_00650_anesthesia_eval - ANESTHESIA EVALUATION PROGRESS...

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Unformatted text preview: ANESTHESIA EVALUATION PROGRESS NOTES Previous Anesthetics: _____________________________ Surgical Diagnosis: _______________________________ Complications: ___________________________________ Proposed Procedure: ______________________________ Anesthesia difficulty within family: ___________________ Current Medications: ______________________________ _____________________________________________ ______________________________________________ Drug Allergies: ___________________________________ ______________________________________________ PAST MEDICAL HX: CNS: __________________________________________ Renal: _________________________________________ ______________________________________________ ______________________________________________ Hypertension ____________________________________ Endocrine: ______________________________________ Cardiovascular: __________________________________ ______________________________________________ ______________________________________________ Bleeding Disorder: ________________________________ Pulmonary: _____________________________________ Anticoagulants: __________________________________ ______________________________________________ Previous Transfusions: _____________________________ Hepatic: ________________________________________ Sickle Cell Disease: ______________________________ GI: ____________________________________________ Other: __________________________________________ PHYSICAL EXAMINATION: Head & Neck Mobility: _____________________________ Airway: _________________________________________ Oral / Dental Issues: ______________________________ Lungs: _________________________________________ Heart: _________________________________________ AGE: _______ SEX: _______ HT.: _______ WT.: _______ B.P.: _______ TEMP.: _______ PULSE: _______ RESP.: _______ RA SpO2: ______ LAB: ____________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ Chest X-Ray: ____________________________________ ASA Physical Status: Class 1 2 3 4 5 EKG: ___________________________________________ E PLAN OF ANESTHESIA: ____________________________________________________________________________ ________________________________________________________________________________________________ Explained to Pt. (parents): No Yes _____________________________________________________________ Discussion of Risks / Alternatives & Complications of Anesthesia to Pt. (parents): No Yes _________________ ________________________________________________________________________________________________ DATE: TIME: _________________ SIGNATURE: ____________________________________ POST-ANESTHESIA COURSE: Satisfactory: Yes No Complications – specify: ___________________________________________________ Comments / Follow-up: ______________________________________________________________________________ DATE: TIME: _________________ SIGNATURE: ____________________________________ Patient Identification Sutter Medical Center, Sacramento A Sutter Health Affiliate Anesthesia Evaluation 00650 (7/6/06) PROGRESS NOTES ...
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This note was uploaded on 12/26/2009 for the course PHYS 341 taught by Professor Mavromatis during the Spring '09 term at American University of Beirut.

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