Subjective
Date of visit
Reason for visit (post-operative follow-up for rhinoplasty)
Day since surgery (post-operative day – POD)
History of Present Illness
Pain level (controlled with medication)
Drainage (amount, color, location)
Nasal congestion
Difficulty breathing
Facial swelling (improving, stable, worsening)
Bruising (improving, stable, worsening)
Bleeding (amount, location)
Loss of taste or smell (temporary and usually resolves)
Medications
Current medications (pain medication, antibiotics, nasal sprays)
Dosage and frequency
Allergies
Allergies to medications (important to monitor for potential reactions)
Objective
Vital signs (temperature, blood pressure) – monitor for signs of infection
General examination (assessing for facial swelling, bruising, bleeding)
Nasal examination (checking for signs of infection, proper splint placement)
Assessment
Healing progress as expected for POD
Presence of any post-operative complications (infection, bleeding, breathing problems)
Need for any adjustments to post-operative care instructions
Plan
Continue pain medication as needed
Monitor for signs of infection (fever, increased drainage, redness)
Continue nasal saline irrigations (promote healing and reduce crusting)
Review post-operative care instructions (diet, activity restrictions, splint care)
Schedule for suture removal (if applicable)
Schedule for follow-up appointments
Education
Reinforce importance of following post-operative care instructions (medication adherence, avoiding strenuous activity, proper splint care)
Discuss expected recovery timeline (gradual improvement in swelling and bruising)
Address any concerns the patient may have about their healing or final outcome (important to manage expectations)
Disclaimer: This information is for educational purposes only and should not be interpreted as medical advice. Please consult with a qualified healthcare professional for post-operative care following rhinoplasty