SURGICAL HISTORY AND PHYSICAL EXAMINATION
Identifying Data: patient's name, age, race, sex; referring physician.
Chief Complaint: Reason given by patient for seeking surgical care; place reason in "quotation marks."
History of Present Illness (HPI): Describe the course of the patient's illness, including when it began, character of the symptoms; pain onset (gradual or rapid), precise character of pain (constant, intermittent); other factors associated with pain (defecation, urination, eating, strenuous activities); location where the symptoms began; aggravating or alleviating factors. Vomiting (characteristics, appearance, frequency, associated pain). Change in bowel habits; bleeding, character of blood, (clots, bright or dark red), trauma; recent weight loss or anorexia; other related diseases; past diagnostic testing.
Past Medical History (PMH): past diseases. All previous surgeries and indications; dates and types of procedures; serious injuries, hospitalizations; significant medical problems; history of diabetes, hypertension, peptic ulcer disease, asthma, myocardial infarction; hernia, gallstones.
Allergies: Penicillin: Codeine?
Family History: Medical problems in relatives. Family history of colonic polyposis, carcinomas, multiple endocrine neoplasia (MEN syndrome).
Social History: Alcohol, smoking, drug usage.
Review, of Systems (ROS):
General: Weight gain or loss; appetite loss, fever, fatigue, night sweats.
Head: Headaches, seizures.
Eyes: Visual changes, diplopia, eye pain.
Mouth & Throat: Dental disease, hoarseness, sore throat, pain, masses.
Respiratory: Cough, shortness of breath, sputum.
Cardiovascular: Chest pain, orthopnea, dyspnea on exertion, claudication, extremity edema.
Gastrointestinal: Dysphasia, abdominal pain, nausea, vomiting, hematemesis, melena (black tarry stools), hematochezia (bright red blood per rectum), constipation, bloody stool, change in bowel habit; hernia, hemorrhoids, gallstones.
Genitourinary: Dysuria, frequency, hesitancy, hematuria, polyuria, discharge; impotence, prostate problems.
Gynecological: Last menstrual period, breast masses.
Skin: Easy bruising, bleeding tendencies.
SURGICAL PHYSICAL EXAMINATION
Vital Signs: Temperature, heart rate, respirations, blood pressure, weight.
Head, Eyes, Ears, Nose, Throat (HEENT):
Eyes: Pupils equally round and react to light and accommodation (PERRLA): extraocular movements intact (EOMI);
Neck: Jugular venous distention (JVD), thyromegaly, masses, bruits; lymph nodes.
Chest: Equal expansion; rhonchi, crackles, breath sounds.
Heart: Regular rate & rhythm (RRR), first & second heart sounds; murmurs (grade 1-6), pulses (graded 0-2+).
Breast: Retractions, tenderness, lumps, nipple discharge, dimpling, gynecomastia; axillary nodes.
Abdomen: contour (flat, scaphoid, obese, distended); scars, bowel sounds, tenderness, organomegaly, masses, liver span; splenomegaly, guarding, rebound, bruits; percussion note (tympanic), costovertebral angle tenderness (CVAT), inguinal masses.
Genitourinary: External lesions, hernias, scrotum, testicles, varicoceles.
Extremities: Edema (grade 1-4+); cyanosis, clubbing, edema (CCE); pulses (radial ulnar, femoral, popliteal, posterior tibial, dorsalis pedis; simultaneous palpation of radial and femoral pulses), Homan's sign (dorsiflexion of foot elicits calf tenderness).
Rectal Exam: Sphincter tone, masses, hemorrhoids, fissures; guaiac test for occult blood; prostate masses.
Neurological: Mental status; gait, strength (graded 0-5); deep tendon reflexes.
Labs: Electrolytes (sodium, potassium, bicarbonate, chloride, BUN, creatinine), CBC; X-rays, ECG (if older than 35 yrs or history of cardiovascular disease), urine analysis (UA), liver function tests, PT/PTT.
Assessment (Impression): Assign a number to each problem and discuss each problem separately.
Plan: Describe surgical plans including preoperative testing, laboratory studies, medications, antibiotics.
Type of Anesthesia Planned:
Laboratory Data: Electrolytes, BUN, creatinine, CBC, PT/PTT, UA, EKG, Chest X-ray; type and screen for blood or cross match if indicated; liver function tests, ABG.
Risk Factors: Cardiovascular, pulmonary, hepatic, renal, coagulopathic, nutritional risk factors.
Consent: Document explanation to patient of risk and benefits of procedure, and document patient's informed consent or guardian's consent and understanding of procedure.
Major Medical Problems:
BRIEF OPERATIVE NOTE
(Written immediately after the procedure)
Date of the Procedure:
Names of Surgeon and Assistant:
Estimated Blood Loss (EBL):
Fluids and Blood Products Administered During Procedure:
Specimens: Pathology specimens, cultures, blood samples.
Subjective: Mental status & patient's subjective condition; pain control.
Vital Signs: Temperature, blood pressure, pulse, respirations.
Physical Exam: Chest and lungs; inspection of wound and surgical dressings; conditions of drains; characteristics and volume of output of drains.
PROBLEM-ORIENTED PROGRESS NOTE
Problem List: Postoperative day number, antibiotic day number if applicable. Hospital day number, hyperalimentation day number. List each surgical problem separately (status post-appendectomy, hypokalemia). Address each numbered problem daily in progress note.
Subjective: Write how the patient feels in the patient's own words; and give observations about the patient.
Objective: Vital signs; physical exam for each system; thorough examination and description of wound. Condition of dressings; purulent drainage, granulation tissue, erythema; condition of sutures, dehiscence. Amount and color of drainage, laboratory data.
Assessment: Evaluate each numbered problem separately.
Plan: For each numbered problem, discuss any additional orders, surgical plans. Discuss changes in drug regimen or plans for discharge or transfer. Discuss conclusions of consultants.
Date of Admission:
Date of Discharge:
Attending or Ward Team:
Surgical Procedures, Diagnostic Tests, Invasive Procedures:
Brief History & Pertinent Physical Examination & Laboratory Data: Describe the course of the patient's disease up until the patient came to the hospital including physical exam & laboratory data.
Hospital Course: Describe the course of the patient's illness while in the hospital; include evaluation, treatment, outcome of treatment, and medications given while in the hospital.
Discharge Condition: Describe improvement or deterioration in patient's condition.
Disposition: Describe the situation to which the patient will be discharged (home, nursing home), and person who will take care of patient.
Discharged Medications: List medications and instructions.
Discharged Instructions & Follow-up Care: Date of return for follow-up care at clinic; diet, exercise.
Problem List: List all active and past problems.
Copies: Send copies to attending physician, clinic, consultants and referring physician.