Test Test

Consult

Clinic visit

post procedure visit

New Patient

Post hospitalization

CONSULT DATE	....		....PROCEDURES
LAST NAME		FIRST NAME	colonoscopy	EGD
MR#		S.S#	colonoscopy & EGD	EGD/dilation
CONSULTING MD		DOB	colonoscopy+/-EGD	EGD/ halo ablation
REFERRING MD			colonoscopy/APC	EGD/APC


BP.sys	P	R	TEMP .. BMI:
BPdias			WT: ... HT:....feet....inches......................


BMI	Normal 18.5-24.9	overweight 25-29.9	obese 30-39.9	mo > 40	underweight

		recommendations	recommendations	recommendations



average risk for colorecteal screening		colorectal polyp surveillance
high risk for colorectal screening		colorectal cancer surveillance
personal history of colon polyps		f/u for colon cancer surgery

iron deficiency anemia		chronic nausea
occult positive stools		chronic abdominal pain
weight loss		chronic nausea and bout of vomiting

upper gi bleeding		Barrett's esophagus surveillance
		Barrett's esophagus for radiofrequency ablation
hematochezia		chronic GERD with possible dilatation
Melena		chronic GERD with esophageal impaction

GERD		chronic IBD
epigastric pain		chronic IBD on immunosuppression
lower abdominal pain		chronic IBD





recent change in bowel habits		chronic Crohns disease
chronic constipation		chronic Crohns with fever
chronic diarrhea		Toxic megacolon

irritable bowel syndrome bloating		acute pancreatis (ETOH induced)
irritable bowel syndrome diarrhea		acute pancreatitis (gallstone induced)
irritable bowel syndrome constipation		Liver Biopsy

elevated liver function test		Evaluation after an episode of "diverticulitis "
cirrhosis		chronic diarrhea
cirrhosis with ascites		hepatic encephalopathy
chronic hepatitis C		Large volume paracentesis


Procedures to be scheduled:
EGD ColonoscopyColonoscopy and EGD		EGD with Savary EGD with Halo 360 EGD with BRAVO

colonoscopy and +/- EGD		flexi-sig

instructions to be given :
EGD colonoscopy Panendoscopy		Please have available the pediatric colonoscope.
large volume paracentisis

Management of Anticouagulation for endoscopic procedures
D/C aspirin 5 days before endoscopic procedures		D/C coumadin and begin Lovenox as instructed:
D/C coumadin 5 days before endoscopic procedures		D/C coumadin , antiplatelets agent and begin Lovenox
D/C all antiplatelet drugs 5 days before endoscopic procedures		D/C coumadin and begin Lovenox and antibiotic prophylaxis
D/C all anticouagulation therapy before endoscopic procedures
Begin antibiotic endocarditis prophylaxis (esophageal )		Begin antibiotic endocarditis prophylaxis (none esophageal )
		moderate risk moderate risk PCN allergic
PCN sensitivity PCN allergic		High risk High risk PCN allergic

Past Medical History


No significant past medical history
unobtainable

Body Mass Index underweight	normal	elevated obese morbid

hypertension	YESNO
diabetes mellitus	YESNO
hyperlipidemia	YESNO

hypothyroidism	YES

Cardiovascular

coronary artery disease	YESNO
CHF	YESNO
myocardial infarct	YESNO
unknown type of " heart disease "	YESNO
atrial fibrillation	YESNO
cardiac dysrhythmia	YESNO

aortic stenosis aortic insufficiency
mitral stenosis mitral insufficiency

pulmonary

asthma	YESNO
COPD	YESNO
community acquired pneumonia	YESNO
sleep apnea	YESNO
aspiration pneumonia	YESNO

gastrointestinal

peptic ulcer disease	YESNO
gastritis	YESNO
gastro esophageal reflux disease	YESNO
cirrhosis	YESNO
Laennec Cirrhosis	YESNO
pancreatitis	YESNO
irritable bowel syndrome	YESNO
chronic hepatitis	YESNO
celiac sprue	YESNO
refractory GERD	YESNO
GERD > 10 years	YESNO
GERD with a distal esophageal ring	YESNO
anemia of chronic blood loss	YESNO

neuropsychiatric

depression	YESNO
bipolar	YESNO
schizophrenic	YESNO
mentally retarded	YESNO

Parkinson's disease	YESNO
dementia	YESNO
Cardiovascular accident (CVA)	YESNO
transient ischemic attack (TIA)	YESNO
CVA with dense paresis	YESNO
migraine headaches	YESNO

