Example of a Pre-Op H&P at the Slc Va

EXAMPLE OF A PRE-OP H&P AT THE SLC VA

***NOTE: this can be copied and pasted into CPRS to start the H&P note and used as a t emplate; the biomechanics chart in the physical exam section looks jacked up in this word doc, but it actually ends up lining up all pretty in CPRS

Surgery History & Physical

Date: ***

Service/Specialty: Podiatry

Date of Surgery: TBD

Diagnosis: ***

Planned Procedure: ***

Crutch Training: Consult placed to PT, patient sent to PT today to have the

training done

CHIEF COMPLAINT:

HPI: Patient is a *** yo non-diabetic male presenting for a pre-op H&P. His

diagnosis is *** .

LAST PCP VISIT/ENCOUNTER: ***

- Relevant Concerns by PCP:

- Would PCP clear for surgery?:

- Is patient followed by Mental Health? ***

- If yes, why and are they cleared by MH for surgery?: ***

MEDICAL PROBLEMS (PMH):

***

CURRENT MEDICATIONS:

***

[ ] daily NSAIDS

[ ] daily ASA

[ ] coumadin

[ ] Platlet inhibitor

[ ] Herbs or nutritional supplements which may affect clotting time:

(e.g., ginko, ginseng, garlic, fish oils, ginger) Stop 10

days pre-op.

[ ] N/A

******************************************************************

MEDICATION RECONCILIATION:

[x] The following information sources were consulted and the

patient's CPRS medication profile was updated with

medication, allergy, OTC, herbal, or illicit drug use

information as necessary.

[x] I have verified patient's understanding of indications.

[x] Medication reconciled

*******************************************************************

P A T I E N T H I S T O R Y

PAST SURGICAL HISTORY, including complications:

***

Bleeding problems: [ ]yes [x]no

Anesthesia problems: [ ]yes [x]no

FAMILY HISTORY: Medical conditions of immediate family (mother, father,

siblings)

***

Has Patient Been Ruled Out for Familial Diseases?:

SOCIAL HISTORY:

Smoking:

[ ] Lifetime non smoker

[ ] No current tobacco use past 12 months

Year quit: ppd x yrs

[ ] Yes currently using tobacco

*** ppd x *** years = *** pack/years

Drugs (IV, narcotics, etc.): denies current/recent use

EtOH:

[ ] Lifetime non-drinker

[ ] No ETOH in past 12 months

[ ] Yes ETOH use

[ ] < 2 drinks/day

[ ] > 2 drinks/day in past two weeks

DNR Status (written within 30 days prior to surgery):

Military History:

Branch: *** x *** years

Current Occupation:

Marital Status:

Living Arrangements:

Ride to and from Surgery:

Exercise:

Recent deaths to loved ones or stressful situations:

Prison/Jail:

ALLERGIES:

R E V I E W O F S Y S T E M S

Cardiovascular:

[ ] Angina

[ ] MI

[ ] HTN

[ ] CHF

[ ] PVD

[ ] DVT

[ ] Arrhythmias

[ ] Previous PTCA

[ ] Previous Cardiac Surgery

[ ] Negative - Denies CV problems

Vascular:

[ ] History of Revascularization/Amputation for PVD

[ ] Rest Pain/Gangrene

[ ] Exercise Tolerance - claudication

[ ] Negative

Respiratory:

[ ] History of severe COPD

[ ] Chronic steroid use

[ ] FEV < 75% predicted

[ ] Chronic bronchodilator therapy

[ ] On oxygen at home

[ ] Sleep apnea

[ ] SOB

[ ] Current pneumonia

[ ] Dyspnea -

[ ] at rest

[ ] RR > 30/min at rest

[ ] with moderate exertion. (pt unable to climb a flight of stairs

without SOB)

[ ] Orthopnea -

[ ] cough - daily

[ ] sputum/color:

[ ] non-productive

[ ] Negative - Denies above or other respiratory problems.

