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Patient History
Procedure Date:
Time:
Patient Name:
In Pt
FirstName LastName
Out Pt
dob:
MOBAPT
01-01-00 Phone:XXX-XXX-XXXX
Alt:
XXX-XXX-
XXXX— daughter
Procedure Scheduled: EGD/EUS/FNA
Reason:
Pancreatic Neoplasm on CT
History: EUS performed 5-15-8 revealed food in stomach. To repeat after two days of clear liquids with erythromycin
250mg one bid x 2 days. Chronic back pain with SOB. CT of chest 4-22-8 revealed mildly prominent right
paratracheal lymph node. Remaining lymph nodes in the hilar & mediastinal areas are densely calcified. A 9mm
hyperenhancing lesion in the body of the pancreas anteriorly raises possibility for endocrine neoplasm of pancreas.
Medical History
Acid Reflux
HTN
Depression
Vaginal basal cell ca
Arthritis in knees
Fibromyalgia
Migraines
CAD
Chronic granulomatous disease of
lung, liver & spleen
DJD spine
Surgical History
2 stents in heart placed 2007
Medications
Plavix 75mg one qd—last dose 5-12
Back Surgery after L4-L5 bar and
two screws and fused
Vaginal ca removed
TAH
Appendectomy
Tummy Tuck 1992
Liposuction Outer thighs 1990s
Prozac 40mg one qd
Tonsillectomy
ASA 81mg one qd
Clonazepam 2mg one hs
Trazadone 100mg two hs
Nitro Patch .2mg apply 6 am remove
8pm daily
Nexium 40mg one qd
Triamterene/HCTZ 37.5mg/25mg ½
qd
Atenolol 25mg one qd
Lipitor 10mg one qd
Allergies:
Sulfa—itches;
Blood thinners:
Plavix 75mg one qd—last dose 5-12-8
Are you experiencing any of the following? CP Y N—with overexertion SOB
cardiologist 1 month ago and “everything was alright”
Jaundice
Y
N
Fatigue
Y
N
Weight Loss
Easy Bleeding
Y
N
Y
N
Y
N—with exertion—saw
Fever
Easy Bruising
Y
Y
N
N
Do any of the following apply:
Hx MI
Y
Hx CVA
Hx Asthma
N date :2007__ Other Cardiac: (CABG, stents, pacemaker/defibrillator)
Y
N date: Residual__
Y
N
Discussed prep?
Y
Rev. 5/2007
Hx COPD
NNOTES:
Hx PE
Y
N
Y
Hx Diabetes
N yr____
Y
N
Completed by: cf Date: 5-5-8_
DVT
Y
Y/
N
N yr____
Hx Seizure Disorder
Y
N