Heads Up if you are having outpatient surgery

[T_R_Oglodyte]

If you don't want to read this entire post, the gist is that if you have outpatient surgery done, be sure that you have an internist or hospitalist review the procedure and your discharge instructions.

*************

To start, the only time I post about my medical experiences at TUG is in response to other people's posting about medical issues. TUG is not the place I go to share my medical experiences. I am making an exception in this case is because I had an experience that might be useful to others - I learned something new with a recent hip replacement surgery that I think is worth passing on.

*************

After monitoring progressive osteoarthritis in my right hip for about seven years, my PCP ordered some updated radiography in 2024 that led us to decide that it was time for replacement. I had the replacement done in an outpatient orthopedic surgery center, and was discharged to home care that afternoon after clearing post-op. Continuing care included physical therapy, at home and with six weeks of sessions with a physical therapist 2-3 times per week.

I had no problems with any of this. Recovery was proceeding nicely, even ahead of schedule. Recovery at home was easily manageable.

On Mothers Day, May 11, we were having a late morning brunch on our patio with DW, DD, DSIL, and DG. As we concluded the brunch, I rose out of my chair and almost immediately fainted. Because I was bearing all of my weight on my left leg, I collapsed to the right, falling on my right hip. Upon coming to, I knew immediately something bad had happened. After getting relocated into a chair, I started doing blood pressure readings over the next hour while I waited in queue to do a tele-health consult with a physician via my medical insurance. During that time my systolics were almost all between 80 and 100 mm Hg, which is about 50 points below my norm.

Following the tele-consult, DW took me to a hospital emergency room. Radiology there confirmed I fractured the femur where the implant had been placed. (That is the second-worst possible post-operation event that can happen with an implant.) I had emergency corrective surgery on May 13. My recovery is progressing well, and my orthopedic surgeon says I am on track for 100% recovery.

***************

But now I wonder, why did I faint? The events prior to the fall on May 11 were not out of the norm - we frequently get together with my daughter's family and have food and wine on a patio, without complication. So what happened on Mothers Day?

The answer is that I'm pretty sure that I was over-medicated on blood pressure medications. How that occurred is the gist of this post.

********

Without blood pressure medications, I am very hypertensive - my systolics run 220-230 mm Hg. To bring my BP under control, I have been taking a meds suite with Lisinopril, hydrochlorothiazine (HCTZ), and amlodipine. In October 2024, we found a combination that kept my systolics in check between 130 and 150.

After the fall on May 11, one of the first things the hospitalist/internist did was to eliminate the HCTZ and amlodipine, and cut my Lisinopril dosage in half. Previously, in working with my PCP, my SPs were about 200 with that particular combination of meds. Yet, while hospitalized my SP was running 100 to 130. I checked back with my PCP, and he responded that he was not surprised because trauma and surgery changes the body's hemodynamics.

I discussed this with my best friend, who is a semi-retired internist. He was not surprised by any of this information, and inquired about what my blood pressure medicine regime had been through all of this. I relayed that it wasn't until I was hospitalized after the fall that my blood pressure medicines had been dialed back. For the implant surgery, the directives were to not take the HCTZ and amolodipine the day of surgery, but to resume them the following day. He immediately rejoined that the initial implant surgery created a hemodynamic effect, and that in resuming my normal suite of BP meds I was actually over-medicated for blood pressure control, with that likely being a major contributor to the fall.

And here's the key part - he added that in his opinion and experience, if the implant surgery had been done in-patient instead of out-patient, a hospitalist/internist would have cut back my meds prior to discharge, with follow blood pressure monitoring. But my outpatient setting did not include that oversight.

********

I know this is a long post - if you've tracked with me through this, my message is that if you undergo an outpatient procedure done by a medical specialist, you should ensure that a medical generalist also provides a more general assessment of the implications of the procedure.

 

[Sandi Bo]

Wow, sooooo sorry to hear of your issues / complications, and thank you for posting. I don't mean the hijack your post in any way, but yikes, currently dealing with post-op issues with my husbands total knee replacement! Your suggestion is 1000% spot on!

We are fortunate to have a daughter who is an internist. She closely monitored the situation and discussed / advocated for medication changes for my husband. I sincerely feel had she not, we might be dealing with a stroke versus atrial fibillation, blood thinners, etc. Two weeks post op he felt bad all day, dizzy and faint every time he got up, we went to ER - bp was 70 / 40, pulse 144, he was in a-fib. I thought that was what you were going to say. Reading up on it, it's not all that uncommon, post major surgery.

My take away of our situation... a surgeon is focused on the success of the operation - blood thinning and anti-inflammatory protocols are very much focused on the recovery of the surgical site. The hospital / internist is focused on the long term / whole body effects. In my husbands case - my daughter discussed with the hospitalist internist (who's job it is to oversee the surgeries / protocols) and had him changed from baby aspirin to eliquis for a blood thinner. She was opposed to meloxicam (anti-inflammatory / pain) but conceded to it short term. He no longer is taking that due to the a-fib incident and additional med changes. Bottom line - you really want an internist calling the shots not a surgeon.

And absolutely, these things really do need to be monitored post op!! Doing this outpatient was surprising to me for several reasons, and scary to think how much worse our situation could have been.

And how many times have we heard low blood pressure (or low blood sugar) are far more serious than the high numbers (due to fall risk). Wishing you success with your recovery, what a terrible thing for you to go through!

 

[jackio]

Wow, thank you for sharing your story. This is an important consideration. Personally, I believe that most surgeries should include an overnight stay in the hospital to monitor for possible complications or even trends, like lower BP, that could lead to complications or even.
I am glad you are recovering nicely.

 

[T_R_Oglodyte]

My take away of our situation... a surgeon is focused on the success of the operation - blood thinning and anti-inflammatory protocols are very much focused on the recovery of the surgical site. The hospital / internist is focused on the long term / whole body effects. In my husbands case - my daughter discussed with the hospitalist internist (who's job it is to oversee the surgeries / protocols) and had him changed from baby aspirin to eliquis for a blood thinner. She was opposed to meloxicam (anti-inflammatory / pain) but conceded to it short term. He no longer is taking that due to the a-fib incident and additional med changes. Bottom line - you really want an internist calling the shots not a surgeon.

And absolutely, these things really do need to be monitored post op!! Doing this outpatient was surprising to me for several reasons, and scary to think how much worse our situation could have been.

That is so much like my situation. Thanks for sharing. I think the pieces I bolded above are exactly on point for what I am saying.

In my case, when I did the tele-visit with a physician, a-fib possibility was the biggest issue in his mind, and he wanted me to go to Emergency as soon as possible. In the ER, a-fib was ruled out immediately, but throughout my post-fall care period I have still had constant cardiac monitoring. I've been at home now for 10 days (following one week in a skilled nursing rehab facility); I am wearing an MCOT monitor until the end of this month.

 

[Panina]

If you don't want to read this entire post, the gist is that if you have outpatient surgery done, be sure that you have an internist or hospitalist review the procedure and your discharge instructions.

*************

To start, the only time I post about my medical experiences at TUG is in response to other people's posting about medical issues. TUG is not the place I go to share my medical experiences. I am making an exception in this case is because I had an experience that might be useful to others - I learned something new with a recent hip replacement surgery that I think is worth passing on.

*************

After monitoring progressive osteoarthritis in my right hip for about seven years, my PCP ordered some updated radiography in 2024 that led us to decide that it was time for replacement. I had the replacement done in an outpatient orthopedic surgery center, and was discharged to home care that afternoon after clearing post-op. Continuing care included physical therapy, at home and with six weeks of sessions with a physical therapist 2-3 times per week.

I had no problems with any of this. Recovery was proceeding nicely, even ahead of schedule. Recovery at home was easily manageable.

On Mothers Day, May 11, we were having a late morning brunch on our patio with DW, DD, DSIL, and DG. As we concluded the brunch, I rose out of my chair and almost immediately fainted. Because I was bearing all of my weight on my left leg, I collapsed to the right, falling on my right hip. Upon coming to, I knew immediately something bad had happened. After getting relocated into a chair, I started doing blood pressure readings over the next hour while I waited in queue to do a tele-health consult with a physician via my medical insurance. During that time my systolics were almost all between 80 and 100 mm Hg, which is about 50 points below my norm.

Following the tele-consult, DW took me to a hospital emergency room. Radiology there confirmed I fractured the femur where the implant had been placed. (That is the second-worst possible post-operation event that can happen with an implant.) I had emergency corrective surgery on May 13. My recovery is progressing well, and my orthopedic surgeon says I am on track for 100% recovery.