Gastrointestinal:

[ ] N/V/D

[ ] Jaundice

[ ] Reflux

[ ] Ulcers

[ ] Hepatitis

[ ] Hernias

[ ] Acities

[ ] Negative - Denies above or other GI problems

Genital/Urinary:

[ ] Acute Renal Failure (creatinine >3)

[ ] Currently on dialysis

[ ] Incontinence

[ ] Reproductive problems

[ ] Prostate BPH

[ ] Hx of prostate cancer

[ ] Negative - Denies above or other GU problems

Neuro/Psychiatric:

[ ] CVA (defined) -

[ ] residual deficit

[ ] no neural deficit

[ ] Seizures

[ ] History of TIA's

[ ] Hemiplegia/hemiparesis

[ ] Tumor involving CNS

[ ] Impaired sensorium

[ ] Migraines/HA

[ ] Psychiatric hx

[ ] Depression

[ ] Anxiety

[ ] PTSD

[ ] Negative - Denies above or other neuro/psych problems

Musculo/skeletal:

[ ] Arthritis: Wrists, fingers, elbows, knees, hips and shoulders

[ ] Back problems

[ ] Fractures

[ ] Joint replacement

[ ] Weakness

[ ] Negative - Denies above or other MS problems

Functional status:

[ ] Patient is independent (able to perform ADL's)

[ ] Partially dependent (needs assistance or adaptive equipment,

on dialysis, or from ECF)

[ ] Totally dependent

Endocrine:

[ ] Diabetes -

[ ] controlled by oral medication

[ ] controlled by insulin injection

[ ] diabetes diagnosed within 2 weeks

[ ] placed on insulin within 2 weeks of surgery

[ ] Thyroid -

[ ] hypothyroid on potx

[ ] hx of hyperthyroid

[ ] Negative - Denies above or other endocrine problems

Nutritional/Immune/Other:

[ ] Disseminated cancer (mets to 2 or more sites)

[ ] Hx of cancer

[ ] Chemotherapy within last 30 days

[ ] Radiation therapy within last 90 days

[ ] Thrombocytopenia

[ ] Bleeding disorders

[ ] Open wound or wound infection

[ ] Chronic steroid use 1 month prior to surgery

[ ] >10% loss body weight within last 6 months

[ ] Sepsis within 48 hours prior to surgery

[ ] Negative - Denies above or other nutritional/immune problems

OBJECTIVE: Patient is AOx3 and in NAD. Patient presents wearing *** .

P H Y S I C A L E X A M

CURRENT VITAL SIGNS:

***

General:

[ ] Thin

[ ] Normal

[x] Obese

HEENT:

PERRLA, CN nerves II-XII are normal, EOMs are normal

[ ] Glasses

[ ] Hearing aids

[ ] Dentures

Neuro: AOx3, NAD, gross sensation intact

HEENT: EOMI, no palpable nodule in the neck

CV: RRR, no MRG

Pulm: good respiratory effort, CTAB, equal breath sounds bilaterally,

Abd: NT, obese, +BSx4

Musculoskeletal: normal ROM to UE, muscle strength 5/5 to UE

LOWER EXTREMITY EXAM:

DERMATOLOGIC EXAM: Skin is warm, smooth, and supple bilaterally. No erythema

noted to the foot and ankle bilaterally. Nails are elongated, thick, dystrophic,

and discolored with subungual detritus x 10. No hyperkeratotic lesions noted

bilaterally. Web spaces are clean, dry, and free of lesions and fissures

bilaterally.

VASCULAR EXAM: DP and PT pulses are palpable bilaterally. CRT is brisk to all

digits. Pedal hair is present to the dorsal foot and digits bilaterally. No

varicosities or telangiectasia noted bilaterally. No edema noted to the foot and

ankle bilaterally.

NEUROLOGIC EXAM: Gross sensation intact bilaterally. Protective sensation is

intact as tested with a 5.07 10g Semmes-Weinstein Monofilament bilaterally.

MUSCULOSKELETAL EXAM: Muscle strength is 5/5 and active motion is pain-free and

symmetrical bilaterally with plantarflexion, dorsiflexion, abduction, adduction,

inversion, and eversion against resistance. No pain or crepitation with passive

range of motion bilaterally to all major pedal joints. Tenderness to palpation

of *** .