musculoskeletal/rheumatological

degenerative joint disease (DJD)	YESNO
rheumatoid arthritis (RA)	YESNO
gout	YESNO
osteoporosis	YESNO
chronic back pain	YESNO
quadraplegic	YESNO


heme/ onc

normochromic normocytic anemia	YESNO
macrocytic anemia	YESNO
microcytic anemia	YESNO
unspecified anemia	YESNO

breast cancer	YESNO
ovarian cancer	YESNO
uternie cancer	YESNO
cervical cancer	YESNO


prostate cancer	YESNO

colon cancer	YESNO
pancreatic cancer	YESNO
lung cancer	YESNO
multiple myeloma	YESNO
metastatic liver disease	YESNO
lymphoma	YESNO

immunosuppression	YESNO
HIV (+)	YESNO
AIDS	YESNO


Renal /Urology

Benign Prostatic hypertrophy (BPH)	YESNO
Nephrolithiasis (kidney stones)	YESNO
diabetic nephropathy	YESNO
nephritic syndrome	YESNO
nephrotic syndrome	YESNO
chronic renal failure (CRF)	YESNO
renal dialysis	YESNO
chronic electrolyte disorder (Hyponatremia)	YESNO

Past Surgical History


No hx of surgery
Unobtainable

appendectomy	YES
cholecystectomy	YES
CABG	YES
cardiac stent	YES
angioplasty	YES
angiogram (cardiac)	YES
heart-valve replacement	YES
pacemaker placement	YES

hysterectomy	YES
laparoscopy (pelvis)	YES
hernioraphy	YES
colon cancer resection	YES

C-section	YES
tubal ligation	YES
orthopedic surgery	YES
brain surgery	YES
abdominal surgery	YES
hernia repair	YES
laminectomy	YES

prostatectomy	YES
TURP	YES

tonsillectomy	YES
hemorrhoid resection	YES
peripheral vascular surgery	YES

mastectomy	YES	RtLt
below knee amputation	YES	RtLt
above knee amputation	YES	RtLt
eye enucleation	YES	RtLt
cataract surgery	YES	RtLt

renal shunt placement	YES

Gastrointestinal Procedures

colonoscopy

year

findings

year

EGD

year

	no previous studies		previous normal flexi-sig		has no clue

ADDITIONAL STATEMENTS ?

Medications

ANTIPLATELETS		coumadin

Plavix (Clopidrogel)	75 mg qd	Warfarin (Cloumadin)
Ticlid (Ticlopidine)	250 mg bid
Aggrenox (ASA + dipyridamole)	25/200 capsule bid
ASA	one qd
Abciximab (ReoPro)

MEDS

see EMR (electronic medical record) for more comprehensive "list of meds"

the patient is not taking RX medication

Allergies

Allergies
No known allergies		allergic to " contrast dye"
hx of Penicillin allergy		allergic to "LATEX"ll
anaphylactic type response to PCN?		multiple environmental allergiesm)
hx of multiple drug allergies-including		single allergy to :
*	*	allergic to sulfa drugs

Social History

Not available Noncontributory Unobtainable Significant for:
Hx of smoking exposure at home /work?			YESNO
Smoker			YESNOquit years ago
If "yes" for smoking then how long ?			Pks/day x years
ETOH how long ?			no use mild moderate heavy quit years ago

Uses cocaine?			YESNO
Uses heroin ?			YESNO
IV drug user ?			YESNO
Quit use of IVDA?			YESNO

Sexual Preference			heterosexual homosexual
			bisexual

Work related questions
employment			enter the type of employment.....
Disability	NO	YES	The patient is disabled because of,,,
Unemployed	NO	YES

Family History

Not available Noncontributory Unobtainable Significant for:
DM	YES	NO	cancer	YES	NO
HTN	YES	NO	breast cancer	YES	NO
Asthma	YES	NO	colon cancer	YES	NO
Gallstones	YES	NO	pancreas	YES	NO
Migraines	YES	NO
CAD	YES	NO	Sickle Cell	YES	NO
"heart disease "	YES	NO	Thalassemia	YES	NO
rheumatological disorders	YES	NO	Cystic Fibrosis	YES	NO

other family history:


	deceased		deceased
father		Aunt
mother		Uncle
siblings		Grandfather
children		Grandmother

Review of Systems

	negative	positive	negative	positive	negative	Positve
GENERAL	wt loss		night sweats		malaise
	fever		weakness		"lack of strength"