***************

But now I wonder, why did I faint? The events prior to the fall on May 11 were not out of the norm - we frequently get together with my daughter's family and have food and wine on a patio, without complication. So what happened on Mothers Day?

The answer is that I'm pretty sure that I was over-medicated on blood pressure medications. How that occurred is the gist of this post.

********

Without blood pressure medications, I am very hypertensive - my systolics run 220-230 mm Hg. To bring my BP under control, I have been taking a meds suite with Lisinopril, hydrochlorothiazine (HCTZ), and amlodipine. In October 2024, we found a combination that kept my systolics in check between 130 and 150.

After the fall on May 11, one of the first things the hospitalist/internist did was to eliminate the HCTZ and amlodipine, and cut my Lisinopril dosage in half. Previously, in working with my PCP, my SPs were about 200 with that particular combination of meds. Yet, while hospitalized my SP was running 100 to 130. I checked back with my PCP, and he responded that he was not surprised because trauma and surgery changes the body's hemodynamics.

I discussed this with my best friend, who is a semi-retired internist. He was not surprised by any of this information, and inquired about what my blood pressure medicine regime had been through all of this. I relayed that it wasn't until I was hospitalized after the fall that my blood pressure medicines had been dialed back. For the implant surgery, the directives were to not take the HCTZ and amolodipine the day of surgery, but to resume them the following day. He immediately rejoined that the initial implant surgery created a hemodynamic effect, and that in resuming my normal suite of BP meds I was actually over-medicated for blood pressure control, with that likely being a major contributor to the fall.

And here's the key part - he added that in his opinion and experience, if the implant surgery had been done in-patient instead of out-patient, a hospitalist/internist would have cut back my meds prior to discharge, with follow blood pressure monitoring. But my outpatient setting did not include that oversight.

********

I know this is a long post - if you've tracked with me through this, my message is that if you undergo an outpatient procedure done by a medical specialist, you should ensure that a medical generalist also provides a more general assessment of the implications of the procedure.

Thank you for sharing. I am glad your prognosis is good.

My other half recently had an outpatient procedure and his blood pressure was coming in lower than usual. We called the cardiologist who reduced his med.

 

[Tia]

Thinking they have moved to all total hip replacements to outpatient status now where I'm at. People go home later that same night , maybe the next day. It's insurance driving this. Yes they generally resume people's preop meds without adjusting unless there is a noticed problem then they'd have someone else consult. The in hospital experience is short.

If someone is going to rehab then they have to admit for a longer stay.

 

[SmithOp]

Do you have low potassium as a result of taking hctz? This can also cause irregular heart problems. I also take hctz for BP and also take slow release potassium because hctz is known to leach potassium from your body. I've had a couple of trips to the ER with irregular heartbeat and fainting, and it was always low potassium, they put me on IV and I'd be fine in an hour, so now I take potassium.

 

[T_R_Oglodyte]

Do you have low potassium as a result of taking hctz? This can also cause irregular heart problems. I also take hctz for BP and also take slow release potassium because hctz is known to leach potassium from your body. I've had a couple of trips to the ER with irregular heartbeat and fainting, and it was always low potassium, they put me on IV and I'd be fine in an hour, so now I take potassium.

Potassium has been in normal range during entire time with HCTZ.

 

[rapmarks]

I too run very high systolic.
Every time I have surgery, and I have had a lot of surgery, the directions are no lossrtin/htcz the morning of. Result blood pressure is 220 when I check in. Then they debate whether I can have surgery.
All through my chemo, blood pressure ran super high and sometimes I had to go home and return the next day for the treatment
I could count on feeling extremely light headed on the third morning after chemo, but I still had to go to radiation. .
I had an episode between surgeries and was sent to ER. On follow up the dr was yelling at me that I wasn’t taking my medication, I was lying about it. This wasn’t true, I come from a family with extremely high blood pressure.
Now my blood pressure runs a lot lower and the bottom number is often 50 , which is way too low.
I am most thankful when I passed out like a ton of bricks, my friend was with me and caught me. If I had been home alone, really bad things could have happened.

 

[T_R_Oglodyte]

Thinking they have moved to all total hip replacements to outpatient status now where I'm at. People go home later that same night , maybe the next day. It's insurance driving this. Yes they generally resume people's preop meds without adjusting unless there is a noticed problem then they'd have someone else consult. The in hospital experience is short.

