PRE-OPERATIVE SURGERY/ANESTHESIA HISTORY & PHYSICAL TEMPLATE

This is the history and physical template that Puget Sound uses. It is
currently being converted to a dialog template format, that will look
and work better than the Ascii character template.

Name: PRE-OPERATIVE SURGERY/ANESTHESIA HISTORY & PHYSICAL TEMPLATE

Abbreviation:

Print Name: PRE-OPERATIVE SURGERY/ANESTHESIA HISTORY & PHYSICAL

TEMPLATE

Type: TITLE

National

Standard: NO

Status: INACTIVE

Owner: CLINICAL COORDINATOR

In Use: YES

PATIENT AGE: \|PATIENT AGE\| GENDER: \|SEX\|

PLANNED PROCEDURE (& SIDE):

PLANNED PROCEDURE DATE:

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HISTORY

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CHIEF COMPLAINT:

HISTORY OF PRESENT ILLNESS:

RELEVANT PAST HOSPITALIZATIONS/SURGERIES:

RELEVANT PAST AND SOCIAL HISTORY:

\|RELIGION\|

PAST ANESTHETIC PROBLEMS AND PERTINENT FAMILY HISTORY:

CARDIOVASCULAR

\~\~\~\~\~\~\~\~\~\~\~\~\~\~

\[\] Angina within past 1 month

\[\] MI within past 6 month

\[\] CHF within past 1 month

\[\] Valvular disease

\[\] Previous PTCA

\[\] Previous operation with CPB

\[\] Pacemaker/AICD

\[\] Revascularization/amputation for PVD

\[\] Leg rest pain/gangrene

\[\] Absent peripheral pulses

\[\] Hypertension requiring meds

\[\] None of the above cardiovascular conditions apply

Cardiac Studies (Other than ECG):

PULMONARY

\~\~\~\~\~\~\~\~\~

\[\] Cigarette smoker within last 1 year, pack-years:

\[\] History of severe COPD

\[\] Dyspneic with minimal exertion

\[\] Dyspneic at rest

\[\] Current pneumonia

\[\] Asthma

\[\] CO2 Retainer

\[\] Steroid Dependent

\[\] Home O2

\[\] Ventilator dependent \> 48 hrs

\[\] Sleep apnea

\[\] Pulmonary hypertension

\[\] None of the above pulmonary conditions apply

Pulmonary Studies:

NEUROLOGIC:

\~\~\~\~\~\~\~\~\~\~

\[\] Impaired sensorium

\[\] Severe head trauma

\[\] Coma

\[\] Quadriplegia

\[\] Paraplegia

\[\] Hemiplegia

\[\] Transient ischemic attack (deficit \< 30 min)

\[\] CVA without current neuro deficit (deficit \> 30 min but resolved)

\[\] Neuromusc degenerative disease

\[\] Tumor involving CNS

\[\] Seizure disorder

\[\] None of the above neurologic conditions apply

Neuro studies:

OTHER SYSTEMS

\~\~\~\~\~\~\~\~\~\~\~\~\~

\[\] Hepatic Disease

\[\] Hepatomegaly \[\] Active hepatitis

\[\] Esophageal varices \[\] Ascites

\[\] Renal Disease

\[\] Acute renal failure \[\] Currently on dialysis

\[\] Diabetes:

\[\] Metformin \[\] Other oral hypoglycemic \[\] Insulin

\[\] EtOH -more than 2 drinks per day within last 2 weeks

\[\] Drug abuse

\[\] GE reflux

\[\] Nausea

\[\] Vomiting

\[\] Difficulty chewing

\[\] Difficulty swallowing

\[\] Modified diet:

\[\] 10% weight loss last 6 months or 5% in one month

\[\] Disseminated cancer

\[\] Chemotherapy for malignancy within 30 days

\[\] Radiotherapy for malignancy within 90 days

\[\] Bleeding disorder

\[\] Transfusion \> 4 RBC this admission

\[\] Number of operations this admission

\[\] Open wound

\[\] Preoperative sepsis

\[\] None of the above conditions apply

Functional Status:

\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~

\[\] Independent

\[\] Partially dependent

\[\] Totally dependent

Advanced Care Directives:

\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~

\[\] Advanced Care Directives on chart

\[\] DNAR orders within 30 days prior to surgery

MEDICATION HISTORY

\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~

MEDICATIONS: \|AMED\|

\[\] Chronic steroid use:

ALLERGIES/ADVERSE REACTIONS: \|ADR\|

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PHYSICAL EXAMINATION

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HEIGHT: \|HT\| WEIGHT: \|WT\|

TEMPERATURE: \|TEMPERATURE\| PULSE: \|PULS\|

BP: \|BP\|

GENERAL APPEARANCE AND MENTAL STATUS:

NORMAL NOT NORMAL COMMENTS:

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HEAD/NECK \[\] \[\]

AIRWAY \[\] \[\]

CARDIAC \[\] \[\]

LUNGS \[\] \[\]

ABDOMEN \[\] \[\]

EXTREMITIES \[\] \[\]

NEURO \[\] \[\]

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LABS & STUDIES

\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--

Hct: \|HCT\|

WBC: \|WBC\|

Platelets: \|PLT\|

PT: \|PRO TIME\|

PTT: \|PTT\|

INR: \|INR\|

Na: \|SODIUM\|

Cl: \|CHLORIDE\|

CR: \|CREATININE\|

BUN: \|BUN\|

Glucose: \|GLUC\|

K: \|POTASSIUM\|

HCO3: \|HCO3\|

CO2: \|CO2\|

ECG: Date:

CXR: Date:

Other: Date:

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ASSESSMENT/PLAN

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Problem 1:

Problem 2:

Problem 3:

Problem 4:

Problem 5: