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CP# CP Eval: Covid RT-PCR: CC

The document is a pre-operative evaluation sheet from De La Salle University Medical Center's Department of Anesthesiology, detailing patient assessments, medical history, and anesthetic plans. It includes sections for physical examination, diagnostics, and immediate post-operative notes, ensuring comprehensive patient evaluation before surgery. Additionally, it contains a screening form for COVID-19 symptoms and exposure history.

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Bhi-An Batobalonos
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104 views2 pages

CP# CP Eval: Covid RT-PCR: CC

The document is a pre-operative evaluation sheet from De La Salle University Medical Center's Department of Anesthesiology, detailing patient assessments, medical history, and anesthetic plans. It includes sections for physical examination, diagnostics, and immediate post-operative notes, ensuring comprehensive patient evaluation before surgery. Additionally, it contains a screening form for COVID-19 symptoms and exposure history.

Uploaded by

Bhi-An Batobalonos
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

DE LA SALLE UNIVERSITY MEDICAL CENTER CP#

DEPARTMENT OF ANESTHESIOLOGY  CP EVAL:


PRE-OPERATIVE EVALUATION SHEET  COVID RT-PCR:
 CC:
TELECONSULT
Name: Date: Hospital No:
Age: Sex: Address: Religion: Room:

Assessment:
Proposed Surgery:
ASA PS 1 2 3 4 5 E
Anesthetic Plans:
Blood: Crossmatched ( ) FWB ( / ) PRBC ( ) __________
Premedications
Standby ( ) FWB ( / ) PRBC ( ) __________
Blood Type/Rh:
Technique:
Previous Operation/Complication:
Unexplained anesthetic/surgical morbidity/mortality in the family:

Perianesthetic History:
Last Meal
 HPN HBP: UBP:  IHD  CHF ___________  Valvular ___________
CVS
 Arrhythmia  others:
Neuro  CVD  Seizures  Psych d/o  others:
 Asthma Last attack: __________ URTI: ___________  PTB  COPD _______
Respiratory
 Pneumonia others:
Endocrine  DM Thyroid Disorder: others:
Renal  Insufficiency  Failure  Dialysis  others:
GI/Hepatic   GERD  others
Metabolic/  Anemia __________  Coagulopathy __________  Pregnant _____________  Arthritis ____________________
Infection/Others  HIV  others
Heredofamilial
Allergy  Medicine:  Food:
Exercise
Habits  Smoking Pack years: Last smoke:  Drinking:
Medications

Physical Examination: BMI:


Vital Signs BP: PR: RR: Temp: Wt: Ht:
Head and Neck Adequate mouth opening and TMD, pink palp conjunctiva
Airway Good air entry Mallampati 1 2 3 4 Dentures: ( )
Chest & Lungs Clear breath sounds
Cardiac NRRR, (-) murmurs
Abdomen Soft, Non-tender
Extremities FEPP
Back/ Genital (-) deformities
Neurological GCS 15 5/5 Motor 5/5 100% Sensory 100%

5/5 5/5 100% 100%

Diagnostics
Hgb Hct PLT WBC BldType Rh FBS HbA1c
BUN Crea 66 Na 136 K 4 Ca Amylase ALT AST
Alb Uric acid A/G TP Chole TSH FT4 FT3
PT % Act INR APTT CT BT LDH
RPR HBsAg HIV TRIG HDL LDL VLDL Mg
URINALYSIS:
ECG:
2D-ECHO: EF %
RADIOGRAPHS:
UTZ

MRI:

CONSULTANTS: DR. SROD/ AROD (DR LOPEZ) RESIDENTS: Dr BATOBALONOS

April 20, 2017 QMS-ORC-F62-0


ANESTHESIA POST-OP NOTES

IMMEDIATE POST-OP NOTES (before discharge from recovery room)

____________ NO COMPLICATIONS OF ANESTHESIA IMMEDIATELY APPARENT

____________ PATIENT HAS RECOVERED FROM IMMEDIATE EFFECTS OF


ANESTHESIA AND MAY BE TRANSFERRED TO WARD

____________ OTHERS

_______________________ M. D. __________________ __________


Signed Date Time

FOLLOW-UP POST-OP NOTES (After discharge from recovery room, before discharge from hospital)

__________ NO APPARENT ANESTHESIA COMPLICATIONS

__________ OTHERS

_______________________ M. D. __________________ __________


Signed Date Time

OPD Patient Screening Form

In the past two weeks did the patient have any of the following: YES NO
1. Respiratory symptoms
 
A. Cough
B. Shortness of breath  
C. Colds  
D. Throat pain  
E. Anosmia  
F. Other respiratory symptoms (headache, muscle and joint pains, diarrhea, lack of taste)  
2. Fever more than 38°C  
3. History of COVID-19 infection  
4. Household member diagnosed with COVID-19  
5. Travel or Residence in an area reporting local transmission of COVID-19  
6. Contact or exposure to someone with recent travel to an area with local transmission of COVID-19  

April 20, 2017 QMS-ORC-F62-0

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