Duration
Quality
Severity
Location
Timing
Modifying


There is one or more chronic illnesses with severe exacerbation, progression, or side effects of treatment. Extensive review of prior extemal notes from each unique source was performed. Extensive review of the results of each unique test was performed. Decision making involving ordering of each unique test was performed. Decision making regarding procedures with patient was performed. If applicable, discussion regarding procedure risk factors was performed. All patients have a corresponding same sex chaperone present during the entire encounter.


May discharge from surgical perspective
Instructions:
-May shower. No jacuzzi or baths for 1 week.
-May clean wound with isopropyl alcohol.
-May have normal oral intake.
-May use acetaminophen or NSAIDS for pain. Avoid narcotics.
-Must ambulate.
-No heavy lifting over 50 lb for 2 weeks.
-408 358 4747 for follow up call / Dr. A. Bastidas


-Laparoscopic cholecystectomy possible open.
-Risks, benefits, options discussed and understood.
-Risks includes but not limited to bleeding, infection, common bile duct injury, hepatic duct injury, bowel injury, bleeding, abscess formation, adhesions, cystic duct leak, intra-abdominal abscess, conversion to open, infection, death, and other intra-abdominal pathologies. Long term complications include but not limited to bowel obstruction, fistulas, chronic pain, chronic numbness and reoccurrence of the gallstone.
-Risks of anesthesia include but not limited to myocardial infarct, pulmonary embolism, stroke, and death were explained to the patient.
-Despite above, patient opted for surgical intervention. Informed face to face consent was obtained and surgery was scheduled.


-Laparoscopic appendectomy possible open -Risks, benefits, options discussed and understood.
-Risks includes but not limited to bleeding, infection, organ / bowel injury, bleeding, abscess formation, adhesions, re-operation, intra-abdominal abscess, conversion to open, infection, death, and other intra-abdominal pathologies. Long term complications include but not limited to bowel obstruction, fistulas, chronic pain, chronic numbness and reoccurrence of the gallstone.
-Risks of anesthesia include but not limited to myocardial infarct, pulmonary embolism, stroke, and death were explained to the patient.
-Despite above, patient opted for surgical intervention. Informed face to face consent was obtained and surgery was scheduled.