Surgeon's note (custom)

Patient Details: Date of admission: 1 November 2024 Age in years: 68 Gender or sex: Male BHT number: 1234567 Presenting Complaint: Reason(s) for consultation, including specific surgical concerns or symptoms related to previous surgery: Patient presents with increasing abdominal pain and distension, concerning for possible bowel obstruction following previous colectomy. History of presenting complaint including duration, severity, aggravating/alleviating factors, associated symptoms, nature, previous treatments and responses: The patient reports worsening abdominal pain over the past week, described as intermittent, crampy, and rated 7/10 in severity. Pain is exacerbated by eating and relieved somewhat by lying down. Associated symptoms include nausea and vomiting. Previous colectomy performed 5 years ago for diverticular disease. Medical and Surgical History: Relevant past medical and surgical history, including hospitalisations and outcomes: Colectomy (2019) for diverticular disease. Hypertension, well-controlled with medication. No previous hospitalisations in the last year. Current medications including anticoagulants, pain medications, antibiotics: Amlodipine 5mg daily, paracetamol as needed for pain. Social history including smoking, alcohol use, and occupation: Smoker (10 cigarettes per day for 40 years), drinks alcohol occasionally, retired accountant. Allergies: Known allergies including drug, latex or material allergies relevant to surgical care: No known drug allergies. Examination: Vital signs including BP, HR, Temp, O2 sats etc.: BP 140/80 mmHg, HR 88 bpm, Temp 37.2°C, O2 sats 98% on room air. Physical examination findings, focusing on areas relevant to surgical assessment: Abdomen distended, tympanic to percussion. Bowel sounds are high-pitched and infrequent. Mild tenderness to palpation in the lower abdomen. System-specific examination (e.g. abdominal, cardiovascular, respiratory) relevant to the surgical issue: No other significant findings on cardiovascular or respiratory examination. Investigations: Completed investigations relevant to surgical assessment including imaging and labs with results and dates: Abdominal X-ray shows dilated loops of bowel with air-fluid levels. Blood tests pending. Assessment: Surgical issue or condition: Suspected small bowel obstruction secondary to adhesions. - Diagnosis and clinical reasoning based on findings: Clinical presentation and imaging findings are consistent with small bowel obstruction. Previous colectomy increases the risk of adhesions. - Differential diagnoses considered: Adhesions, recurrent diverticular disease, malignancy. - Investigations planned for diagnostic clarification or surgical planning: CT scan of the abdomen and pelvis with IV contrast. Operative Details and Management: Surgical procedure planned including type, expected outcomes, potential risks: Exploratory laparotomy with adhesiolysis. Expected outcomes include relief of obstruction. Potential risks include bleeding, infection, and injury to bowel. Pre-operative preparation including fasting, medications, or lifestyle instructions: NPO from midnight. IV fluids and antibiotics to be administered. Patient to be informed about the procedure and risks. Post-operative care including hospital stay, analgesia, wound care, and follow-up plan: Patient will be admitted to the surgical ward. Analgesia will be provided. Wound care instructions will be given. Follow-up appointment in 2 weeks. Referrals: Referrals to other services or specialties for multidisciplinary or follow-up care: N/A Additional Notes: Patient education and consent including discussion of procedure, risks, benefits and alternatives: Patient was informed about the procedure, risks, benefits, and alternatives. Informed consent obtained. Emergency instructions for post-operative complications or red flags: Contact the surgical team immediately if there is severe abdominal pain, fever, or signs of wound infection. Concerns raised by patient or family and responses provided: Patient expressed concern about the recovery period. Reassured that pain management will be provided. Condition at Discharge: Haemodynamic parameters at discharge and any post-operative complications relevant to surgery: Stable haemodynamic parameters. No post-operative complications. Discharge Plan: Discharge instructions, medications, wound care, follow-up appointments and return precautions: Wound care instructions provided. Medications: paracetamol and codeine for pain. Follow-up appointment in 2 weeks. Return to the hospital if there are any signs of infection or complications.