Patient: Surgeon: Room: Time: Length:

Surgery: Reason: Attending: Wt: Ht: BMI

Surgical Hx: PMH: Pulm: Neuro: Meds: (esp CV, insulin, anticoag)
CV:

Anesthesia Hx (PONV, MH, airway, FHx):

CXR

ECG GI/GU Endo/Other

ECHO
Exercise Tolerance

Allergies: (esp latex, iodine, shellfish)

Stress

T:
A:
D:

Physical Exam: Anesthetic Plan: (GETA, spinal, epidural, regional, MAC, bier block) ASA #
Mallampati: I II III IV
TM Distance: <3 FB >3 FB Preop
Neck ROM: Full Limited Premed anxiolytic (midazolam)
Dental: PPX (GI, b-blocker, bronchodilator, steroids)
CV: Possible problems + Solutions
Resp:
Neuro:

Intraop
Access (PIV, CVC)
Labs/Studies: Monitors (standard, a-line, TOF, CVC, BIS)
Regional
Induction (lido, fent, ppofol, roc, sux, keta, dexmed)
Airway (LMA, ET, Mac, Mil, glidescope, OGT)
Maintenance (sevo, dex, iso, N20, propofol, opioid)
Fluids:
Blood products:
Emergence (glyco/Neo vs sugamma; deep vs awake)

Postop
Pain (hydromorphone, IV Tylenol)
PONV (odanse, steroids)
Dispo (ICU, PACU, PTU, Home)