Colon Surgery General Template

Chief Complaint

Patient Referral and Assessment

Template

Thank you for referring [Patient Name], a [Age] year old [Gender], who reports [chief complaints and symptoms]. [Provide a brief summary of the patient's primary concerns, including any notable symptoms, their descriptions, and any relevant history provided by the patient.] [[HPI mentioned (in a concise bullet list format), include family history, other symptoms mentioned, prior experience with previous colonoscopy, and social history] Example: - He states that he also develops anal pain with prolonged sitting which has been going on for quite some time now as well. - He has not had a previous colonoscopy. - Family history is significant for colon cancer in the maternal grandmother. - The patient follows a plant-based diet, does not consume alcohol and reports no other significant social history. ] Past medical history: [[List the patient's past medical diagnoses, including the year of diagnosis if available.] For example: - [Condition 1] diagnosed in [Year] - [Condition 2] diagnosed in [Year]] Past surgical history: [[List any past surgeries the patient has undergone, including the type of surgery and any relevant details.] For example: - [Surgery 1, e.g., Oral surgeries, including bone grafts] - [Surgery 2]] Medications: [[List all current medications the patient is taking, including the name and dosage if available.] For example: - [Medication 1] - [Medication 2] ] Allergies: [[List any known allergies the patient has, or state 'None' if there are no known allergies.] For example: - [Allergy 1] - [Allergy 2]] Physical Examination: [[Document the findings of the physical examination in detail narrative format, including any abnormalities or normal findings.] For example: Abdominal exam reveals no abnormalities and a rectal exam revealed no masses, narrowing or significant hemorrhoids on rectal examination. ] Assessment: [[Provide a summary of the most likely diagnosis or cause of the patient's symptoms, including any relevant explanations or pathophysiology discussed with the patient.] For example: The most likely cause of the patient’s symptoms is [Diagnosis]. This was explained to the patient, including [brief explanation of the condition].] Plan and Recommendations [[Outline the plan of care and recommendations provided to the patient. Include any dietary or lifestyle modifications, medications, procedures, or follow-up plans.] For example: 1. [Recommendation 1, e.g., Dietary modifications such as adopting a low FODMAP diet and incorporating fiber sources.] 2. [Recommendation 2, e.g., Use of medications such as polyethylene glycol (Restoralax) with dosing flexibility.] 3. [Recommendation 3, e.g., A colonoscopy to rule out structural abnormalities, including explanation of risks and patient consent.] 4. [Recommendation 4, e.g., Use of a memory foam pillow to alleviate pain associated with prolonged sitting.] 5. [Other Recommendation mentioned] ] Sincerely, Dr. Nathan Schneidereit