Preoperative Note

Complete Note
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History of Present Illness:

Surgeon:
Date Of Surgery:
Procedure:

Past Medical History:
Medical: Denies any chronic medical problems such as;
Diabetes mellitus-II. Hypertension. Coronary Artery Disease.
Surgery:
Medications:
Allergies: No known drug allergies.
Social Hx/Habits:
Tobacco: None.
Alcohol: None.

Review of Systems:
CV: Chest pain- not noted. Shortness of breath- not noted. Edema- not noted. DOE- not noted. Orthopnea- not noted.
GI: Abdominal pain- not noted. Nauseavomitingdiarrhea-not noted. Melena or hematochezia- not noted.
GU: Urgency-not noted. Frequency- not noted. Dysuria- not noted. Hematuria- not noted. Incontinence- not noted.
CNS: Headaches- no significant symptoms. Dizziness- not noted. Visual Changes- not noted.

Review of Studies:
EKG:
Labs:
Spirometry:

Physical Examination:
Weight: __ lbs. Blood Pressure: ______ mmHg. Temperature: __ F. Pulse: __ beats/min.
Resp.Rate: __ breaths/min. O2 Sat: __.
ENT: NCAT. Tympanic membranes: within normal limits. External Canals: within normal limits.
Oropharynx: moist, no lesions, clear. Eyes: PERRLA, Conjunctiva: normal.
Neck: Supple, no adenopathy, no jvd, no abnormal masses. Carotid pulses normal bilateral.
Chest: Within normal limits.
Cardiac: RRR, no rubs, no gallops.
Lungs: Breath Sounds normal, no crackles, no wheezing, no rhonchi.
Abd: Flat, soft, bowel sounds normal, no organomegaly, no tenderness.
Extr: Warm, no edema.
Skin: No rashes, no significant lesions.

Diagnoses:
Presently Clinically Stable for Scheduled Surgery. Avoidance of; Aspirin, Ibuprofen, Naproxen, and other NSAIDS 5-7 days prior to surgery. To call with any changes in present status

Discussion-Plan:
Labs: pending. EKG: pending.
Labs: No significant issues noted. EKG: NSR, no significant issues noted.

Labs reviewed, XXXX; Glucose within normal limits. Renal and LFTs within normal limits. Lytes within normal limits. PT, PTT within normal limits. CBC within normal limits.
UA within normal limits.
No contraindication to surgery based on present laboratory data.
[html]<hr>[/html][checkbox memo="display/hide references" name="footnotes" value=""][conditional field="footnotes" condition="(footnotes).is('')"][html]
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posted by: J Bordas
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History of Present Illness:

Surgeon:
Date Of Surgery:
Procedure:

Past Medical History:
Medical: Denies any chronic medical problems such as;
Diabetes mellitus-II. Hypertension. Coronary Artery Disease.
Surgery:
Medications:
Allergies: No known drug allergies.
Social Hx/Habits:
Tobacco: None.
Alcohol: None.

Review of Systems:
CV: Chest pain- not noted. Shortness of breath- not noted. Edema- not noted. DOE- not noted. Orthopnea- not noted.
GI: Abdominal pain- not noted. Nauseavomitingdiarrhea-not noted. Melena or hematochezia- not noted.
GU: Urgency-not noted. Frequency- not noted. Dysuria- not noted. Hematuria- not noted. Incontinence- not noted.
CNS: Headaches- no significant symptoms. Dizziness- not noted. Visual Changes- not noted.

Review of Studies:
EKG:
Labs:
Spirometry:

Physical Examination:
Weight: __ lbs. Blood Pressure: ______ mmHg. Temperature: __ F. Pulse: __ beats/min.
Resp.Rate: __ breaths/min. O2 Sat: __.
ENT: NCAT. Tympanic membranes: within normal limits. External Canals: within normal limits.
Oropharynx: moist, no lesions, clear. Eyes: PERRLA, Conjunctiva: normal.
Neck: Supple, no adenopathy, no jvd, no abnormal masses. Carotid pulses normal bilateral.
Chest: Within normal limits.
Cardiac: RRR, no rubs, no gallops.
Lungs: Breath Sounds normal, no crackles, no wheezing, no rhonchi.
Abd: Flat, soft, bowel sounds normal, no organomegaly, no tenderness.
Extr: Warm, no edema.
Skin: No rashes, no significant lesions.

Diagnoses:
Presently Clinically Stable for Scheduled Surgery. Avoidance of; Aspirin, Ibuprofen, Naproxen, and other NSAIDS 5-7 days prior to surgery. To call with any changes in present status

Discussion-Plan:
Labs: pending. EKG: pending.
Labs: No significant issues noted. EKG: NSR, no significant issues noted.

Labs reviewed, XXXX; Glucose within normal limits. Renal and LFTs within normal limits. Lytes within normal limits. PT, PTT within normal limits. CBC within normal limits.
UA within normal limits.
No contraindication to surgery based on present laboratory data.

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