Date: [Date of encounter]
Patient: [Patient Name]
Post-operative Day: [Number]
Chief Complaint:
Document the patient’s main concerns following tonsillectomy, such as:
Throat pain (worsens with swallowing)
Ear pain (referred pain from the throat)
Difficulty swallowing (dysphagia)
Bleeding (usually minimal bright red blood)
Fever
Bad breath (halitosis)
History of Present Illness:
Summarize the surgical procedure (e.g., tonsillectomy with or without adenoidectomy).
Note any intraoperative complications or blood loss.
Document the time of surgery and any pain medications administered in the recovery room.
Physical Exam:
Vital signs (monitor for fever).
Oral cavity examination:
Assess the tonsillar fossa for bleeding (minimal expected).
Evaluate the uvula and soft palate for edema (swelling).
Look for signs of dehydration (dry mucous membranes).
Neck examination:
Palpate for lymph node enlargement (common).
Assessment:
Pain level and response to pain medication.
Degree of oral intake (crucial for post-operative recovery).
Presence of any bleeding or other surgical site complications (e.g., infection).
Hydration status.
Plan:
Pain Management:
Continue pain medication regimen as prescribed (typically opioids for the first 1-2 days, transitioning to non-opioids like acetaminophen or ibuprofen later).
Encourage frequent use of pain medication to stay ahead of discomfort, especially before meals.
Oral Intake:
Emphasize the importance of maintaining adequate hydration with clear liquids.
Encourage gradual progression to a soft diet as tolerated (e.g., popsicles, applesauce, mashed potatoes).
Avoid acidic, spicy, or rough foods that may irritate the surgical site.
Bleeding:
Instruct the patient on monitoring for excessive bleeding (bright red blood) and to report it immediately.
Advise avoiding strenuous activity, straining, or coughing which can increase bleeding risk.
Hygiene:
Encourage gentle mouth rinses with warm salt water several times a day to promote healing and reduce discomfort.
Follow-up:
Schedule a follow-up appointment in 7-10 days to monitor healing and address any concerns.
Patient Education:
Educate the patient about typical post-operative symptoms and their expected duration.
Explain the importance of maintaining pain medication schedule and adequate oral intake for optimal recovery.
Discuss bleeding precautions and hygiene measures.
Provide information on warning signs of potential complications (e.g., persistent fever, severe bleeding).
Reassure the patient that pain gradually improves over the first week, and swallowing will become easier with time.
Disclaimer: This template is for informational purposes only and should be adapted to fit the specific needs of each patient. The post-operative course following tonsillectomy can vary depending on individual factors. It is crucial to follow the specific instructions provided by the surgeon and seek medical attention if any concerning symptoms develop