Return Office Visit
Date Of Visit
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Physician:
Please Select
Ganesh Deshmukh MD
Adewunmi Adeyemo MD
Vishnu Pemmaraju MD
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for Visit
*
Current Medications
*
Topical Medications l
*
n/a
Analpram HC 2.5
Diltiazem Hydrocortisone cream 2%
Miconazole Hydrocortisone cream 2%
Calmoseptine
Previous Abdominal Surgery:
*
None
Other
Laparoscopic possible Hand Assisted right colectomy
Laparoscopic possible Hand assisted left colectomy
Robotic right colectomy
Robotic left colectomy
Robotic low anterior resection / possible loop ileostomy
Robotic APR
Robotic pelvic exenteration
Robotic Posterior pelvic exenteration
Robotic Total colectomy
Robotic Proctocolectomy IPAA / loop ileostomy
Robotic proctocolectomy / end ileostomy
Open right colectomy
Open left colectomy
Open LAR possible Loop Ileostomy
Open APR
Open pelvic exenteration
Open pelvic posterior exenteration
robotic rectopexy possible resection possible colpopexy with mesh (Strattice)
Previous Anorectal Surgery:
*
None
Hemorrhoidectomy
Fistulotomy possible Seton
Rectal advancement Flap
Lateral Internal sphincterotomy
I and D perirectal abscess
Sphincteroplasty
Repair of Rectocele with Mesh
Open transanal excision of rectal tumor
Robotic transanal excision of rectal tumor
Anorectal complaints:
*
none
hematochezia
Burning
itching
anorectal pain
protrusion
incontinence
incomplete defecation
Abdominal complaints:
*
none
abdominal pain
nausea
vomiting
constipation
diarrhea
bloating
Allergies:
*
none
penicillin
sulfas
tetracyclines
quinolones
ASA
narcotics
Systemic complaints:
*
Denies chest pain, shortness of breath, dyspnea on exertion, palpitations Respiratiory: Denies cough, hemoptysis, wheezing Neurological: Denies dizziness, weakness in face or trunk or extremities, weakness in face or trunk or extremities, loss of sensation Musculoskeletal and Extremities: Denies joint pains, joint swellings, claudication, rest pain
cough
chest pain
shortness of breath
palpitations
chest pain
joint pains
joint swelling
weakness
loss of sensation
Other surgery:
*
none
hysterectomy
cholecystectomy
gasterctomy
gastric bypass
splenectomy
pancreatic resection
liver resection
cystectomy
oophorectomy
other:
Height in inches
Weight in LBS
Last BP
HEENT
*
Abdominal Exam
Inspection:
Rows
Not distended no scars herniae visble organs or peristalsis or pulsations
Distended
Masses
Peristalsis
Hernia
scars
Liver Palpable
Spleen Palpable
Inspection
Palpation:
Rows
Soft non tender no masses, organomegaly, herniae, pulsations
Soft
Firm
Pulsations
Masses
Hernia
Tender CV angle
Palpation
Percussion:
Rows
Normal
Tympantic
Free Fluid
Percussion
Auscultation:
Rows
Bowel Sounds normal
Bowel sounds Hyperactive
Bowel Sounds Hypoactive
Bruits
Auscultation
Details of Abdominal Exam
*
Inspection: abdomen is not distended, there are no visible masses, peristalsis, pulsations, or hernias Palpation: the abdomen is soft and non tender, non distended, there are no masses, no abnormal pulsations, liver or spleen isnot palpable, there are no hernias, CV angles are not tender, spine is not tender Percussion/Auscultation: Normal tympany, no signs of free fluid, normal bowel sounds, no bruits.
as above
Other:
Details of Exam
GU exam
*
not examined
Normal GU/Pelvic exam
Testicular Mass
Abnormal Prostate exam
Small Rectocele
Moderate Rectocele
Large Rectocele
Rectovaginal Fistula
Cloacal Defect
Narrow perineum
Anorectal Exam:
Inspection:
*
Not examined
Normal anal margin, no mass /lesion
External hemorrhoids
Prolapsed Internal Hemorrhoids
Thrombosed External Hemorrhoid
Thrombosed Prolapsed Internal Hemorrhoids
Anal Fissure
Anal Fistula
Perirectal Abscess
Mucosal Prolapse
Full Thickness Rectal Prolapse
Anal Condylomas
Anal Cancer
Pruritis Ani Gr I
Pruritis Ani Gr II
Pruritis Ani Gr III
Anal Herpes
Candidiasis
Tinea Infection
Perianal Mass
Other findings:
Location:
Left Lateral
Right Lateral
Anterior Midline
Posterior Midline
Right Anterior
Left Anterior
Right Posterior
Left Posterior
Circumferential
Size of mass/ hemorrhoid/abscess in CM
Digital Exam:
*
not examined
Normal DRE, no Masses/ lesion
Anal Stenosis Mild
Anal Stenosis Severe
Patulous Anus
Presacral Mass
Abnormal Prostate
Sphincter Defect
Other findings:
Anal Tone:
*
Please Select
n/a
Normal
Poor
Fair
Anal Squeeze:
*
Please Select
n/a
Normal
Poor
Fair
Other Details Of Anorectal Exam:
Anoproctoscopy
*
Not performed
Normal Canal Minimal if any hemorrhoids
1st degree hemorrhoids
2nd degree hemorrhoids
3rd degree hemorrhoids
4th degree hemorrhoids
Inflamed anorectal mucosa
Rectal polyp
Rectal mass
Location:
