Summary (John Larson) Patient Care
Rounds: Postoperative Check in Results
,The Complete Postoperative Case Presentation: John Larson
1. Identifying Data (Patient Profile)
This section begins the presentation by introducing the patient.
• Patient: John Larson (use patient's preferred name).
• Age/Sex/Race: [e.g., 65-year-old male].
• Date of Encounter & Setting: [e.g., Post-op Day 14 follow-up in outpatient
clinic].
• Source of History: Patient, accompanied by his wife.
2. Chief Complaint (CC)
This is the primary reason for the visit, in the patient's own words.
• Example: "I'm here for my follow-up appointment after my surgery."
3. History of Present Illness (HPI)
The OLDCARTS mnemonic ensures a thorough narrative of the postoperative
course.
Component Example Finding for John Larson
Onset Discharge from the hospital 12 days ago.
Location Abdominal incision site.
Duration Pain has been decreasing since post-op day two.
Character Describes pain as 3/10 on the numeric scale, an "ache" rather than a sharp pain
Aggravating Coughing and deep palpation at the site.
Relieving Ibuprofen 600 mg every 8 hours as needed.
Timing Intermittent throughout the day.
, Component Example Finding for John Larson
Severity Currently 0/10 at rest, 3/10 with activity.
Other pertinent HPI details:
• Pro Tip: Standard postoperative monitoring includes checking that urine
output is at least 30 mL per hour to assess renal perfusion and fluid
balance. If a patient reports any pain with urination, it could indicate a
urinary tract infection.
• Post-Op Course:
o Day of Surgery (POD 0): Underwent an open [type of procedure,
e.g., right hemicolectomy].
o Day 2 (POD 2): Ambulated successfully in the hallway.
o Day 3 (POD 3): Bowel function returned.
o Day 4 (POD 4): Oral pain medication was adequate, and IV was
discontinued.
o Day 5 (POD 5): Discharged home with prescriptions for ibuprofen
and acetaminophen.
4. Review of Systems (ROS)
The ROS screens for any other issues that may have developed postoperatively.
• General: Denies fever, chills, or night sweats. Reports feeling more tired
than usual but is improving daily.
• Cardiovascular: Denies chest pain, palpitations, or lower extremity edema.
• Respiratory: Denies shortness of breath or cough.
• Gastrointestinal: Apical pulse (report on GI motility) is positive for flatus
and bowel movement today.
• Musculoskeletal: Reports generalized body aches from inactivity but no
focal joint swelling.
• Integumentary: Denies new rashes or itching. States the abdominal incision
is "healing nicely."
5. Physical Examination & Diagnostic Assessment
A targeted exam focuses on the systems most affected by the surgery.
Rounds: Postoperative Check in Results
,The Complete Postoperative Case Presentation: John Larson
1. Identifying Data (Patient Profile)
This section begins the presentation by introducing the patient.
• Patient: John Larson (use patient's preferred name).
• Age/Sex/Race: [e.g., 65-year-old male].
• Date of Encounter & Setting: [e.g., Post-op Day 14 follow-up in outpatient
clinic].
• Source of History: Patient, accompanied by his wife.
2. Chief Complaint (CC)
This is the primary reason for the visit, in the patient's own words.
• Example: "I'm here for my follow-up appointment after my surgery."
3. History of Present Illness (HPI)
The OLDCARTS mnemonic ensures a thorough narrative of the postoperative
course.
Component Example Finding for John Larson
Onset Discharge from the hospital 12 days ago.
Location Abdominal incision site.
Duration Pain has been decreasing since post-op day two.
Character Describes pain as 3/10 on the numeric scale, an "ache" rather than a sharp pain
Aggravating Coughing and deep palpation at the site.
Relieving Ibuprofen 600 mg every 8 hours as needed.
Timing Intermittent throughout the day.
, Component Example Finding for John Larson
Severity Currently 0/10 at rest, 3/10 with activity.
Other pertinent HPI details:
• Pro Tip: Standard postoperative monitoring includes checking that urine
output is at least 30 mL per hour to assess renal perfusion and fluid
balance. If a patient reports any pain with urination, it could indicate a
urinary tract infection.
• Post-Op Course:
o Day of Surgery (POD 0): Underwent an open [type of procedure,
e.g., right hemicolectomy].
o Day 2 (POD 2): Ambulated successfully in the hallway.
o Day 3 (POD 3): Bowel function returned.
o Day 4 (POD 4): Oral pain medication was adequate, and IV was
discontinued.
o Day 5 (POD 5): Discharged home with prescriptions for ibuprofen
and acetaminophen.
4. Review of Systems (ROS)
The ROS screens for any other issues that may have developed postoperatively.
• General: Denies fever, chills, or night sweats. Reports feeling more tired
than usual but is improving daily.
• Cardiovascular: Denies chest pain, palpitations, or lower extremity edema.
• Respiratory: Denies shortness of breath or cough.
• Gastrointestinal: Apical pulse (report on GI motility) is positive for flatus
and bowel movement today.
• Musculoskeletal: Reports generalized body aches from inactivity but no
focal joint swelling.
• Integumentary: Denies new rashes or itching. States the abdominal incision
is "healing nicely."
5. Physical Examination & Diagnostic Assessment
A targeted exam focuses on the systems most affected by the surgery.
