Question
How Can I write history of patient with cholestomy
Answers
Answered by
GPT-4o mini
Writing a comprehensive history for a patient with a colostomy involves gathering information about the patient’s medical background, the reasons for the colostomy, and the current status of their health. Here’s a structured approach to writing a patient history:
### 1. Patient Identification
- **Name**: [Patient's Name]
- **Date of Birth**: [DOB]
- **Gender**: [Gender]
- **Medical Record Number**: [MRN]
- **Date of Admission/Visit**: [Date]
- **Referring Physician**: [Referring Doctor’s Name]
### 2. Chief Complaint
- Document the patient's primary concern or reason for the visit/referral, such as issues relating to the colostomy.
### 3. History of Present Illness
- Provide a detailed description of the events leading to the colostomy:
- **Indications for Colostomy**: Detail the underlying condition(s) (e.g., cancer, inflammatory bowel disease, trauma, congenital anomalies) that led to the creation of the colostomy.
- **Surgical Details**: Include the date of the procedure, type of colostomy performed (e.g., end colostomy, loop colostomy), and the surgeon's name.
- **Postoperative Complications**: Note any immediate complications such as infection, bowel obstruction, or leakage.
- **Current issues**: Document any problems with the stoma (irritation, stenosis) or issues with the colostomy bag (leakage, skin irritation).
### 4. Past Medical History
- Summarize relevant medical history:
- Previous surgeries (especially gastrointestinal or abdominal surgeries)
- Chronic diseases (e.g., diabetes, heart disease)
- Previous gastrointestinal issues (e.g., diverticulitis, ulcerative colitis).
### 5. Medications
- List current medications, including over-the-counter drugs and supplements:
- Dosage and frequency
- Any recent changes in medications.
### 6. Allergies
- Document any known allergies, especially to medications or materials related to colostomy care (e.g., adhesives).
### 7. Family History
- Note any family history of gastrointestinal diseases, cancers, or conditions that may be relevant.
### 8. Social History
- Include important social factors:
- Living situation (alone, with family)
- Occupational status (current job, retirement)
- Lifestyle factors (smoking, alcohol use, exercise habits)
- Social support (caregiver availability).
### 9. Review of Systems
- Conduct a comprehensive review of systems to assess any current symptoms related to various body systems not covered above.
### 10. Physical Exam
- Summarize findings from the physical examination:
- General appearance
- Exam of the abdomen (distension, tenderness)
- Inspection of the stoma and surrounding skin.
### 11. Assessment and Plan
- **Assessment**: A summary of the patient’s condition based on the history and exam findings.
- **Plan**: Recommendations for management, follow-up, and any necessary referrals (e.g., to a dietitian, wound care specialist, or surgeon).
### Example
**Patient Identification**:
- Name: John Doe
- Date of Birth: 01/01/1980
- Gender: Male
- Date of Visit: 10/10/2023
- Referring Physician: Dr. Smith
**Chief Complaint**:
- The patient reports skin irritation around the colostomy stoma.
**History of Present Illness**:
- John had an end colostomy performed on 01/15/2023 due to complications from diverticulitis. He reports that the skin around the stoma has become red and inflamed for the past week. He also mentions issues with leakage of the colostomy bag.
**Past Medical History**:
- Diverticulitis, Hypertension.
**Medications**:
- Lisinopril 10 mg daily, Metamucil as needed.
**Allergies**:
- Allergic to Penicillin.
**Family History**:
- Father had colon cancer; mother has hypertension.
**Social History**:
- Lives with spouse, works as an accountant, stops smoking 5 years ago.
**Review of Systems**:
- Denies significant weight loss, no blood in stool, and no abdominal pain.
**Physical Exam**:
- Mild erythema noted around the stoma, no signs of systemic infection.
**Assessment and Plan**:
- Skin irritation around stoma likely due to improper fitting of the colostomy bag.
- Plan to consult with a wound care specialist for management, recommend barrier creams, and reassess in two weeks.