Left Lateral Right Anterior Right Posterior
Left Lateral
Right Lateral
Anterior Midline
Posterior Midline
Right Anterior
Left Anterior
Right Posterior
Left Posterior
Circumferential
Sigmoidoscopy
Please Select
Not performed
Findings:
Details of Sigmoidoscopy
Please Select
Normal
Rectal Mass
Proctitis
Other:
Normal Exam to 25 cm
Insertion Distance 25 cm
Insertion distance 10-25 cm
Mass present
Proctosigmoiditis mild /moderate
Proctosigmoiditis severe
Rectal ulcer
Blood in lumen
Details of mass if present
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Systemic Exam:
Exam:
*
Normal Cardiovascular, respiratory musculoskeletal, Neurological and Endocrine exam
Cardiovascular Exam: normal apical beat, S1, S2, no gallop, no murmur
Respiratory Exam: normal air entry, no rales, ronchi, rub
Musculoskeletal Examination: No joint swelling, deformity, soft tissue nodules or masses, joint effusions, erythema nodosum
Neurological & Peripheral Vascular Exam: no new motor or sensory deficits, alert oriented X3
Endocrine: no thyroid swelling, normal lymph nodes, no carotid bruit, goitre
Exam normal except for following abnormalities:
Abnormal Findings:
Assessment/ Recommendations:
Diagnosis:
*
Medical management
*
None
Omeprazole
Prevacid
Protonix
Aciphex
Dexilant
Carafate
H2 Blocker
Apriso
Lialda
Asacol
Sulfasalazine
Prednisone
6MP
Azathioprine
Inflixamab
Humira
Stelara
Entyvio
Miralax
Cytotec
Amitiza
Motegrity
Linzess
Trulance
Fiber Supplement
Other medication or custom dose:
Custom Dosage or medications
Medications:
Topical Medications
*
n/a
Analpram HC 2.5
Diltiazem Hydrocortisone cream 2%
Miconazole Hydrocortisone cream 2%
Calmoseptine
Endoscopy:
*
None
Colonoscopy
EGD
EGD with dilatation
EGD with Halo
Colonoscopy with EUA in Endo
Colonoscopy with Balloon dilation
Colonoscopy with Stent placement
Flexible pouch endoscopy
EGD and Colonoscopy
Abdominal Surgery:
*
None
other
Laparoscopic possible Hand Assisted right colectomy
Laparoscopic possible Hand assisted left colectomy
Robotic right colectomy
Robotic left colectomy
Robotic low anterior resection / possible loop ileostomy
Robotic APR
Robotic pelvic exenteration
Robotic Posterior pelvic exenteration
Robotic Total colectomy
Robotic Proctocolectomy IPAA / loop ileostomy
Robotic proctocolectomy / end ileostomy
Open right colectomy
Open left colectomy
Open LAR possible Loop Ileostomy
Open APR
Open pelvic exenteration
Open pelvic posterior exenteration
robotic rectopexy possible resection possible colpopexy with mesh (Strattice)
Anorectal Surgery:
*
None
Hemorrhoidectomy
Fistulotomy possible Seton
Rectal advancement Flap
Lateral Internal sphincterotomy
I and D perirectal abscess
Sphincteroplasty
Repair of Rectocele with Mesh
Open transanal excision of rectal tumor
Robotic transanal excision of rectal tumor
Other surgery :
Office Procedure:
*
None
Using 1% xylocaine with epinephrine, the external hemorrhoid was excised, hemostasis was achieved
Using 1% xylocaine with epinephrine, the abscess was drained, with cruciate incision and skin edges excised to create 1.5 cm opening
Hemorrhoid rubber band ligation performed
Using 1% xylocaine local injection 3 cc the external hemorrhoid was excised and hemostasis was achieved, wound was left open and dressed.
Dietary Recommendations:
*
Regular diet
High Fiber
avoid insoluble fiber
avoid caffeine, nuts, carbonated beverages, alcohol
Lactose free diet
Gluten free diet
Dairy free diet
Liquid Diet
Tests Recommended:
*
None
Preop evaluation: CBC renal liver panel, glucose, PT, PTT, T&H CXR and EKG as indicated
Chest Xray
CT scan abd pelvis with contrast oral and iv
CT scan of chest with contrast
MRI abd pelvis
MRI liver protocol
MRI rectal Protocol
MRCP with contrast
PET scan
Defecating Proctogram
Colon transit study
Air contrast BE
Single contrast BE with water soluble contrast
Upper GI and small bowel study
6MP starting protocol TMPT enzyme assay CBC CMP
6MP maintenance protocol, 6TG 6MMP CBC CMP
USG abd and pelvis
CT enterography
MR Enterography
CT Angiography abdomen
CTA chest
Dupleix scan both Legs
Stool for C/S O/P fecal leukocytes
Stool fecal fat
Stool for C difficile toxin
H pylori Breath test
Medical Clearance required:
*
Please Select
n/a
yes
no
The above management plan including any surgical procedure(s) recommended was discussed with patient and family/legal guardian(s) and they were explained the risks and benefits of this plan and they have consented without exception
follow up
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number
days
weeks
months
next visit
ICD 10
*
CPT code
*
Please Select
99213
99214
99215
99203
99204
99205
Other CPT
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