DR. AKA'S PRE-OPERATATIVE CONSULTATION TEMPLATE

General
Chief cardiac diagnostic reason for consult
Physician who requested consult
Type of surgery planned

History
Characterize the history of present illness-
Location
Quality
Severity
Duration
Timing
Context
Modifying factors
Associated signs/symptoms 

OR status of chronic conditions

Past Medical History
Social History
Family History

ROS
(Questions asked of the patient)
Must have at least 10 systems or the reason that you are unable to obtain them

General 
fevers
sweats
weight change
energy level
exercise tolerance

Skin 
rashes
lumps
sores
itching
hair
nail changes
changing moles 

Head
headache
head injuries

Eyes
vision problems
glasses/contacts
pain
double vision
redness/inflamation

Ears
hearing
pain
tinnitus
vertigo
discharge

Nose/Sinuses 
stuffiness
discharge
bleeding
itching

Mouth/Throat
dentures
dental pain
sore throat
bleeding gums
tongue pain
voice change

Neck
pain/stiffness
lumps
swollen glands
thyroid problems
 
Breasts  
pain
lumps
discharge
self-examination
       
Respiratory 
cough
dyspnea
sputum(describe)
hemoptysis
wheezing
pleuritic chest pain
snoring
apnea
history of TB exposure
PPD
          
Cardiovascular      
chest pain
angina
hypertension  
PND
orthopne
heart murmurs
dyspnea
palpitations
claudication
leg cramp
history of DVT
peripheral edema
 
Gastrointestinal  
appetite
dysphagia
heartburn
abdominal pain
nausea
vomiting
hematemesis
jaundice
constipation
diarrhea
hemorrhoids
melena
rectal bleeding 
        
Urinary   
frequency
urgency
dysuria
hematuria
dribbling
hesitancy
incontinence
flank pain

Male Genital 
discharge
sores
testicular pain
testicular masses
hernias
sexual orientation
birth control
          
Female Genital  
menstrual history
dysmenorrheal
discharge
vaginal itching
sores- lumps
dyspareunia
sexual orientation
birth control method
         
Musculoskeletal   
joint or back pain
muscle aches
stiffness
swelling
deformity
locking of joints

Hematologic 
anemia
bleeding problems
easy bruisability
prior transfusions  
  
Endocrine 
thyroid disease
heat or cold intolerance
polyuria
polydipsia
diabetes
     
Psychiatric    
depression
sleep disturbance
suicidal ideation
nervousness
anxiety
hallucinations

Examination 
Vitals
Ht, Wt – (if available / by pt. report)
HR – (regularity)
RR – (labored?)
BP – (where/position)
Temp – (if taken)
Pulse Oximetry – (if available)
Pain – (on scale of 10)

General
Appearance, distress, behavior / cooperativity
Brief assessment of Mental Status – A & O x 3 (person, place, time)

Skin
Hair
Nails

HEENT
Head: [AT/NC (atraumatic, normocephalic), including TMJ, sensory and motor]
Eyes: (visual fields, EOMI, PERRLA, fundus)
Ears: (exterior, hearing, Weber, Rinne, TM)
Nose: (exterior, patency, septum, sinuses)
Throat & mouth: (palate elevation, tongue mobility, tonsils)

Neck
trachea
JVD
lymph nodes
thyroid
ROM
shoulder shrug
carotids

Thorax & Respiratory
Inspection: (expansion, symmetry, use of accessory muscles)
Palpation: (tenderness, tactile fremitus)
Percussion: (CVA tenderness, lungs, diaphragmatic excursion)
Ausculation: (breath sounds, voice sounds)

Cardiac
Inspection: (heaves / lifts)
Palpation: (thrills, PMI)
Percussion: (heart span)
Ausculation: [S1, S2, relative intensities, murmurs, rubs, gallops (m/r/g), friction rubs, clicks]

Peripheral vascular
varicose veins
pulses at carotid, radial, femoral, popliteal, posterior tibial, & dorsalis pedis arteries
capillary refill in fingers and toe
hair on toes
edema

Abdomen
Inspection: (surgical scars, distention)
Ausculation: (bowel sounds, bruits)
Percussion: (liver span, ascites)
Palpation: (tenderness, masses, organomegaly)
Short version: NT/ND, BS+ (non-tender, non-distended, bowel sounds present)

Musculoskeletal & Extremities
Inspection: [Movement of all extremities; cyanosis, clubbing, edema (c/c/e); muscle bulk; spinal curvature]
Palpation: [peripheral pulses (PPPx4), characterize edema, specific joint exams]
ROM: (active & passive)
Special testing: (specific joints examined)

Neurological
Mental Status Exam:
Cranial nerves: 2-12 grossly intact bilaterally (see HEENT).
Sensation: (light touch, vibration, position sense)
Motor: (bulk, tone, strength 5/5)
Deep tendon reflexes: (biceps, triceps, brachioradialis, knee, ankle 2/4, Babinski)
Cerebellar function: (posture, gait, Romberg, pronator drift, rapidly alternating tasks)

Results
Lab Results

Studies
Most recent EKG findings
Relevant previous EKG findings
                        X-rays
                        CT
                        Echo
                        Stress Test
                        Cardiac Cath results

Assessment & Plan
Cardiac risk assessment - Is patient an acceptable risk for the surgery?