Thai female 30 years old. HN:55362729. Dx: Rt ovarian tumor with Lt ovarian cyst. Admission date: 26/3/2022 at 8.05A.M.
Student give patient to take care: 28/3/2022 to 30/3/2022. Weight: 63.5 kg. Height: 160 cm. BMI: 24.8
Vital sign: T: 36.7 c, P: 90 bpm, PB: 120/71 mmHg,
RR: 20 bpm, O2: 98%

O: Patient has operation about Rt.SO with Lt. ovarian cystectomy with myomectomy with BPNS with Omental biopsy under SB with morphine with GA with ET

Post operation day 1 Patient has normal Vital sign and good consciousness. Pain score 3/10. Wound at bikini line close with gauze and hypafix. no discharge, no swelling and no redness at wound. On F/C >>urine can flow, yellow color. On IV fluid>> no phlebitis. No N/V. No numbness

Post operation day 2, Patient has normal Vital sign,She has pain at surgery wound. Pain score 3/10. Wound at bikini line close with gauze. no discharge, no swelling and no redness at wound. Patient have flatulence. Start soft diet. Plan discharge on tomorrow.

Post operation day 3 Patient has normal Vital sign,Patient said " I have flatulence." but She can void by herself. She has pain at surgery wound. Pain score 2/10. Wound at bikini line close with gauze. no discharge, no swelling and no redness at wound.

Objective data : 1.Patient has less ambulate after operation. 2.Patient got antipyretic drugs during operating.

2. No sign of CHF leakage include headache, dizziness, nausea and vomoitting.

Subjective data : Patient said “The doctor order me to go home today”.

Objective data : The doctor plans discharge the patient today.

The patient able to take care of themselves properly.

The patient able to tell or answer questions about how to take care of themselves properly in 4/5 of questions.

The patient able to tell and answer questions properly in 5/5 of questions.

1.Assessed knowledge and understanding to take care of themselves.

3.Test understand by having the patient tell or answer questions how to take care of themselves. And giving patient opportunities to ask questions.

D Diagnosis : Rt ovarian tumor with Lt ovarian cyst with subserous myoma.

M Medication : Cephalexin 500mg 1cap po qid ac is used to treat infections. Paracetamol 500mg 1tap po q 6hr prn when pain. Simethicone 80mg 1tap po tid pc for antiflatulent. Ibuprofen 400mg 1tap po tid pc is used to reduce fever and treat pain or inflammation.

E Environment and Economic : Organize the environment, such as keep your object/equipment at the right level, not high or low. Avoid take heavy object/equipment.

T Treatment : Make an appointment for the patient to come to the dressing wound and Provide information how to observe infected wound

H Health : Encourage patients to exercise by walking and get enough rest.

O Outpatient referral : Should see a doctor immediately when there are abnormal symptoms. Make an appointment with the patient for follow-up.

D Diet : Provide information about avoid food color black, red , brown. And eat more fruits and vegetables to prevent constipation. And protein and vitamin C

One day order
8.00am.

• CT whole abdomen with contrast + notify doctor at 8.00am.
• Admit at ward 8
• Set OR for Fertility sparing surgery staging on 27/03/22 at 2.00pm.
• Dexamethasone 4mg/ml IV stat
• CPM 10mg/ml IV stat
• Swab covid
• NPO AMN.
• Prep skin abdomen & mons pubis
• SSE hs. and before go to OR.
• Reserve LPRC 2 unit
• 5%DN/2 1000ml IV rate 120ml.hr.
• Cefazolin 2g. go to OR
• Retained Foley’s cath at OR
• Xannax (0.5) 1tab hs.
• Omeprazole 40mg. IV on 27/04/22 at 6.00am.
  

One day order
1.00am.

• OR for Rt.SO with Lt. ovarian cystectomy with myomectomy with BPNS with Omental biopsy under SB with morphine with GA with ET

Patient came to hospital for operation appointment.

1 month PTA Patient came to hospital for annual health check up. The doctor was palpated founded ovarian tumor. So, patient came to hospital for special laboratory >> TAS+TVS found uterus size 5.13.44.6 cm vol.41.77 cm3 thin ET 0.5 cm. mixed echoic cyst size 14.59.314 cm. with solid part R/O ovarian tumor. The doctor was appointed patient to operation.

Food allergy (shrimp : After eating, Have mount swelling and rash.).

3. No sign of respiratory failure include difficult to breathing and downsiness

4. No sign of Peripheral nerve damage include numbness.

Continuous order
6.00pm.

• Metoclopramide 10mg/2ml IV prn. every 4 hr. 3days
• Tramadol 50mg./ml. IV prn every 4 hr. 3 days.
• CPM 10mg/ml IV prn. every 6 hr. 3days.