 units FWB properly typed and cross matched for possible OR use Monitor VS every for hours Refer For Intra operative referral to surgery for Adhesiolysis POST OP ORDERS (Anasthesia) S/P Exlap, subtotal TAHBSO, Adhesiolysis ______ CSEA______ _________ O2 INHALATION VIA FACE MASK AT 4-5 LPM NPO Flat on bed with 1 pillow _____0300H (January 9,2013) IVF to regulate at 31-32 gtts/ min IVF to ff: 1) D5 LR 1L X 8 hours 2) D5 LR 1L X 8 hours

January 8, 2013 6: 40am Stable VS No hypogastric pain No vaginal spotting

January 8,2013

January 8,2013

January 8,2013 11: 45 pm Stable VS Adequate UO Hypoactive BS Post op IE: cervix closed, (-) bleeding, (-) packing

3) D5 LR 1L X 8 hours Medication: 1) Tramadol 100mg TIV as LD then 50mg TIV q6 x 4 doses defer if BP < 90/ 60 (LD given at 1700 H) 2) Ketorolac 30mg TIV Q 8 X 3 DOSES (-) ANST (1st dose given at 1900 H) 3) Ranitidine 50mg TIV q8 while on NPO (1st dose given at 1430 H) 4) Tranexamic Acid 1 gram TIV q8 x 3 doses, LD given at 1800 H 5) Cefoxitin 1 gram TIV q8 6) Captopril 25mg tab SL if BP> 160/100 Monitor VS q15 x 2 hours, q 30 mins x 2 hours, q1 thereafter UO q1 WOF S/S respiratory distress, hypotension, tachycardia, etc Specimen for his to path Keep patient warm and comfortable For adequate BP control For post BT H and H 6 hours after BT Refer

NPO May transfer patient to room once fully awake 1L okay with anaesthesiologist Continue IVF series Bottle 1: D5 LR 1L x 8 hours (due at 7am) Bottle 2: D5 LR 1L x 8 hours (7am 3pm) Bottle 3: D5 LR 1L x 8 hours (3pm 11pm)

January 09,2013 6:40 am 11 hours postop BP = 140/90 T = 36- 37.8 (37.7) Last refer 6am 37.8 Adequate UO Normoactive BS (+) soft abdomen (+) pink palpebral conjunctiva (+) palmar pallor

Continue medications 1) Cefoxitin 1g IV 8hours x 4 doses, defer if BP , 90/60 2) Ketorolac 30mg IV every 8 hours x 3 doses 3) Ranitidine 50mg IV every 8 hours while on NPO 4) Tranexamic acid 1g IV every 8 hours x 3doses 5) Captopril 25mg/ tab, 1 tab SL if BP > 160/100 Retain IFC May apply abdominal binder For repeat haemoglobin and haematocrit 10 hours post BT of 1 unit FWB instead of 6 hours(7am) Daily perineal hygiene Flat on bed until 3am, then may have 1 pillow VS and UO every hour Refer May have sips of water then tea and crackers for lunch Continue IV series: Bottle 1: D5 LR 1L x 8 hours (due at 10am) Bottle 2: D5 LR 1L x 8 hours (10am 6pm) Bottle 3: D5 LR 1L x 8 hours (6pm 2pm) Continue medications: 1) Cefoxitin 1g IV q 8 hours 2) Tramadol 50mg IV 6 hours x 4 doses, defer if BP < 90/60 (last dose 4pm) 3) Ketorolac 30mg IV every 8 hours x 3 doses

(last dose 12nn) 4) Tranexamic acid 1g IV every 8 hours x 3 doses (last dose 6pm) 5) Captopril 25mg/ tab tab SL for BP> 160/100 Discontinue Ranitidine May resume Amlodipine 10mg/ tab tab OD as previously ordered by IM Retain IFC Increase oral fluid intake Daily perineal hygiene Encourage gradual ambulation TSB for fever VS and UO every 1 hour Refer

January 9, 2013 7:30 am

Once on soft diet start medicatons: Ferrous Sulfate tablet, 1 tablet BID Ascorbic Acid 500mg/ tab 1 tab OD