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General Surgeon Template

Surgical Review

About this template

The Surgical Review template is a comprehensive documentation tool designed for general surgeons to efficiently capture patient information during surgical consultations. This template includes sections for presenting complaints, medical history, physical examination, and management plans, ensuring a thorough review of the patient's condition. It is ideal for documenting pre-operative assessments and post-operative follow-ups. This template is particularly useful for creating detailed surgical notes and improving clinical workflow.

Preview template

Patient Information: - John Doe - 45 - Male - 123456 Presenting Complaint: - Abdominal pain and bloating for the past two weeks. History of Presenting Complaint: - The patient reports a gradual onset of abdominal pain, which has been persistent and worsening over the last two weeks. The pain is described as a dull ache, primarily in the lower abdomen, and is associated with bloating and occasional nausea. Past Medical History: - Appendectomy in 2010, hypertension. Medications: - Lisinopril 10 mg daily, multivitamin. Allergies: - Penicillin (rash). Family History: - Father had colon cancer at age 60. Social History: - Works as an accountant, non-smoker, drinks alcohol socially, no recreational drug use. Review of Systems: - Positive for abdominal discomfort and bloating. Negative for fever, weight loss, or changes in bowel habits. Physical Examination: - Vital signs: BP 130/85, HR 78, Temp 98.6Β°F. General appearance: alert and oriented. Abdominal examination: mild tenderness in the lower quadrants, no rebound tenderness, normal bowel sounds. Investigations: - Ordered abdominal ultrasound and complete blood count. Impression: - Possible diverticulitis or other gastrointestinal pathology. Plan: - Start on a clear liquid diet, prescribe antibiotics (Ciprofloxacin and Metronidazole), and schedule a follow-up in one week. Educate the patient on signs of complications and when to seek immediate care.

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