Central nervous system	transient loss of vision		numbness to arm /legs		memory loss
	paresthesias		hypesthesias		anesthesias

	disturbances in smell		visual disturbances		oral facial paresthesia
	difficulty chewing		facial weakness		hearing and equilibrium
	swallowing problems		incoordination		involuntary movement s
					.
Gastrointestinal	BRBPR		change in bowel habits		melena
	dysphagia		odynophagia		reflux
	hematemesis		jaundice		hemorrhoids
	decrease in appetite		flatulence		chronic diarrhea


Respiratory	SOB with exertion		cough with sputum		wheezing
	hemoptysis		change in color of sputum		chronic cough


Cardiovascular	chest pains		PND/orthopnea		ankle swelling
	palpitations		tachycardia		dizziness
	near syncope		cyanosis		dependent edema
	exertional dyspnea		exertional chest pain		exertional diaphoresis
	cold extremities		stasis dermatitis		claudication


Renal	frequency/ urgency		blood in urine		flank pains
	incontinence		dysuria		renal colic

Musculoskeletal	joint pains		joint swelling		myalgias
	intermittent claudication		leg cramps		past clots in the veins

Urological	dribbling		decrease force of stream		penile discharge
	testicular mass		erectile dysfunction		testicular pain


Gynecological	amenorrhea		dysmenorrhea		DUB
	vaginal discharge		chronic pelvic pain		postmenopausal bleeding
	"vaginal itching"		dyspareunia		DES exposure

Breasts	lumps		breast pain		nipple discharge

Endocrine	polyuria		polydipsia		polyphagia
	heat/cold intolerance		"goiter"		excessive sweating
	change in skin pigmentation		exophthalmos		tremor


Skin	changes to moles		lesion with poor wound healing		bleeding skin lesions


ENT	hoarseness		neck masses		dysphagia
	diplopia		visual loss		eye discharge
	epistaxis		sinusitis		nasal discharge

	deafness		tinnitus		vertigo
	leukoplakia		Trush		mouth sores

all other systems negative...............'' the rest of the ROS are unobtainable

GYNE Hx


last menstrual period

last mammography
is the patient on Birth Control Pills?	No	YES
is the patient on Depo-Provera?	No	YES
history of hysterectomy?		YES
history of tubal ligation ?		YES
S/P Menopause		YES

had a recent positive pregnancy test ?	No	YES
does the patient think she is pregnant ?	No	YES
Is the patient sexually with multiple partners ?	No	YES

hx of STD ?	No	YES
hx of PID?	No	YES
hx of ectopic pregnancy?	No	YES
hx of in-vitro fertilization?	No	YES
hx recent gynecological procedure ?	No	YES
hx of ovarian cyst ?	No	YES
hx of vaginal discharge?	No	YES
watery ?		YES
foul smelling?		YES

VITALS

Physcal Exam

PHYSICAL EXAMINATION


HYDRATION	Good	adequate	Dry
GENERAL	Focused	Expanded	Detailed
EYE	Focused	Expanded	Detailed
EAR NOSE & THROAT	Focused	Expanded	Detailed
NECK	Focused	Expanded	Detailed

CARDIAC	Focused	Expanded	Detailed
LUNG	Focused	Expanded	Detailed
ABDOMINAL EXAM	Focused	Expanded	Detailed

PERIPHERAL PULSES	Focused	Expanded	Detailed
NEUROLOGICAL EXAM	Focused	Expanded	Detailed
PSYCHIATRIC	Focused	Expanded	Detailed

FEMALE EXAM	Focused	Expanded	Detailed
FEMALE EXAM	Focused	Expanded	Detailed
RECTAL EXAM	heme negative	heme positive	deferred

MUSCULOSKELETAL	Focused.	Expanded	Detailed
LYMPHATICS	Focused	Expanded	Detailed.
SKIN	Focused	Expanded	Detailed.

Working Diagnosis

Treatment

Recommendation

Nursing order Lab stuties IV fluids special orders Recommended Drug Therapy

Nursing orders	Laboratory Studies
Vitals :	CBC , platelets , PT,PTT, SMA 12 ,ECG, UA, AST, ALT, CALCIUM,
q 15 min q 2hrs q15 min until stable	CBC , platelets , PT,PTT, COMPREHENSIVE, Amylase and lipase: today and repeat in AM
q 30 min q shift (at least)	Serum Amylase and Lipase today and repeat in AM
	ABG (Stat)
Call If B/P < 90/60 , P>110 , Res > 22	Gallbladder Ultrasound (today)
	HIDA Scan (today)l
Diet :	CT (abdomen) with and without contrast IV : no oral cotrast
NPO	Obstructive Series (today)
NPO except for PO meds and ice chips
NPO except for meds	LIVER PROFILE (AST, ALT, ALP, total bili, direct , ALB, total protein)
	Gamma glutamyl / transpeptidase GT/GGT
Clear Liquid
Full liquids
Ad libitum
IV Access	RECOMMENDED SEROLOGY:
Central line access	Hepatitis Hepatitis Hepatitis Hepatitis	B C D A	Hepatitis B-RNA by PCR Hepatitis C-RNA by PCR Hepatis C Genotype
Large bore #16 angiocath X1
Large bore #16 angiocath x2

