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Surgery - Anesthesiology

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Common Causes of Post-Op Fever - the “5 W's” Mnemonic.

Morning Presentation

Example: “This is Mr. X who is post op day _ from a _. He complains of _. His vitals are _. His physical exam shows _. His diet is _. His meds are _. His iv fluids are _ and his urine output is _. His activity level is _. His active issues are _. The plan for Mr. X is _."

Tips:

  1. Streamlined and concise--not as much focus on FHx/SHx, only relevant PMH/PE
  2. Include post-op day and type of surgery (POD#0= day of surgery, POD#1=day after surgery)

Progress Note

ID – 73M POD 3 from R Hemicolectomy

Subjective - Past 12 hr events – (MI, transfusion, confusion, chest pain), Bowel fxn

Objective

PE Gen*

*may not necessarily have to present if focused rounds

(Labs, imaging and pathology presented in PM rounds)

A/P (Assessment and Plan): POD 3, doing well

Op Note

Sample Post-Op Orders

Post-Op Check

Pre-Operative Anesthetic Evaluation

Age / Sex / Indications and Procedure

Preoperative Assessment

Physical Exam

ASA Physical Classification 1-5
ASA 1 Patient with no systemic disease
ASA 2 Patient with mild systemic disease
ASA 3 Patient with severe systemic disease that limits activity
ASA 4 Patient with incapacitating disease that is a constant threat to life
ASA 5 Patient that is moribund and not expected to survive 24 hours
In the event of emergency surgery the letter E is added to the classification

Anesthetic Management Plan

General anesthesia vs. Regional anesthesia vs. MAC

Components

Induction agents

Maintenance agents

Emergent

Fluid management

Postoperative/PACU course

Pain management