9/20 – 6:35 AM 

Procedure: 38 y/o F s/p total thyroidectomy POD 1 

S 

Pt notes pain with swallowing and hoarse voice since the procedure yesterday morning. Pt given Tylenol and Dilaudid which provided minimal relief. She reports nausea when admitted to the floor last night. It resolved on its own but it returned 30 mins ago. Pt notes 1 episode of voiding. Pt denies Bowel movements, chest pain, SOB or calf pain. Pt has only been eating ice chips. 

O 

Vitals: 

BP: 114/79 

HR: 63 

Temp: 99.2 

RR:18 

SpO2: 100% 

Wt: 189lb 

Ht: 5’7 

BMI: 29.6 

PE: 

General: Alert and oriented x 3 

Neck: long horizontal Incision covered with steri-strips. Incision is clean, dry, and tender to palpation

Heart: RRR, no murmurs or gallops 

Lungs: Clear to auscultation 

Calves: non tender to palpation

38 y/o F s/p total thyroidectomy POD 1 appears to be in pain, and has hoarse voice.

Plan is to be discharged today,

A speech pathology consult is ordered and is necessary for pt to be discharged.

Pt is encouraged have normal diet and eat breakfast today.

Pain control with PO dilaudid (2 mg, every 4 hours/PRN). Do not use ibuprofen due to increased risk of hematoma

Follow up with Dr. Zagzag in 6 days.