	Ceruloplasmin
	Serum Iron , TIBC and Ferritin
IV FLUIDS	Alpha-1- antitrypsin
LR 1 liter bolus .9NaCl 1 liter bolus
then start
LR .9NaCl D5w + .45 NaCl	Serum AMA
	Serum Smooth Muscle Antibody Antimytochondrial Antibody
IV RATE :	Serum Alpha fetoprotein
ml/hour or ml /minute
ACTIVITY	IgA endomysial antibodies
Bed rest Bed rest with BRP	Antigliadin antibody
	Antireticulin Antibody
	Anti liver /kidney microsomal


Daily Weights :	DIAGNOSTIC TESTS
	stool for C. difficile antigens and antibodies
Gluco scan q 8 hr	stool for LEUKOCYTE SMEAR
regular insulin (sliding scale)	stool for guaiac test x 3
Humolog insulin (sliding scale)	stool for enteric pathogens (E. Coli O157 H7, Salmonella and Shigella, campylobacter ,
	stool for Ova and parasites
	Gastric Carcinoma (CA 19-9)
	Stool for H-PYLORI



Special Procedures	Special orders
Gastric Lavage	Type and Screen
continue lavage until clear	Type and Cross for 2 units of PRBC'
discontinue lavage after 2 Liters	Give 2 units of PRBC's to run as fast as possible then give 2 additional units over 4 hours /unit
	Serial Hb/HCT's q 4 hours
EGD	Hb and HCT 1 hour post transfusion
EGD(Today) when hemodynamically stable	Hb/Hct q 2hr x 6
EGD scheduled in AM	Hb/Hct and repeat q 6 hours and in AM
	Hb/Hct and repeat q 6 hours and in AM
COLONOSCOPY
Colonoscopy in AM	GENERAL SURGERY CONSULTAION (ASAP)
Colonoscopy during hospitalization	General surgery consultation (Today )
Colonoscopy as an outpatient	General surgery consultation ( in AM )

Flexible Sigmoidoscopy	Correct coagulopathy with 2 units of FFP
No prep	Correct coagulopathy with 2 units of FFP + Vitamin K 10 mg SC
2 fleet enemas before procedure

GI MEDICATIONS

prhelicobacer1 h21blocker antacids1

Recommended Drug Therapy
Proton Pump Inhibitor		Helicobacter pylori therapy
omeprazole (Prilosec)		Helidac (bismuth subsalicylate + flagyl + tetracycline) 1 dose qid x 2wk + H2 blocker
20 mg 40 mg qd 40 mg BID		1 dose qid x 2wks + H2 blocker

lansoprazole (Prevacid)		Prevpac (lansoprazole + Amoxil + clarithromycin)
30 mg qd 15 mg qd		1 tab po bid X 14 days

rabeprazole (Aciphex)		Tritec (ranitidine+bismuth citrate) + Biaxin
20 mg qd		400 mg bid x 4 wks + Biaxin 500 mg po tid for 2 wk

pantoprazole (Protonix)		omeprazole +Biaxin + Amoxil x 14 days
40 mg po qd 40 mg IV qd		20 mg bid +500 md bid+ 1 gm po bid


H2 Blockers		Antacids and Miscellaneous
Cimetidine (Tagamet)		Maalox (aluminum and mag hydroxide)
400 mg BID 800 mg BID		20 ml up to 6 times /day

ranitidine (Zantac)		sucralfate (Carafate)
150 mg q12 hrs 6.25 mg IV/drip		1 gm po 1 hr. AC and qhs 1gm / 10 ml

famotidine (Pepcid)		misoprostol (Cytotec)
40 mg BID		100 mcgm PO QID

nizatidine (Axid)
300 mg qhs 150 mg qhs

antiemetics1 laxatives1 antiemetics antidiarrhea 1

Antiemetics		Laxatives
prochlorperazine (Compazine)		MiraLax 17 grams PO qd
5-10mg IV 25 mg sup		PEG 4 liters for bowel prep

