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.
