EXAMPLE Kevin Stuart, M.D. PREOP H&P ________________________________ HISTORY OF PRESENT ILLNESS: The patient is a 72-year-old female with documented anemia. The patient denies any history of anemia, denies any rectal bleeding, melena, hematuria, or vaginal bleeding. She has been on iron supplementation since November of 2005. She was taking Ibuprofen and aspirin on a daily basis and has subsequently stopped the Ibuprofen. She denies any localizing joint symptoms. Specifically, she denies any change in bowel habits, abdominal pain, dysphagia, odynophagia, or early satiety. There has been no weight loss. There is no personal or family history of gastrointestinal malignancy. PAST MEDICAL HISTORY: Pulmonary fibrosis, diabetes, hypertension, hypercholesterolemia. PAST SURGICAL HISTORY: Negative. MEDICATIONS: Diovan, Hydrochlorothiazide, Avandamet, Glipizide, Interferon, Albuterol, TriCor. ALLERGIES: No known drug allergies. REVIEW OF SYSTEMS: Patient denies any chest pain, increased shortness of breath, or neurologic symptoms. PHYSICAL EXAMINATION: GENERAL APPEARANCE: Patient is a well-developed, well-nourished female. CHEST: Reveals diffuse crackles. CARDIOVASCULAR: Regular rate without murmurs. ABDOMEN: Soft, non-tender without any masses or hepatosplenomegaly. RECTAL: To be performed at time of endoscopy. LABORATORY: Serum iron 26 with the normal being greater than 27. IMPRESSION: Anemia, borderline lower iron, and prior nonsteroidal antiinflammatory use. The patient requires panendoscopy to assess etiology of her anemia. The procedures of colonoscopy and esophagogastroduodenoscopy were fully explained to the patient. Possible complications including bleeding, infection, perforation requiring surgical repair, reaction to medication, missed lesions, life-threatening cardiopulmonary events were all fully described. Ample time was given to ask questions and receive answers. Consent was obtained, which was informed, competent, and voluntary, and the patient expressed desire to proceed with endoscopy as workup for above problem. PLAN: Colonoscopy, esophagogastroduodenoscopy on 02/09/2006.