SURGICAL HISTORY AND PHYSICAL EXAMINATION Identifying Data: Patient's name, age, race, sex; referring physician.

Chief Complaint: Reason given by patient for seeking surgical care; place reason in "quotation marks." History of Present Illness (HPI): Describe the course of the patient's illness, including when it began, character of the symptoms; pain onset (gradual or rapid), precise character of pain (constant, intermittent); other factors associated with pain (defecation, urination, eating, strenuous activities); location where the symptoms began; aggravating or alleviating factors. Vomiting (characteristics, appearance, frequency, associated pain). Change in bowel habits; bleeding, character of blood, (clots, bright or dark red), trauma; recent weight loss or anorexia; other related diseases; past diagnostic testing. Past Medical History (PMH): Past diseases. All previous surgeries and indications; dates and types of procedures; serious injuries, hospitalizations; significant medical problems; history of diabetes, hypertension, peptic ulcer disease, asthma, myocardial infarction; hernia, gallstones. Medications: Allergies: Penicillin: Codeine? Family History: Medical problems in relatives. Family history of colonic polyposis, carcinomas, multiple endocrine neoplasia (MEN syndrome). Social History: Alcohol, smoking, drug usage. Review of Systems (ROS): General: Weight gain or loss; appetite loss, fever, fatigue, night sweats. Head: Headaches, seizures. Eyes: Visual changes, diplopia, eye pain. Mouth & Throat: Dental disease, hoarseness, sore throat, pain, masses. Respiratory: Cough, shortness of breath, sputum. Cardiovascular: Chest pain, orthopnea, dyspnea on exertion, claudication, extremity edema. Gastrointestinal: Dysphasia, abdominal pain, nausea, vomiting, hematemesis, melena (black tarry stools), hematochezia (bright red blood per rectum), constipation, bloody stool, change in bowel habit; hernia, hemorrhoids, gallstones. Genitourinary: Dysuria, frequency, hesitancy, hematuria, polyuria, discharge; impotence, prostate problems. Gynecological: Last menstrual period, breast masses.

Skin: Easy bruising, bleeding tendencies. Lymphatics: Lymphadenopathy.

SURGICAL PHYSICAL EXAMINATION Vital Signs: TPRBP, weight. Head, Eyes, Ears, Nose, Throat (HEENT): Eyes: Pupils equally round and react to light and accommodation (PERRLA): extraocular movements intact (EOMI); Neck: Jugular venous distention (JVD), thyromegaly, masses, bruits; lymph nodes. Chest: Equal expansion; rhonchi, crackles, breath sounds. Heart: Regular rate & rhythm (RRR), first & second heart sounds; murmurs (grade 1-6), pulses (graded 0-2+). Breast: Retractions, tenderness, lumps, nipple discharge, dimpling, gynecomastia; axillary nodes. Abdomen: contour (flat, scaphoid, obese, distended); scars, bowel sounds, tenderness, organomegaly, masses, liver span; splenomegaly, guarding, rebound, bruits; percussion note (tympanic), costovertebral angle tenderness (CVAT), inguinal masses. Genitourinary: External testicles, varicoceles. lesions, hernias, scrotum,

Extremities: Edema (grade 1-4+); cyanosis, clubbing, edema (CCE); pulses (radial ulnar, femoral, popliteal, posterior tibial, dorsalis pedis; simultaneous palpation of radial and femoral pulses), Homan's sign (dorsiflexion of foot elicits calf tenderness). Rectal Exam: Sphincter tone, masses, hemorrhoids, fissures; guaiac test for occult blood; prostate masses. Neurological: Mental status; gait, strength (graded 0-5); deep tendon reflexes. Labs: Electrolytes (sodium, potassium, bicarbonate, chloride, BUN, creatinine), CBC; X-rays, ECG (if older than 35 yrs or history of cardiovascular disease), urine analysis (UA), liver function tests, PT/PTT. Assessment (Impression): Assign a number to each problem and discuss each problem separately. Plan: Describe surgical plans including preoperative testing, laboratory studies, medications, antibiotics.

PROBLEM-ORIENTED PROGRESS NOTE Subjective: Write how the patient feels in the patient's own words; and give observations about the patient. Objective: Vital signs; physical exam for each system; thorough examination and description of wound. Condition of dressings; purulent drainage, granulation tissue, erythema; condition of sutures, dehiscence. Amount and color of drainage, laboratory data. Assessment: Evaluate each numbered problem separately.