If someone is going to rehab then they have to admit for a longer stay.

I have the "benefit" of doing both out-patient and in-patient hip surgeries pretty close together. I don't have a problem with doing the hip replacement outpatient; reflecting on the two experiences, I think I would prefer outpatient for the implant. For my replacement, outpatient was selected by the surgeon. Yes, outpatient is cheaper, but I believe that Medicare will reimburse the insurance company for either option.

 

[artringwald]

I've had 2 knees and a shoulder replaced. DW has had 2 hips replaced. All were done in a hospital except her last hip was done in a orthopedic surgery center. If your insurance will cover it, I'd highly recommend the hospital. Pain management is better, and PT includes occupational therapy. The surgery center was very quick on the PT (they needed the room), and there was no occupational therapy. If there's any complications, surgery centers may not be prepared for it. With standard Medicare and supplemental insurance, we paid almost nothing for all the surgeries.

TIP: The FDA cleared my Fitbit Charge 5 to detect A-fib. It also measures the normal stuff like pulse, calories, sleep score, etc. Fitbit Charge 6 does the same things and is only $68 at Walmart. If you're worried about A-fib, it's not a bad investment.

 

[beejaybee]

12 days post TKR. Discharged from hospital same day. Took a nap at home and woke up to a drooping left side of my face. Luckily our hospital is just 10 minutes away so off to the E.R. Thank heavens CT showed no stroke but was admitted overnight for observation and to get an MRI. Bell's Palsy!
Knee is exceeding recovery expectations and Bell's is improving to the point I can now drink without using a straw; however, I am constantly queasy. Only current meds are Tylenol, baby aspirin, lisinopril and astorvastin so IDK what's up?
Sorry to hear of your ordeal, Trog!

 

[silentg]

I was on a 40 mg Astorvastin for cholesterol and CQ 10 also. I’ve been having weaknesses in my legs and my tremor was getting worse. My neurologist suggested a lower dose 20 mg and she prescribed Primodone once a day. It has made a difference sometimes your body changes and I didn’t realize the side effects from the medication. I don’t mean to go off topic but this was helpful to me so just sharing.

 

[rapmarks]

12 days post TKR. Discharged from hospital same day. Took a nap at home and woke up to a drooping left side of my face. Luckily our hospital is just 10 minutes away so off to the E.R. Thank heavens CT showed no stroke but was admitted overnight for observation and to get an MRI. Bell's Palsy!
Knee is exceeding recovery expectations and Bell's is improving to the point I can now drink without using a straw; however, I am constantly queasy. Only current meds are Tylenol, baby aspirin, lisinopril and astorvastin so IDK what's up?
Sorry to hear of your ordeal, Trog!

So sorry. They can’t explain what happened?

 

[Sandi Bo]

Thinking they have moved to all total hip replacements to outpatient status now where I'm at. People go home later that same night , maybe the next day. It's insurance driving this. Yes they generally resume people's preop meds without adjusting unless there is a noticed problem then they'd have someone else consult. The in hospital experience is short.

If someone is going to rehab then they have to admit for a longer stay.

In my husband's case, he could have stayed longer, I think, but the surgeon said no. I suspect surgeries out-patient, they can do more. That is a terrible acusation to make make, but... my husband did have to wait for a bed (post surgery), and they needed his when we left... So you have that, as well as insurance driving things, granted there are some positives such as prevention of infection... But I certainly didn't have warm fuzzies sitting around an ER (I would think that environment would be higher risk to pick up an infection).

Other 'irks' for me:
* in a hospital you have those machines that massage the legs to prevent blood clots. DH came home with a groin to ankle ace bandage that was good enough for compression (and the importance of those hospital ones poo-pooed)
* How DH iced his knee was up to him. There were many suggestions and alternatives - including a device for icing. Whatever he did was out of pocket.

To me if you are going to do out-patient and save the insurance company tons of money - why wouldn't the equipment one would have in the hospital be provided at home? Those things surprised me.

The whole 3 day stay before rehab is covered is a long-standing flaw in the industry, IMO. The games we play!

