EXAMPLE
Kevin Stuart, M.D.
PREOP H&P
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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.