BIOMECHANICAL EXAM: R L

Ankle DF (KE/KF): 0/5 0/5

STJ ROM (Inv/Ev) 20/10 20/10

STJ Neutral Position: 0 degrees 0 degrees

FF TO RF (1-5): 1 deg valgus 1 deg valgus

FF TO RF (2-5): Perpendicular Perpendicular

1st MPJ DF (NWB/WB): 65/35 65/35

1st ray Position: Neutral Neutral

1st ray Motion: 5mm DF, 5mm PF 5mm DF, 5mm PF

Limb Length Discrepancy: none none

ASIS to MM: *** cm *** cm

MM to floor: *** cm *** cm

ASIS to floor: *** cm *** cm

RCSP: Perpendicular Perpendicular

NCSP: 2 deginv 2 deginv

NCSP Calculated: 2 deginv 2 deginv

Tibial Position: 2 degvarus 2 degvarus

Knee Position: varum varum

Muscle Strength: Muscle strength is 5/5 and active motion is pain-free and

symmetrical bilaterally with plantarflexion, dorsiflexion, abduction, adduction,

inversion, and eversion against resistance.

Quality of Motion: No pain or crepitation with passive range of motion

bilaterally to all major pedal joints.

Gait Analysis: Gait is propulsive and steady without need for assistance

(apropulsive, antalgic, circumduction). Head is upright with no head tilt

noted. Left-side shoulder drop. Arm swing is symmetrical and not overpowering.

Hips are symmetrical and even. Knees exhibit normal flexion and extension

throughout gait and are normal in position in the sagittal and frontal planes.

Ankles exhibit normal motion throughout gait. Heel is inverted at heel strike

andeverted at early midstance. Heel inverts during late stance before

propulsion. No early heel lift. Normal angle (15-20 degrees abducted) and base

of gait (6-10 cm). Extensor substitution noted in swing phase. No abductory

twist.

LABS:

***

RADIOGRAPHS:

***

EKG:

Pending, ordered today

CXR:

Not indicated

ASSESSMENT/PLAN:

- Patient will continue conservative care as outlines in previous podiatry

encounters, consisting of ***

- Given that the patient has tried and failed conservative therapy for the issue

for ***, surgical intervention is indicated and recommended at this time.

Discussed surgical correction of the problem with the patient, which includes

***. Explained in detail the benefits, risks, possible complications,

perioperative course, and alternatives to the procedure. Risks of surgery

include, but are not limited to: infection, and / or inflammation of the

operated areas, excessive swelling, significant or chronic pain (including

complex regional pain syndrome or reflex sympathetic dystrophy), excessive

bleeding, delayed or non-healing of incision and / or operated bones, poor

cosmesis, peripheral vascular complications (i.e.- phlebitis, thrombosis,

compartment syndrome), skin necrosis / ulcer, transfer callus or lesion, floppy

toe, stiff toe, short toe, elevated or floating toe, loss of toe or limb,

allergic reaction to the suture, implant, or implanted materials, adverse

reaction to the anesthesia, failure of procedure or re-occurrence of the

condition, worsening of the condition / disability, damage to adjacent nerves or

vascular structures, other deformities may develop, and repeated surgery may be

needed to correct the current condition or new conditions. Patient understands

all that was discussed and all questions were answered to the patient's

satisfaction. After understanding all that was described regarding surgical

correction of the problem, patient elects to have the procedure performed.

- Consent was signed in iMedConcent after above discussion

- Surgery is tentatively scheduled on ***

- After visit today, patient was sent to PT for crutch training, was sent to

obtain EKG, Labs, CXR, and was sent to Same Day Surgery for anesthesia

evaluation

- MH consult was offered for amputation, patient declined

- Medications that need started/stopped prior to surgery include: ***

- Lengthy discussion was had with patient about narcotics and obstructive sleep

apnea. Patient understands that failure to fully comply with OSA therapy,

especially the CPAP, while on narcotic medications can lead to respiratory

distress/failure and/or death. Patient has committed to comply fully with OSA

therapy after surgery.

- Post-op NWB will consist of ***

- Post-op pain management will consist of Oxycodone 5-10 mg PO q4-6h prn with

Ondansetron 8 mg PO q6h prn for nausea.

- Continue to f/u with PCP, cont use of ***

- Continue to f/u with PCP, cont use of ***.

- Continue to f/u with PCP, cont use of ***

Patient offerred MH consult (Mandatory for Amputations):

[x]Yes [ ]No [ ]NA

CODE STATUS: [x] Full code [ ] DNR, or otherwise specified

Staffed with Dr. Young, attending physician.

The procedure with benefits and risks was explained in detail, with possible

complications including but not limited to: infection and/or bleeding leading

to possible loss of toe, foot, limb, life; and the consent form was signed.

[x]Yes [ ]No Patient has decision making capacity.