### Conclusion
Keep the documentation clear, respectful, and patient-centered. Confidentiality is crucial so ensure the documentation adheres to HIPAA or relevant privacy regulations as applicable. This structure assists in forming a holistic view of the patient's situation and supports effective management.
### 1. Patient Identification
- **Name**: [Patient's Name]
- **Date of Birth**: [DOB]
- **Gender**: [Gender]
- **Medical Record Number**: [MRN]
- **Date of Admission/Visit**: [Date]
- **Referring Physician**: [Referring Doctor’s Name]
### 2. Chief Complaint
- Document the patient's primary concern or reason for the visit/referral, such as issues relating to the colostomy.
### 3. History of Present Illness
- Provide a detailed description of the events leading to the colostomy:
- **Indications for Colostomy**: Detail the underlying condition(s) (e.g., cancer, inflammatory bowel disease, trauma, congenital anomalies) that led to the creation of the colostomy.
- **Surgical Details**: Include the date of the procedure, type of colostomy performed (e.g., end colostomy, loop colostomy), and the surgeon's name.
- **Postoperative Complications**: Note any immediate complications such as infection, bowel obstruction, or leakage.
- **Current issues**: Document any problems with the stoma (irritation, stenosis) or issues with the colostomy bag (leakage, skin irritation).
### 4. Past Medical History
- Summarize relevant medical history:
- Previous surgeries (especially gastrointestinal or abdominal surgeries)
- Chronic diseases (e.g., diabetes, heart disease)
- Previous gastrointestinal issues (e.g., diverticulitis, ulcerative colitis).
### 5. Medications
- List current medications, including over-the-counter drugs and supplements:
- Dosage and frequency
- Any recent changes in medications.
### 6. Allergies
- Document any known allergies, especially to medications or materials related to colostomy care (e.g., adhesives).
### 7. Family History
- Note any family history of gastrointestinal diseases, cancers, or conditions that may be relevant.
### 8. Social History
- Include important social factors:
- Living situation (alone, with family)
- Occupational status (current job, retirement)
- Lifestyle factors (smoking, alcohol use, exercise habits)
- Social support (caregiver availability).
### 9. Review of Systems
- Conduct a comprehensive review of systems to assess any current symptoms related to various body systems not covered above.
### 10. Physical Exam
- Summarize findings from the physical examination:
- General appearance
- Exam of the abdomen (distension, tenderness)
- Inspection of the stoma and surrounding skin.
### 11. Assessment and Plan
- **Assessment**: A summary of the patient’s condition based on the history and exam findings.
- **Plan**: Recommendations for management, follow-up, and any necessary referrals (e.g., to a dietitian, wound care specialist, or surgeon).
### Example
**Patient Identification**:
- Name: John Doe
- Date of Birth: 01/01/1980
- Gender: Male
- Date of Visit: 10/10/2023
- Referring Physician: Dr. Smith
**Chief Complaint**:
- The patient reports skin irritation around the colostomy stoma.
**History of Present Illness**:
- John had an end colostomy performed on 01/15/2023 due to complications from diverticulitis. He reports that the skin around the stoma has become red and inflamed for the past week. He also mentions issues with leakage of the colostomy bag.
**Past Medical History**:
- Diverticulitis, Hypertension.
**Medications**:
- Lisinopril 10 mg daily, Metamucil as needed.
**Allergies**:
- Allergic to Penicillin.
**Family History**:
- Father had colon cancer; mother has hypertension.
**Social History**:
- Lives with spouse, works as an accountant, stops smoking 5 years ago.
**Review of Systems**:
- Denies significant weight loss, no blood in stool, and no abdominal pain.
**Physical Exam**:
- Mild erythema noted around the stoma, no signs of systemic infection.
**Assessment and Plan**:
- Skin irritation around stoma likely due to improper fitting of the colostomy bag.
- Plan to consult with a wound care specialist for management, recommend barrier creams, and reassess in two weeks.
### Conclusion
Keep the documentation clear, respectful, and patient-centered. Confidentiality is crucial so ensure the documentation adheres to HIPAA or relevant privacy regulations as applicable. This structure assists in forming a holistic view of the patient's situation and supports effective management.