Requesting physician
Usually the surgeon, sometimes a PCP or specialist, or anesthesiologist
Consult for
Specific reason for or question for consultation
Chief complaint
Include the intended surgical procedure
Date of surgery
(If known)
PCP/active consultants
List here
HPI
A brief summary of the history as it pertains to the proposed surgery. As the surgical workup has already been completed by the surgery team, only the most important elements should be repeated in the medical preoperative HPI
Active and past medical problems
Focus on the ones for which advice has been requested (e.g., diabetes and hypertension) but be complete
Past surgical history and past surgical complications
Especially assess medical complications such as bleeding, thrombosis, infection, delirium, cardiovascular events, and respiratory problems
Drug sensitivities
Include type of reaction(s)
Medications
Include prescription, over-the-counter, and herbal preparations
Family history
Assess family history of problems with anesthesia, or bleeding/clotting disorders, in addition to the standard family history
Social history
Patient’s living situation and care network—especially important if there are postop complications requiring additional support after discharge
Habits
Smoking (see Chap. 27)
Alcohol (see Chap. 43)
Illicit/recreational drugs
Review of systems
See Table 3.2
Functional status and exercise tolerance
Independent, partially dependent, or dependent?
Performs own ADLs?
Number of blocks able to walk at a normal pace
Number of flights of stairs
Physical exam
See chapter text and Table 3.3
Studies
See chapter text and Table 3.4
Assessment
Include
• Problem list
• Risk assessment, including cardiopulmonary risks
Recommendations
Be specific (doses of drugs, etc.) and concise
Include preventative measures, e.g., VTE prophylaxis
Table 3.2
Preoperative review of systems (ROS)
Constitutional | Fevers, weight change (quantify), chills, night sweats, unexplained falls |
Eyes | Visual changes or impairment |
Ears/nose/mouth/throat | Sinus pain/pressure, hearing impairment, frequent nose bleeds, tooth pain |
Cardiovascular | Chest pain, orthopnea, PND, palpitations, edema, syncope or presyncope, claudication symptoms, history of CHF, CAD, valvular disorder, arrhythmia, murmur, hypertension |
Respiratory | Dyspnea (at rest and/or exertion), cough, wheeze, snoring/choking/gasping, witnessed apnea, daytime sleepiness/napping, history of COPD, asthma, OSA, other lung disease |
Gastrointestinal | Abdominal pain, difficulty swallowing, nausea/vomiting, diarrhea, constipation, heartburn/reflux, black or bloody bowel movements, abdominal swelling, history of liver disease, peptic ulcer disease, or other gastrointestinal disorders |
Genitourinary | Dysuria, hematuria, hesitancy, urgency, urinary retention or incontinence, first day of last menstrual period, contraception use (if relevant), vaginal/penile discharge, history of frequent UTIs, kidney disease |
Musculoskeletal | Joint or muscular pain, problems with mobility, history of arthritic or rheumatologic disease |
Skin | Rash, wound healing problems, sensitivities (e.g., tapes), skin color changes (jaundice, hyperpigmentation) |
Neurologic | Difficulty with balance/speech/memory/cognition, tremor, neuropathy, headache, history of seizures, cerebrovascular disease including TIA or CVA, chronic pain, history of delirium |
Psychiatric | Depression, anxiety, psychosis, insomnia |
Endocrine | Hot/cold intolerance, fatigue, dry skin, history of diabetes, thyroid disease, recent steroid use, orthostasis, flushing, polydipsia, polyuria |
Hematologic | Easy bruising or bleeding, history of anemia, excessive bleeding, use of anticoagulants, personal or family history of hemophilia or thromboembolic disease, blood transfusion preferences |
Allergic/immunologic | Environmental allergies, history of significant allergic response (dyspnea, wheezing, swelling, rash) to an exposure, including anaphylaxis
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