Medications: please list doses, schedule (e.g. lisinopril 5 mg once daily)

 

Allergies: Medication, Latex, environmental

 

Family history: perioperative bleeding/clotting, or problems tolerating anesthesia.

 

Social history: tobacco, alcohol, illicit drugs, exercise tolerance.

 

Past Surgical History: surgery type, anesthesia provided (if known). Problems tolerating anesthesia or with bleeding/clotting?

 

Review of Systems: ability to climb 2 flights of steps or walk 4 blocks.

 

PMH:

Cardiac:  Please identify if any of the following are present, and if the condition is stable (controlled) versus unstable (not controlled):

Hypertension, coronary artery disease, valvular heart disease, congestive heart failure (systolic vs diastolic, NYHA Class I to IV, provide left ventricular ejection fraction)

Provide stress test or catheterization results if available.

 

Pulmonary: Asthma (note severity), COPD, other lung disease.  Provide functional status, ABG’s, PFT’s

 

Renal: Chronic kidney disease, dialysis history. History/risk of acute kidney injury.

 

GI: Inflammatory bowel disease (list type). Prior bariatric surgery (if lap band, is it deflated?).

Liver disease (list type and sequelae).  Peptic ulcer disease.

 

Hematologic:  Anemia (list Hb/Hct and therapy provided). Coagulopathy (list type and prior bleeding/clotting problems).

 

Endocrine: DM (list type, insulin use, and history of DKA or hyperosmolar syndrome).  Thyroid disease.

 

Cancer: Type, extent of disease, current physiologic effect on patient (from disease or ChemoRx).

 

Infections:   Site, organisms, Rx previously provided.

 

Neurologic: Type, symptoms, physiologic limits to pt.

 

Musculoskeletal/Rheumatologic: Type, steroid/immunosuppressant history, presence of cervical spine disease complicating intubation.

 

Psychiatric: depression, anxiety, substance abuse, medication/pain management issues.

 

Other: List problem and recommendations

 

Physical Exam: VS, heart, lungs, neurologic, other pertinent.

 

Data: Pertinent lab results and other studies

 

Impression: Is patient in his/her optimal medical condition for the scheduled surgery?  Yes or No

 

Recommendations:

Include all perioperative medication adjustments

List any changes recommended to optimize patient’s medical condition

List any recommended perioperative testing