Soap Note #7


85 year old male underwent colonoscopy in 06/2023 where a 5 cm mass in the proximal rectum was removed and biopsied. On pathology, an invasive moderately differentiated adenocarcinoma was identified. Pt has been on chemotherapy for 6 weeks. Pt underwent a robotic low anterior resection with loop ileostomy 2 days ago. 


85 year old male POD 2 s/p robotic low anterior resection with loop ileostomy for adenocarcinoma of the rectum. There were no acute events overnight. Pt is on a PCA and pushed it 5 times yesterday, once overnight. Foley was removed yesterday. Pt was seen and examined at bedside. Pt says that the pain is improving, but states that whenever he moves he feels pain. Pt says that he drank 2 ensure clear drinks yesterday and was able to tolerate them without any pain. He denies passing gas. Pt says that he walked around with the help of PT yesterday, but was unable to walk around on his own. Pt has been urinating on his own with no pain. Pt denies any nausea and vomiting.  


Vital signs

  • BP: 152/67 (range- 138/68 to 162/69)
  • HR: 65 bpm regular rate, rhythm and amplitude (range- 65 to 71)
  • RR: 18/min regular rate and rhythm, unlabored (range- 18 to 19)
  • Temp: 36.6 C, orally


  • Urine: 800/2900 pale yellow urine
  • JP drain: 20/70 serosanguinous fluid
  • Ostomy: 150/350 dark bilious sludgy fluid 

Physical exam

  • General: Well developed, well nourished male in mild discomfort, unable to find comfortable position. Appears stated age of 85. Alert and oriented x3.
  • Lungs: Unlabored breathing, clear to auscultation bilaterally. No adventitious sounds. 
  • Heart: Regular rate and rhythm. 
  • Abdomen: Abdomen flat and symmetric with no striae or pulsations noted. No tenderness, guarding or rebound noted. Incision sites healing well- clean and dry, no signs of infection (erythema, warmth, exudates). Stoma pink and well perfused. JP drain in place. 
  • Extremities: No erythema, warmth or crepitus noted. No pitting edema noted. Non-tender to palpation. Full range of motion of all upper and lower extremities bilaterally. 
  • Neuro: Sensation is intact bilaterally to pain and light touch. Good muscle tone. 


  • CBC
  • BMP


85 year old male POD 2 s/p robotic low anterior resection with loop ileostomy for  adenocarcinoma of the proximal rectum. Pt has completed 6 weeks of chemotherapy. Pt is doing well post-operatively. No bowel function as of yet and pain is well controlled. Vital signs remain within normal limits. Incision sites healing well. Hb is moderately low which may be expected with this surgery. Glucose is elevated at 133 with other labs unremarkable. 


  • Surgery
    • Advance to full liquid diet
    • Morning labs (CBC, BMP)
    • Discontinue PCA and start oral pain medications
      • Tylenol 975 mg PO Q8H 
      • Oxycodone 5 mg Q4H PRN pain
    • Home PT as per PT
    • Continue Entereg 12 mg PO Q12H
    • Encourage walking and getting out of bed
    • DVT prophylaxis
      • Lovenox 40 mg subq Q24H
    • Dispo: pending
  • Hyperglycemia
    • Insulin Lispro 1-5 U TID x60 days