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IST Sample Book - Arab Health Version-low resolution


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NAME: KAREN CARPENTER AGE: 40 YEARS PHONE: 962628335 ID.: 44795938B REQUESTING DATE: 27/03/2014 DELIVERY DATE: 27/03/2014 SEX: F REQUEST NUMBER: 00112233 COMPANY: SUBLIME LTD DEPARTMENT: PRE-SURGERY HISTORY: 447959 REQUESTER: Dr. Hannibal Lecter CHAPTER NUMBER: A27777 ANESTHESIA REPORT 1.-MEDICAL HISTORY Drug allergies: No Previous transfusions: No Toxic habits: No Ulcus: No Other pathologies: Aosteoarthritis with glufan and calodis 2.-SURGICAL BACKGROUND With: Local anesthesia Locoregional anesthesia General anesthesia Previous interventions: Canal stenosis, cataracts, crural hernia, hysterectomy Complications: No 3.-PHYSICAL EXPLORATION Pulmonary auscultation: Good ventilation both fields. No added noises. Cardiac auscultation: Rhythmic tones, without murmurs or frictions. Degree of anxiety: leve / moderate / severe Mallanpati: I II III IV Oral opening > 3,5 Thyromentonian distance: > 6 Dental prosthesis mobile: Yes NO 4.-COMPLEMENTARY EXAMS E.K.G.: Sinus rhythm at 65 bpm. QRS at + 10º without specific alterations in repolarization. Analytics: within normality (attached) RX thorax: Bilateral and diffuse increase of the bronchointerstitial pattern of nonspecific character. Risk estimation ASA: I/II Final assessment by your anesthesiologist Signature: Dr Hannibal Lecter IST Medical Cullera, nº 73 - FERIA Building - 46100 VALENCIA (SPAIN) - Phone: +34 963 90 40 49 Fax: +34 96 394 32 02

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