metoclopramide (Reglan) )		Phosphosoda
10 mg po qid 10 mg IV q2-3 hr		Mag Citrate one to two 240 ml q12 hours PRN

droperidol (Inapsine)		Sorbitol 30 cc PO QID PRN
.625 -2.5 mg IV or 2.5-10 mg IM		lactulose 30 cc PO QID PRN

tigan (trimethobenzamide)		MOM 15 to 30 mgl tid
100 mg sup tid 200 mg sup tid		Cascara 5ml PO qhs on an empty stomack
		Senna 2- 4 tabs PO qd or bid

Antiemetics		Anti-Diarrheals
phenergan		Imodium ( loperamide)
400 mg BID 800 mg BID		2mg PO per dose : Start 4 mg x 1 then 2mg po after each loose stool to a Max of 16 mg/day

ondansetron (Zofran)		Lomotil (atropine /diphenoxylate)
4 mg q12 hrs 6.25 mg IV/drip		1-2 tabs po tid/qid prn: start with 2 tabs po qid

granisetron (kytril)		Octreotide (Sandostation )
40 mg BID		50 to 100 mcg IV qday or tid (may give dose SC)

dolasetron (Anzemet)		Kaopectate (attapulgite)
300 mg qhs 150 mg qhs		750 mg /15 ml : 30 ml with each loose stool for a total of 6 dose

antiflammatory bowel digestive enzymes antispasmodics

inflammatory bowel2 and digestive enzymes2

Inflammatory Bowel (1)		Digestive Enzymes
mesalamine (Asacol)		Cotazym
400 mg tabs : 800 mg po tid x3-6 wks		Cotazym-S

mesalamine (Pentasa)		Creon pancrelipase
250 mg ; 1 gram po qiq x 2 months	\	10 20 5

mesalamine (Rowasa)		Pancrease MT
500 mg supp ; 4 gram/60 ml bid x 3-6 wks		10 16 20

olsalazine (Dipentum)		Donnazyme
250 mg tabs ; 500 mg bid		500 mg tabs 1 to 2 tabs with meals: donot crush

sulfasalazine (Azulfidine)		Ku-Zyme amylase/cellulase/lipase/ protease (30/2/1200/6)
500 mg tabs : 500 mg po qid		1 to 2 tabs po with meals and snack

Inflammatory Bowel (2)		Anti-spasmodics
hydrocortisone 100 mg/ 60 ml		Levsin 0.125 - 0.25 mg PO /SL qid
60 ml enema qhs x 21 days		Levsinex Timecaps .375 mg q12

Cortenema 100 mg/60 ml		Donnatal 1- 2tabs PO q6hr
60 ml enema qhs x 21 days		Donnatal Extentabs 1 tab PO q12 h

Cortifoam 10 % Rectal Foam		Pro-Banthine 15 mg PO qac and 30 mg qhs
one applicatorful qd /bid x 3 wks		propatheline generic

Entocort EC budesonide		Bentyl (dicyclomine) 40 mg qid or 20 mg IM
3 mg tabs ; 9 mg PO qam		Librax (chlordiazepoxide/clidinium)


Vancomycin 1 gm IV over 1-2 hours
Gentamicin 1.5 mg/kg IM 30 minutes before procedure


Nasogastric tube insertion with : clear gastric content coffee ground return Bright red blood return Maroon return Refuses NG placement

NG for decompression
Central line placement	IJ Femoral Vein Subclavicular
Lumbar Puncture	performed Refuses LP
Foley-Catheter	inserted (Urine sent for U/A , C&S)
Chest tube placement	RT LT
Endotracheal intubation
Non invaside positive pressure ventilation initiated
Conscious Sedation procedure note


Orthopedic Procedures
long arm splint short arm posterior Ulnar gutter splint thumb spica short leg posterior splint Knee immobilizer shoulder immobilizer


ADDITIONAL STATEMENTS ?

CARDIAC MONITORING

ECG: Normal sinus rhythm Not clinically indicated

CARDIAC MONITORING: No evidence of ectopy Not clinically indicated (

IMAGING

CHEST-X-RAY: Normal study Not clinically indicated

ABDOMINAL SERIES : Normal study Not clinically indicated

CT(HEAD):Normal study Not clinically indicated

PLEASE ENTER OTHER STUDIES

DISPOSITION

Admit :

Medical floor .. Medical Telemetry . CCU Telemetry