History of Present Illness:
The patient is a who presents for screen colonoscopy
Last colonoscopy was
denies any abdominal pain, nausea, vomiting, constipation, diarrhea, fever, or chills
denies any bowel changes, no blood in bowel movement, no appetite changes, no change in weight
Past Medical History -reviewed
Past Surgical History - reviewed
Family History - reviewed
Social History - reviewed
Medication - Reviewed
Allergies - Reviewed
REVIEW OF SYSTEMS: All pertinent positives and negatives are stated in HPI and below, all other systems reviewed and are negative.
GENERAL: No malaise. No weight loss. No fever. No chills.
HEENT: No headache.
Eyes: No decreased vision.
Ears: No decreased hearing.
Nose: No bleeding.
Throat: No sore throat.
LUNGS: No shortness of breath. No cough. No COPD. No asthma.
CARDIAC: No chest pain. No palpitations. No orthopnea, no PND, no lower extremity edema.
GI: No Abdominal pain. No nausea. No vomiting. No constipation. No diarrhea. No change in weight. No change in appetite.
GU: No frequency. No hesitancy. No hematuria. No pyuria.
NEUROLOGIC: No dizziness. No neuropathy. No CVA. No headache.
MUSCULOSKELETAL: No neck pain or lower back pain.
Skin/Integuments - No breakdown
Physical Examination
Vitals: Reviewed
GENERAL APPEARANCE: Patient is alert, awake, resting, talking in complete sentences with no acute distress.
HEENT: No facial trauma or abnormalities. No tonsillar hypertrophy, no uvula deviation. No tongue swelling.
NECK: Supple, no lymphadenopathy. Trachea midline. No mass. No JVD
LUNGS: Clear to auscultation bilaterally. Normal breath sound. No Wheezing, rales or rhonchi.
HEART: Auscultation: RRR. Normal heart sound. No Gallop. No Murmur or rubs.
Palpation: Normal cap refill. Normal skin turgor. No JVD. No Pedal edema
ABDOMEN: Normal bowel sounds. Soft, nontender, nondistended. No mass or hernia appreciated. No hepatosplenomegaly. No peritonitis
EXTREMITIES: Patient ambulatory. Good muscle tone. Moving all extremities equally. Good range of motion.
NEUROLOGIC: GCS 15. Patient is ambulatory with no gait abnormalities. Cranial 2-12 is grossly intact.
VASCULAR: Bilateral radial pulses, strong, equal.
SKIN: Pink, warm, dry. No pathological skin rash or lesion.
PSYCH: normal mentation, awake, alert, not suicidal, not homicidal.
Imaging Results:
I have personally reviewed the imaging results
Labs/path:
I have personally reviewed the lab results
Assessments and Plans:
encounter for screening colonoscopy
I have discussed with the patient the
intended procedure.
as well as alternatives
For endoscopy, we discussed risks of the procedure
This includes, but are not limited to, bowel perforation, bleeding from biopsy and or intra-abdominal organ injuries during the maneuver of the procedure.
Pt agrees and would like to proceed with endoscopy
For colonoscopy, we discussed risks of the procedure
This includes, but are not limited to, bowel perforation, bleeding from biopsy and or intra-abdominal organ injuries during the maneuver of the procedure.
Pt agrees and would like to proceed with colonoscopy