EXAMPLE
PAMF Pre-Op H&P
Laurel Greenfield - note last paragraph is her "risks and benefits are standard" template
available on our website.
________________________________________________________________________
DATE OF ADMISSION: 06/22/2007.
REASON FOR ADMISSION: Right knee exam under anesthesia with diagnostic and
operative arthroscopy with possible ACL reconstruction with allograft, probable partial
medial meniscectomy, and possible meniscal repair.
CHIEF COMPLAINT: Right knee pain.
HISTORY OF PRESENT ILLNESS: This is a 38-year-old male who injured his right
knee on 06/08/07 when he was dragging a giant tree limb. His grip gave way and he
suffered a hyperextension injury to his knee. He had swelling. He felt a pop. He was
unable to straighten his leg. He was seen at urgent care and evaluated by Dr. Van Egeren
and had an MRI that was performed at the Palo Alto Clinic. He was then referred in to
see Dr. King. He was seen and evaluated on 06/14/07 and found that he had a probable
bucket handle tear of the medial meniscus with a partial versus possible complete tear of
the anterior cruciate ligament. Options, surgical and nonsurgical were discussed with
him as well as the risks and complications. At this time he would like to proceed with
surgical intervention, undergoing a right knee exam under anesthesia with possible ACL
reconstruction with allograft, probable partial medial meniscectomy, and possible
meniscal repair.
CURRENT MEDICAL PROBLEMS: The patient denies any history of hypertension,
diabetes, seizures, or heart murmurs.
CURRENT MEDICATIONS: None.
ALLERGIES: None.
PREVIOUS SURGICAL HISTORY: Left knee arthroscopy.
PHYSICAL EXAMINATION: This is a 38-year-old male who stands 5'9" and weighs
190 pounds. He is under no apparent distress. Tobacco use: None. Alcohol use:
Occasional. His chest is clear. There are no wheezes or rales appreciated. His heart has
a regular rate and rhythm, no murmurs, rubs, or gallops are noted.
Examination of his right lower extremity and his right knee shows a 1+ effusion. Motion
is -20 degrees of extension. He has 110 degrees of flexion. There is 1+ anterior drawer,
1+ Lachman. He has 2+ medial joint line tenderness.
MRI shows a bucket handle tear of the medial meniscus and a normal anterior cruciate
ligament.
ASSESSMENT: Right knee with probable bucket handle tear of the medial meniscus
and possible ACL partial tear versus complete.
RECOMMENDATION AND PLAN OPTIONS: A long discussion was carried out with
Warren in regard to his treatment and alternatives, surgical and nonsurgical. At this time
he would like to proceed with surgical intervention, undergoing a right knee exam under
anesthesia with diagnostic and operative arthroscopy, possible ACL reconstruction with
allograft, probable partial medial meniscectomy, and possible meniscal repair.
The patient was told of the diagnosis and was given a choice of the treatment options
available. The patient was told of the surgical and the nonsurgical treatment options as
well as the risks and benefits associated with each of the treatment options. Prior to the
patient giving consent the patient expressed an understanding of the diagnosis and the
treatment options, both surgical and nonsurgical. The patient's questions were answered.
With an expressed understanding of the diagnosis and the treatment alternatives, the
patient requests surgical intervention.