Anesthesia/Pre-Op Assessment

Nota preenchida

Date/Time: Preoperative visit

Patient Information: adult patient; weight, height, and BMI reviewed in chart.

Surgical Procedure:
- Elective laparoscopic cholecystectomy planned.

History of Present Illness:
Reports episodic right upper abdominal pain after meals over several months, with ultrasound showing gallstones. No current pain, fever, vomiting, or jaundice. Symptoms have led to avoiding some meals. No prior anesthesia complications reported. Review of systems is negative for exertional chest pain, dyspnea, or recent respiratory illness.

Past Medical History:
- Mild controlled hypertension.
- No prior surgery reported.

Medications:
- Amlodipine 5 mg orally daily.

Allergies:
- No known drug allergies (NKDA).

Airway Assessment:
- Mallampati II; mouth opening 4 cm; neck mobility normal; dentition intact.

Physical Examination:
- HR: 70 bpm, BP: 128/76 mmHg, RR: 14/min, T: 36.7 °C, SpO₂: 99%.
- Cardiovascular: Regular rhythm, no murmur.
- Respiratory: Clear bilaterally, normal effort.

Laboratory and Imaging Studies:
- Ultrasound: Gallstones without reported ductal dilation.
- Basic metabolic panel reviewed; no significant abnormality noted.

ASA Physical Status Classification:
ASA II due to controlled hypertension.

Anesthetic Plan:
General anesthesia with standard monitoring; airway and hemodynamic status to be reassessed on procedure day.

Consent:
Risks, benefits, and alternatives discussed; patient expresses understanding and agrees to proceed.

Plan for Postoperative Pain Management:
- Multimodal non-opioid analgesia as appropriate; rescue medication per recovery assessment.

Other Considerations:
- Routine perioperative antibiotic and VTE prophylaxis per surgical protocol.

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Pre-Op Assessment

Date/Time: [MM/DD/YYYY HH:MM]

Patient Information: [Name, age, sex, weight, height, BMI, medical record number]

Surgical Procedure:
- [Planned procedure, site/side, scheduled start time]

History of Present Illness:
(Begin with the chief complaint and duration. Then provide a chronological, problem-oriented narrative that focuses on the reason for consultation. Group related symptoms into coherent separate paragraphs rather than a single block of text. For each main problem or symptom cluster, explicitly address where available: onset, duration, tempo/progression, location and radiation, quality, severity, aggravating and relieving factors, associated symptoms, and key negatives. Include relevant baseline function, prior episodes, relevant past investigations or imaging, prior treatments and response, and any recent triggers. Comment on relevant risk factors for the presenting problem when available. Summarize functional impact where available.  End with a review of systems related to the presenting problem)

[Reason for surgery, onset and course of symptoms, prior interventions]

[Paragraph 2]

[Review of systems relevant to the speciality]

Past Medical History:
(hyphenated list)
- [Chronic condition]
- [Prior surgeries or hospitalizations]
- [Other relevant diagnoses]

Medications:
(hyphenated list)
- [Medication name, dose, route, frequency]
- [Herbal supplements or OTC agents]

Allergies:
(hyphenated list)
- [Allergen]: [Type of reaction]
- If none: No known drug allergies (NKDA)

Airway Assessment:
(hyphenated list)
- Mallampati score: [I–IV]
- Mouth opening (interincisor distance): [cm]
- Neck mobility: [normal/limited]
- Dentition: [normal/loose/missing]
- Other findings: [e.g., thyromental distance, beard]

Physical Examination:
(hyphenated list)
- Vital signs: HR: [ ], BP: [ ], RR: [ ], T: [ ], SpO₂: [%]
- Cardiovascular: [e.g., heart sounds, murmurs]
- Respiratory: [e.g., chest auscultation, effort]
- Other systems as relevant: [e.g., neurologic, gastrointestinal]

Laboratory and Imaging Studies:
(hyphenated list)
- [Test name]: [Result with date]
- [Imaging modality]: [Key finding with date]

ASA Physical Status Classification:
(in paragraphs)
- [Assigned ASA class (I–VI) and brief justification]

Anesthetic Plan:
(in paragraphs)
- [Choice of anesthesia technique (e.g., general, regional, MAC)]
- [Induction agents, maintenance agents, monitoring plan]
- [Special considerations (e.g., difficult airway, hemodynamic goals)]

Consent:
(in paragraphs)
- [Confirmation that anesthesia risks and alternatives were discussed and consent obtained]

Plan for Postoperative Pain Management:
(hyphenated list)
- [Opioid plan: agent, route, dosing]
- [Non-opioid adjuncts: NSAIDs, acetaminophen, regional blocks]
- [Patient-controlled analgesia if applicable]

Other Considerations:
(hyphenated list)
- [VTE prophylaxis: type and timing]
- [Antibiotic prophylaxis: agent and timing]
- [Positioning/equipment needs]
- [Consultations requested]