 

[clifffaith]

In my husband's case, he could have stayed longer, I think, but the surgeon said no. I suspect surgeries out-patient, they can do more. That is a terrible acusation to make make, but... my husband did have to wait for a bed (post surgery), and they needed his when we left... So you have that, as well as insurance driving things, granted there are some positives such as prevention of infection... But I certainly didn't have warm fuzzies sitting around an ER (I would think that environment would be higher risk to pick up an infection).

Other 'irks' for me:
* in a hospital you have those machines that massage the legs to prevent blood clots. DH came home with a groin to ankle ace bandage that was good enough for compression (and the importance of those hospital ones poo-pooed)
* How DH iced his knee was up to him. There were many suggestions and alternatives - including a device for icing. Whatever he did was out of pocket.

To me if you are going to do out-patient and save the insurance company tons of money - why wouldn't the equipment one would have in the hospital be provided at home? Those things surprised me.

The whole 3 day stay before rehab is covered is a long-standing flaw in the industry, IMO. The games we play!

Not just three days — three midnights! Totally bizarre to me.

 

[rapmarks]

Not just three days — three midnights! Totally bizarre to me.

Here’s what is bizarre to me
I was sent home after total knee replacement to a husband with advanced Alzheimer’s, told I was not eligible for rehab. I explained that he needed constant care and in No way could help me. I went home and basically waited on him
But my friends husband at same age got three days in hospital and ten days in rehab because she told the nurse she didn’t think she could help care for him. But I was not eligible. What the heck.

 

[clifffaith]

Here’s what is bizarre to me
I was sent home after total knee replacement to a husband with advanced Alzheimer’s, told I was not eligible for rehab. I explained that he needed constant care and in No way could help me. I went home and basically waited on me
But my friends husband at same age got three days in hospital and ten days in rehab because she told the nurse she didn’t think she could help care for him. But I was not eligible. What the heck.

Two women on my floor have fallen and broken their pelvises. Extremely painful to move let alone walk, but apparently nothing they can do besides manage pain at home. Both went to The Orchards (our skilled nursing) and rumor has it that Reata Glen gave them a break on the cost and/or knows how to use the proper buzzwords on the Medicare paperwork. During the first instance I was incensed that that meant they were sending old non-RG women home either on their own or with elderly spouses. Good way to then potentially end up with two people more grievously injured when trying to get to the bathroom or out of bed.

 

[moonstone]

Two women on my floor have fallen and broken their pelvises. Extremely painful to move let alone walk, but apparently nothing they can do besides manage pain at home.

We were just talking to a long time (since high school) friend the other day for the first time since last fall. We had heard from other friends who are on Facebook, that doug had had a hip replacement before Christmas while we were south but we hadnt heard what happened. It seems that a few years ago he fell from a height (but not too high) at work and landed on his shoulder and hip. His shoulder took the brunt of the fall and he needed surgery for a dislocated shoulder and torn ligaments. At the time of the fall his employer took him to the hospital and his shoulder was x-rayed even though he told them his hip was also sore, it was never x-rayed. He said a Dr looked at his hip several hours after the fall and said he had a nasty bruise there (he doesnt have much 'padding') and it would turn some lovely colours in the next few days, which it did. Well the hip continued to be sore but he could walk ok and since he was off work and taking pain meds from his shoulder surgery, he wasnt doing much anyways. A year or so later his wife became ill, and months later died, he was so depressed that he never got around to seeing about his hip. Two years ago Doug met a very nice woman and last spring they were married. She got tired of hearing about his sore hip and got him to go to an orthopedic surgeon. The x-rays that Dr had ordered showed that Doug's pelvis had been fractured in the fall and the bones had not healed together properly, leaving a displacement ridge at the fracture site. It was the ball joint of his hip rubbing on that ridge that was causing all the pain & discomfort. During the replacement surgery the Dr had to grind off the ridge on the pelvic bone and cement a new lining in place then replace the rest of the hip. Doug said the difference is like night and day. So he said anytime we hear of anybody with a fractured pelvis to make sure the bones are lined up or they'll end up with a hip replacement too.

 

[DebBrown]

Without going into too much detail, I opted for an outpatient surgery instead of inpatient a year ago. Who wouldn't want to go home, right? Well, any meds they give you in the hospital after outpatient surgery that you take orally are not covered by insurance, Medicare, gap, etc. I don't even remember taking the one single pill that ended up costing me $450. Besides that, I wasn't ready to be home. I fainted and was in a lot of pain.

