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

GRQ PMH PSH ALLERGIES MEDS SH FH ROS PHYSICAL EXAM


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



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

Chemoprevention
ASA Statins Calcium all (ASA,+Statins ,+ calcium)


iron deficiency anemia with no GI symptoms		iron deficiency anemia with GI symptoms
	plan		plan
iron deficiency anemia (no gi symptoms)		iron deficiency anemia
(+anemia+ ASA+NSAIDS)		iron deficiency anemia (lower symptoms no upper complaints)
(+anemia -ASA-NSAIDS)		iron deficiency anemia (GERD, no lower symptoms)
(+anemia+ ASA+NSAIDS + Coumadin)
(+anemia+ ASA-NSAIDS - Coumadin)
		upper symptoms lower symptomsboth upper and lower symptoms

Heme positive with no GI symptoms :		Heme positive with GI symptoms :

	plan		plan
(-anemia- ASA-NSAIDS)		(-anemia- ASA-NSAIDS)
(-anemia+ ASA+NSAIDS)		(-anemia+ ASA+NSAIDS)
(+anemia+ ASA+NSAIDS)		(+anemia+ ASA+NSAIDS)
(+anemia -ASA-NSAIDS)
(+anemia+ ASA+NSAIDS + Coumadin)		(+anemia+ ASA+NSAIDS + Coumadin)

		upper symptoms lower symptoms both upper and lower symptoms
		takes Plavix doe not take Plavix Constitutional symptoms?no yes

hemetochezia with no GI symptoms :		hemetochezia with GI symptoms

	plan		plan
very small volume		suggestive of Inflammatory bowel disease
large volume but with significant blood loss anemia		suggestive of ischemic colitis
requiring admission and transfusions






Upper gI bleeding		plan


cg emesis,+ melena+ dyspepsia, + NSAIDS, +ASA,+ anemia -coumadin, stable, no liver disease		general recommendations :






Acute abdominal pain		Chronic abdominal pain

	plan		plan
acute pancreatis unknown cause		irritable bowel syndrome bloating
acute pancreatitis (+stone gallbladder)		irritable bowel syndrome diarrhea
		irritable bowel syndrome constipation
epigastric pain
lower abdominal pain (diverticulitis)		recent change in bowel habits
suggestive of PUD		chronic constipation


		chornic abdominal pain


Esophageal diseases

	plan
GERD (refractory to PPI qday)

Barrett's
esophagus surveillance
esophagus for radiofrequency ablation
chronic GERD with possible dilatation
GERD/ esophageal impaction


Colonic diseases

	plan		plan
chronic diarrhea		chronic Crohns disease
fecal incontinency		chronic Crohns with fever
		Toxic megacolon

		chronic IBD
		chronic IBD on immunosuppression
		chronic IBD


Liver diseases

	plan		plan
elevated liver function test		Evaluation after an episode of "diverticulitis "
cirrhosis well compensated		chronic diarrhea
cirrhosis with ascites		hepatic encephalopathy
chronic hepatitis C		Large volume paracentesis
		Liver Biopsy
Childs-Peugh classification
A B C


Functional problems

	plan
chronic nausea and bout of vomiting
weight loss




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

Past Medical History


No significant past medical history
unobtainable



hypertension	YESNO
diabetes mellitus	YESNO
hyperlipidemia	YESNO

hypothyroidism	YESNO

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		SBE (esophageal)PCN sensitivityPCN allergic ;;...... SBE (colon) moderate Highrisk PCN allergic

valvular heart disease (unknown type)	YESNO
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
inflammatory bowel disease	YESNO
ulcerative colitis	YESNO
Cronhs disease	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
anxiety	YESNO
musculoskeletal/rheumatological

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


heme/ onc

Anemic	YESNO
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



Enter additional medical history below

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

gastric bypass surgery	YES
vertical band gastroplasty	YES
ad-justable gastric bandinig	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



Enter additional surgical history below

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 (Coumadin)
Ticlid (Ticlopidine)	250 mg bid
Aggrenox (ASA + dipyridamole)	25/200 capsule bid
ASA	one qd
Abciximab (ReoPro)









	Prilosec OTC	Prevacid	Prednisone
	omeprazole	Protonix	Mesalamine
	Nexium	Aciphex	Entocort EC
	Zegrid	Zantac 150mg bid	Imuran 6 mercapotpurine Methotrexate

	MVI		Intercourse Extended
	Folic Acid
	Ferrous sulfate

MEDS

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

the patient is not taking RX medication

Allerg ies B

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			quit years ago no use mild moderate heavy #number of drinks /day beers mixed drinks both beers & mixed drinks for 5 years 10 years 15 years 20 years 20 years plus many years

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 alive		deceased alive
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