I am not sure where to put what in the care plan. This is a case study. Day 1 notes - 39 year old female with a past med

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I am not sure where to put what in the care
plan. This is a case study.
Day 1 notes
- 39 year old female with a past medical hx for anemia, anxiety,
depression, asthma, IBS, hyperlipidemia, hypertension,
hypothyroidism, morbid obesity, osteoarthritis, and an umbilical
hernia as well as about 3 weeks status post robotic sleeve
gastrectomy.
- Admitted from the ER for n/v, diarrhea, as well as RUQ
abdominal pain.
Day 2 notes
Physical assessment
- She had RUQ pain with a postive Murphy's sign. Hida scan with
CCK positive for 0% ejection fraction. Plans were made for robotic
assisted laparoscopic cholecystectomy.
- Patient underwent the procedure yesterday. Patient tolerated
the procedure well. She was extubated and brought the post-op floor
to resume recovery.
- Patient restarted on bariatric stage II diet. She is
tolerating her diet well. She has no nausea or vomiting, or
diarrhea. Also no RUQ pain.
- Independently voiding and ambulating
Discharge plan
- Home today without services
- may advance her bariatric diet as scheduled on her bariatric
plan
General appearance
- good
- height 1.6m
- weight 105.233 kg
- BMI: 41.1
- build: morbid obese
- ADL's: self
- Precautions: standard, fall prevention, bleeding
- Vitals: temp: 97.9F, pulse: 77, RR: 18, BP: 142/78, O2Sat: 96%
RA.
Pain level
- 8/10 at 0646
- location: at incision site
- quality: sharp, throbbing, shooting
- duration: constant
- frequency: constant
- precipitating factors: sitting for extended periods of
time
- alleviating factors: meds, heat, warm blankets, change
positions, rest
- time 1100
- Reassess: 1200
Diagnostics
- labs and chemistry are within normal
limits.
Date admitted: 3/8/2022
Chief complaint: abdominal pain,
n/v, diarrhea?
Medical Diagnosis: Choleocystitis
Background info: i don't know what to
put here
Related surgery and date: do i put the
3 weeks s/p bariatric surgery here and/or the
robotic sleeve gastrectomy?