Colorectal Surgery SOAP Note Transcription Sample Report

DATE OF SERVICE:  MM/DD/YYYY

SUBJECTIVE:  The patient is here for a long office visit. He was recently discharged from an outside clinic where he had been admitted after he had a bowel obstruction. He had recurrent strictures of ileum from Crohn's disease.

He is followed by Dr. John Doe. He finally underwent a resection by Dr. Jane Doe, 2-3 feet of terminal ileum, which was reattached to the colon.

He had some diarrhea treated with Imodium tablets 4 times a day. Otherwise, he has had no nausea or vomiting. His appetite is improved. He has followup with the Colorectal Surgery in about a week.

PAST MEDICAL HISTORY:  Other histories include labile blood pressure, hyperlipidemia, reflux esophagitis.

OBJECTIVE:  On examination, his vital signs include blood pressure of 122/84, pulse 82, respirations 18, weight is 240. HEENT:  Sclerae anicteric. Neck was supple. Lungs:  Clear. Heart:  Regular rhythm. No gallop or ectopy. Carotids had no bruits. Abdomen:  Soft, distended. He had a healing midline scar going from the entire midline. He had some mild eschars coming off without signs of infection or drainage. Extremities:  No edema, cyanosis or clubbing. Pedal pulses were intact. Neurologically, he was nonfocal.

ASSESSMENT AND PLAN:  The patient is recovering from extensive colorectal surgery with the lower terminal ileum. He is having some postoperative diarrhea, which is to be expected at this time. We can check to see if his CBC, liver profile, albumin are recovered.

His list of medications are aspirin 81 mg a day, he takes B12 1000 mcg monthly intramuscularly. He is going to be restarting his Humira after he has healed from his surgery. He is taking loperamide, which is Imodium 2 tablet 4 times a day for diarrhea. Takes a multivitamin daily, Protonix 40 mg daily. He had been on Welchol, but this has been held and he is now on Metamucil 2 tablets once daily.

We will see him back in 2-3 months. He will call sooner if any problems.

Bloody Diarrhea Transcription Consultation Sample Report

REASON FOR CONSULTATION:  Bloody diarrhea for about 10 days.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old female who presented to the emergency room with 10 days of bloody diarrhea.  She had been given Augmentin 875 mg for a total of 10-day course for presumed infection of her foot and pain about 2-1/2 weeks ago.

She had no problems with GI symptoms until 7 days later, when she began to have bloody diarrhea, not having severe abdominal cramping prior to the passage of small volume or frankly bloody stools about 8-10 times per day.

She denies fever, but she has chills and nausea.  No vomiting but decreased appetite, minimal weight loss, diffuse abdominal tenderness throughout the day with left residual weakness and dry mouth which has gotten better as the days go on with IV dehydration.

No neck pain, rash, anal lesion or heartburn.  She does complain of rectal soreness.  The patient had recent C. diff that was negative.

PAST MEDICAL HISTORY:  Ulcerative proctosigmoiditis.  She had a flare in January after being given Avelox.  The patient had a colonoscopy at that time that showed evidence for pseudomembrane.  Type 2 diabetes, hypertension and increased cholesterol.

Her first episode of ulcerative proctitis was 11 years ago.  Colonoscopy was performed.  Most recent colonoscopy was done by myself 9 months ago that showed colitis in the anal verge at 20 cm with loss of vascularity, increased erythema, exudate and friability.  For 20 to 30 cm, the mucosa was normal, for 30 cm into the right colon there was evidence of colitis and multiple pseudomembranes.  The plan was to perform a colonoscopy when she was not having a flare, so as to document the extent of her ulcerative colitis to determine the frequency of colonic evaluations in the future.

She canceled that because she had just started a new job 3 weeks prior.

PAST SURGICAL HISTORY:  Cholecystectomy and carpal tunnel surgery.

SOCIAL HISTORY:  Cigarette smoking.  Alcohol:  None.

FAMILY HISTORY:  Cousin has Crohn's disease.

MEDICATIONS:  Prior to coming to the hospital; Crestor, lisinopril and Glucophage.

ALLERGIES:  NONSTEROIDAL, CODEINE, QUINOLONES.

MEDICATIONS:  Phenergan.

PHYSICAL EXAMINATION:
VITAL SIGNS:  Temperature 97.2, pulse 104, respiratory rate 20, blood pressure 128/84.
LUNGS:  Clear.
HEART:  Unremarkable.
ABDOMEN:  Soft.  There is diffuse periumbilical tenderness, more on the left lower quadrant than the right lower quadrant.  Positive bowel sounds.  Nondistended.

LABORATORY AND X-RAY DATA:  White count 7.8, hemoglobin 13.6, hematocrit 39.8, MCV of 83.8, platelet count 306,000, calcium 8.9. PT 13.4 with an INR 1.18.  Serum sodium 138, potassium 3.7, chloride 102, CO2 of 27.8, BUN 4, creatinine 0.7, glucose 190.  Urinalysis is pending.  Stool studies, culture and stain are pending.

DIAGNOSIS:  The patient is a (XX)-year-old female with history of ulcerative proctosigmoiditis who presents with bloody diarrhea.

DIFFERENTIAL DIAGNOSES:
1.  Recurrence pseudomembranous colitis.
2.  There is an entity called ampicillin/ampicillin derivative colitis that can present with hemorrhagic colitis. It is more typically in the right colon than left colon, and it gets better with the resolution of taking antibiotic.  This also has been reported with cephalosporin.
3. Infectious colitis.
4. Less likely that of flare of ulcerative proctosigmoiditis.

PLAN:
1. The plan is to repeat C. diff.
2. IV fluids.
3. The patient is scheduled for CT of the abdomen and pelvis.
4. If the C. diff is positive, we do not think any further GI evaluation is required except to treat her positive C. diff.  If her C. diff is negative, then we would recommend sigmoidoscopy with just tap water enema prior to this.  This was discussed in detail with the patient.

Thank you very much for allowing us to participate in this interesting consultation.