Consult - History and Phy.
Sample Name: Consult for Colostomy Reversal
Description: Patient presents for a colostomy reversal as well as repair of an incisional hernia.
(Medical Transcription Sample Report)
CHIEF COMPLAINT: "I want my colostomy reversed."
HISTORY OF PRESENT ILLNESS: Mr. A is a pleasant 43-year-old African-American male who presents to our clinic for a colostomy reversal as well as repair of an incisional hernia. The patient states that in November 2007, he presented to High Point Regional Hospital with sharp left lower quadrant pain and was emergently taken to Surgery where he woke up with a "bag." According to some notes that were faxed to our office from the surgeon in High Point who performed his initial surgery, Dr. X, the patient had diverticulitis with perforated sigmoid colon, and underwent a sigmoid colectomy with end colostomy and Hartmann's pouch. The patient was unaware of his diagnosis; therefore, we discussed that with him today in clinic. The patient also complains of the development of an incisional hernia since his surgery in November. He was seen back by Dr. X in April 2008 and hopes that Dr. X may reverse his colostomy and repair his hernia since he did his initial surgery, but because the patient has lost his job and has no insurance, he was referred to our clinic by Dr. X. Currently, the patient does state that his hernia bothers him more so than his colostomy, and if it were not for the hernia then he may just refrain from having his colostomy reversed; however, the hernia has grown in size and causing him significant discomfort. He feels that he always has to hold his hand over the hernia to prevent it from prolapsing and causing him even more discomfort.
PAST MEDICAL AND SURGICAL HISTORY:
1. Gastroesophageal reflux disease.
2. Question of hypertension.
3. Status post sigmoid colectomy with end colostomy and Hartmann's pouch in November 2007 at High Point Regional.
4. Status post cholecystectomy.
7. Status post unknown foot surgery.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient lives in Greensboro. He smokes one pack of cigarettes a day and has done so for 15 years. He denies any IV drug use and has an occasional alcohol.
FAMILY HISTORY: Positive for diabetes, hypertension, and coronary artery disease.
REVIEW OF SYSTEMS: Please see history of present illness; otherwise, the review of systems is negative.
VITAL SIGNS: Temperature 95.9, pulse 67, blood pressure 135/79, and weight 208 pounds.
GENERAL: This is a pleasant African-American male appearing his stated age in no acute distress.
HEENT: Normocephalic, atraumatic. Pupils are equal, round, and reactive to light and accommodation. Moist mucous membranes. Extraocular movements intact.
NECK: Supple, no JVD, and no lymphadenopathy.
CARDIOVASCULAR: Regular rate and rhythm.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Soft, nontender, and nondistended with a left lower quadrant stoma. The stoma is pink, protuberant, and productive. The patient also has a midline incisional hernia approximately 6 cm in diameter. It is reducible. Otherwise, there are no further hernias or masses noted.
EXTREMITIES: No clubbing, cyanosis or edema.
ASSESSMENT AND PLAN: This is a 43-year-old gentleman who underwent what sounds like a sigmoid colectomy with end colostomy and Hartmann's pouch in November of 2007 secondary to perforated colon from diverticulitis. The patient presents for reversal of his colostomy as well as repair of his incisional hernia. I have asked the patient to return to High Point Regional and get his medical records including the operative note and pathology results from his initial surgery so that I would have a better idea of what was done during his initial surgery. He stated that he would try and do this and bring the records to our clinic on his next appointment. I have also set him up for a barium enema to study the rectal stump. He will return to us in two weeks at which time we will review his radiological studies and his medical records from the outside hospital and determine the best course of action from that point. This was discussed with the patient as well as his sister and significant other in the clinic today. They were in agreement with this plan. We also called the social worker to come and help the patient get more ostomy appliances, as he stated that he had no more and he was having to reuse the existing ostomy bag. To my understanding, his social worker, as well as the ostomy nurses were able to get him some assistance with this.
Keywords: consult - history and phy., gastroesophageal reflux disease, cholecystectomy, sigmoid colectomy, colostomy, colostomy reversal, hartmann's pouch, incisional hernia, incisional, hernia, sigmoid,