HISTORY OF PRESENT ILLNESS
The patient is a _____ year old patient who presents with abdominal pain
The duration has been
Pain level is
This is associated with
It is better with
It is worse with
Past surgical history include
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Past Medical History -
Social History - reviewed
Home Medication - Reviewed
Allergies - Reviewed
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REVIEW OF SYSTEMS:
GENERAL: No malaise. No weight loss.
HEAD: No CO headache. No Trauma
No swollen lymph nodes
Eyes: No CO decreased or blurred vision. No yellow color
Ears: No CO decreased hearing.
Nose: No bleeding.
Throat: No sore throat. No mass noted
Symmetrical, no deviation,
LUNGS: No shortness of breath. No cough. No Wheezing, No difficulty with breathing
CARDIAC: No chest pain. No palpitations. chest heaviness. No arm or leg swelling or edema
GI:
GU: No frequency. No hesitancy. No blood in the urine, no burning on urination
NEUROLOGIC: No dizziness. No neuropathy. No headache.
MUSCULOSKELETAL: No neck pain or lower back pain.
Skin/Integuments - No breakdown
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Vitals:
Reviewed
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PHYSICAL EXAMINATION
GA: comfortable, no distress
HEAD : Atraumatic; normo-cephalic;
Eyes: EOMI, PERRLA. No Jandice
Nose: Nares patent, no sign of bleeding
Throat: Mouth is clear and no adenopathy, no deviation
NECK: Supple, no adenopathy, and no thyromegaly. Symmetrical
LUNGS: No rhonchi, no wheezing. Displays no work of breathing
CHEST: Symmetrical excursion. No mass
CARDIAC: Regular, rate, & rhythm
No pedal edema, no orthopnea
ABDOMEN:
EXTREMITIES: No cyanosis, No clubbing, No edema
SKIN: No lesions
NEURO: Alert Ox3, CN11-12 are intact grossly, motor and sensory grossly intact
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IMAGING
I have personally reviewed the imaging studies
CT scan showed
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LABS
I have personally reviewed the lab results
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DIAGNOSIS/ASSESSMENTS AND PLANS
This is a ______pt with small bowel obstruction
I have discussed the diagnosis and finding with the patient.
I have also discussed the findings on imaging studies.
I have also outlined the treatment options and alternatives.
The recommend plan at this time would ben NPO, IV fluid and correct any underlying
electrolyte deficits.
If not resolved, the pt may eventually need surgery
For surgery, the risks, benefits, were discussed with patient, which includes, but are not limited to, postoperative or chronic pain, bleeding, wound infection, hematoma, bile duct injury, bile leak, injury to other organs, or need for further procedures or workup. Other Complications may include deep vein thrombosis(blood clots), as well as other side effects affecting other organ systems such as the heart or lungs, and in rare circumstances, death as a result of the above complications.
The patient understand and agrees to proceed with the proposed procedure.