ANYWHERE HOSPITAL USA
OB/GYN Clinic Encounter Note
Preoperative History and Physical
PATIENT NAME: Roach, Nanette
MRN:
633654
ACCT#: 021476
DOS:
06/06/10
IDENTIFICATION: The patient is here today for her preoperative history and physical exam for
surgery which is scheduled for next week.
HISTORY OF PRESENT ILLNESS: The patient is a 43-year-old gravida 6, para 5-0-1-5, who was
diagnosed to having a pedunculated fibroid protruding through her cervical as that is
approximately 3 mm in diameter. She is being admitted for outpatient surgery in the near
future, for a possible diagnostic hysteroscopy, excision of the pedunculated fibroid, and a D
and C if indicated.
PAST MEDICAL HISTORY: Significant for obesity and anemia.
PAST SURGICAL HISTORY: Noncontributory.
OBSTETRICAL HISTORY: NSVD by five.
SOCIAL HISTORY: Denies any alcohol, drug, or tobacco abuse.
FAMILY HISTORY: Noncontributory.
CURRENT MEDICATIONS:
1. Ferrous sulfate 325 mg one pill twice a day.
2. Tramadol 50 mg one pill every six hours p.r.n. pain.
3. Naproxen 250 mg one pill every six hours p.r.n. pain.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
REVIEW OF SYSTEMS: HEENT: No headaches or blurred vision. CARDIOVASCULAR: No chest
pains, palpitation. PULMONARY: No hematemesis or shortness of breath. GI: Negative for
nausea, vomiting, diarrhea, constipation. GU: No dysuria or hematuria.
PHYSICAL EXAMINATION:
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VITAL SIGNS: Blood pressure 122/52, pulse 71,
temperature 99.1 degrees Fahrenheit, respiration 18.
HEENT: pupils’ equal, reactive and responsive to light and accommodation.
NECK: Supple. No palpable lymph nodes. No thyromegaly. Oropharynx moist.
No oropharyngeal erythema. No lymphadenopathy.
LUNGS: Clear to auscultation bilaterally.
CARDIOVASCULAR: Regular rate and rhythm.
ABDOMEN: Soft, nontender. No rebound, no guarding.
EXTREMITIES; No clubbing, cyanosis, or edema.
NEUROLOGICAL; Alert and oriented times three. Motor and sensory grossly
intact.
ASSESSMENT AND PLAN: Pedunculated fibroid uterus. Plan is for the patient to undergo an
exam under anesthesia with a resection of the pedunculated fibroid, possible hysteroscopy,
possible D and C. She is informed that the risks include, but are not limited to, infection which
might require prolonged antibiotics, bleeding which might require blood transfusion, risk of
blood transfusion include, but not limited to, blood borne infections such as hepatitis B which is
1 in 400,000, or hepatitis C or HIV which the risk is 1 in 2 million, uterine perforation and
possible hospitalization. The patient states she understands the risks and wants
to proceed with surgery.
Electronic Authentication: Lisa Lazaro, MD
Dictated:
06/06/10
Transcribed: 06/06/10
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