 

[Panina]

I was on a 40 mg Astorvastin for cholesterol and CQ 10 also. I’ve been having weaknesses in my legs and my tremor was getting worse. My neurologist suggested a lower dose 20 mg and she prescribed Primodone once a day. It has made a difference sometimes your body changes and I didn’t realize the side effects from the medication. I don’t mean to go off topic but this was helpful to me so just sharing.

I was on simvastatin for many years. I came off it for 5 days because an over the counter medicine I needed to use for 7 days during my research said not to use with simvastatin. Within five days my muscle pains disappeared and my light headedness when I go out in heat was gone. They took me off it for 60 days (of course bad cholesterol was high) and changed me to atorvastatin in a lower dose with CQ10. So far so good. I have a blood test next week so we will see the numbers.

 

[moonstone]

I am going in for a TKR on the 20th. I was given a choice of day surgery (with a shorter wait list) or a 2 night stay. I went on the wait list in Oct. of 2023 but I wanted a specific surgeon in 1 of the 3 hospitals that are within a 30 min drive from us. A former co-worker went to another brand new surgeon at a different hospital and only had to wait 7 months. I chose the day surgery, not just for the shorter wait time but I've spent enough time in the hospital in the last few years. My name actually came to the top of the list in February but we were in Belize and I wasnt going to give up any part of our winter south for the surgery so I told the Dr's office to call me in May. Since I am Canadian everything at the hospital is no cost but I was given a list of things I need to buy for my recovery. One is a surgical dressing to change out (from the one applied at surgery) on day 5 post-op, then a 2nd one for day 10. They are $70. Cndn each! I told the nurse I can buy a roll of Elastoplast bandages about a yard long for way less than 1/2 the price of 1 dressing! Haha. I will buy 1 of them since I have an allergy to many adhesives so I dont want to fork out $70. for a big bandage that I cant use. If the adhesive doesnt bother me Dh will pickup another one for me. Another item is some cryotherapy iceman system for $335.Cndn - I'm not sure what it is but I have lots of thick plastic bag type ice packs in the freezer that I got for free with post-chemo meds that I have molded over a 2 liter pop bottle so they would wrap around my knee. DH can fetch them for me and put the melted ones back in the freezer as I use them, so I'm not buying that. The other item that I will get is a passive range of motion exerciser. It costs $130. to buy it or $65. to rent it for 4 weeks. Since I am having the other knee done next spring I will buy it. I already have my MiL's walker and shower chair so I think I'm all set. I am not looking forward to the surgery, just anxious to get rid of the pain and stiffness I've had for far too long.


~Diane

 

[T_R_Oglodyte]

Without going into too much detail, I opted for an outpatient surgery instead of inpatient a year ago. Who wouldn't want to go home, right? Well, any meds they give you in the hospital after outpatient surgery that you take orally are not covered by insurance, Medicare, gap, etc. I don't even remember taking the one single pill that ended up costing me $450. Besides that, I wasn't ready to be home. I fainted and was in a lot of pain.

The post-op prescription meds that were prescribed for me in connection with outpatient surgery were Percocet (oxycodone and acetaminophen) and Keflex (for possible bacterial infection). Both of those were covered by Medicare Advantage insurance. We picked them up before the operation, so they would be available when I got home.

FWIW - I never needed the oxycodone. Any pain issues I had were manageble with Tylenol.

 

[T_R_Oglodyte]

… Since I am having the other knee done next spring I will buy it. I already have my MiL's walker and shower chair so I think I'm all set. I am not looking forward to the surgery, just anxious to get rid of the pain and stiffness I've had for far too long.

Prior to my hip replacement, I also got a raised toilet seat - very worthwhile. Then my son installed a toilet bidet attachment to that. That was a great idea!!! We installed the unit below on top of the toilet riser. After recovery, we will remove the riser and reinstall it as shown in the picture.

 

[beejaybee]

Update re: nausea post-tkr.
I forgot my protein drink Tuesday but didn't connect that to my tummy feeling normal that day! Was about to have one yesterday morning when I realized that I'd not had it the day before. Googled and sure enough- protein drinks can cause nausea! I did take the pantoprazole that doc had prescribed meantime and skipped the drink. Appetite and tummy ok! Today I am forgoing the med and the beverage- we shall see!