Anesthesia Post OP orders -To pain -O2 inhalation via __ with 5-6 Lpm -monitor vsq 15min and

record ____ stable -(NPO) DAT once fully awake -regulate WF: PLR x 30atb / min -IVFTF: PLR 1L x 30atb / min x 3 cycles Meds: -Tramadol 100mg SIVP q8 x 3 doses -Paracetamol 300 mg TIV q6 x 4 doses -Ranitidine 50mg TIV q8 while on NPO -Moderate high back rest -Keep warm & comfortable -Advise deep breathing exercises -Refer Add: -Add med. - Continue Tranexamic Acid 500mg TIV q8 for 6 more doses - Hyanocortisone 100mg TIV q8 x 9 doses - Coanoxicane 625 mg/cap TID PO -Refer 1/10/13 7AM -DAT -IVF: none for now -For total thyroidectomy/GA -Secure 1 ______ properly typed and crosswatched -Secure ___ -Refer ANESTHESIA PRE OP ORDERS 1:45PM -NPO post midnight -Hook IVF: PLR 1L x 30 ____/min Med: - Diphenhydramine 50 mg TIV 30mm prior to OR - Ranitidine 50 mg TIV q8 while on NPO - Tranexamic Acid 1gm TIV at midnight PRN o 500mg TIV q8 x 3doses 5 - V q4, I & O qshift

Please secure prescribed medications for OR use Fair ____ cardiac monitor rental For rpt TSH,FT4 For endo clearance Secure 1 unit of PRBC properly typed & crosswatched o For possible OR use Please attach official CXN results Refer

1-10-13 5PM -DAT -IVF _________________ -For total Thyroidectomy (GA) -Serum -Serum Consent -Serum 1 with _____ properly typed and crosswatched _ 6:30PM - For total Thyroidectomy/GA tom, 2nd case - NPO after midnight - Awaiting endo clearance - Please retrieve official CXR result and incorporate to this chart - Full body hygiene prior to procedure - Refer

9:15pm IM ENDO STAT - Thank you for this referral - Patient referred for endo clearance prior to total thyroidectomy - Noted TSH, FT4 - No absolute contraindication to contemplated procedure - Refer

1/9/13 4:30PM -Admit patient in room 652E under the service of Dr. Malanyarn/Padre/Bautista/Lim -Please secure consent for this admission -DAT -Monitor I&D qshift record, monitor VS qshift and record

-IVF:none for now Diagnostics CBC with pH CXR CT, BT 12L-ECG -Therapeutics: none for now -For total Thyroidectomy / GA Please inform service of this admission Complete database c/o 1st yr Head and Neck service rotator _PM DAT IVP none per now For total thyroidectomy / GA Secure consent for the admission Secure __IV B properly typed and and crosswatched Refer CARDIO-PULMONARY SURGICAL RISK ASSESSMENT FORM PATIENT INFORMATION NAME: BURAC, DOLORES AGE/SEX: 42/F DEPARTMENT:ENT WARD/ROOM:OPD CONTEMPLATED SURGICAL PROCEDURE: FOR TOTAL THYROIDECTOMY REVIEW OF SYSTEM: CHEST PAIN COUGH ANOREXIA FEVER EASY FATIGABILITY PALPITATION HEMOPTYSIS WEIGHT LOSS EDEMA BLEEDING TENDENCY DYSPNEA PND BODY WEAKNESS CLAUDICATION ORTHOPNEA PAST MEDICAL HISTORY ALLERGIES

PREVIOUS SURGERY/ANESTHESIA DM COPD ASTHMA PTB CAD/MI CVA HPN PERSONAL/SOCIAL HISTORY NON-SMOKER -EX-SMOKER NON ALCOHOLIC -FORMER ALCOHOLIC -ALCOHOLIC -ILLICIT DRUG USE CURRENT MEDICATIONS ASPIRIN OTHERS WARFARIN OTHER ANTI COAGULANT INSULIN ORAL HYPOGLYCEMIC ANTI HYPERTENSIVE STEROIDS PHYSICAL EXAMINATION BP= 100/70 HR=72 RR=20 T=____ WEIGHT= GENERAL SURVEY: AWAKE, ORDER CHEST HEENT: PARTS____ CHEST/LUNGS:_____ CVS:______ ABDOMEN: FLOBBY SOFT WATER EXTREMETIES: GOOD AD EQUAL PULSES NEUROLOGICAL: EDEMA SUMMARY OR CARDIO PULMONARY RISK ASSESSMENT [ ]LOW RISK [/] MODERATE RISK [ ] HIGH RISK THANK YOU FOR THIS REFERRAL PLEASE PROVIDE ADEQUATE HYDRATION, OXYGENATION, AND ANALGESIA PLEASE HOOK TO PULSE OXYMETER AND O2 SAT SHOULD BE >95% WE WILL INFORM OUR CONSULTANT REGARDING THIS REFERRAL

RESULTS: CBC 39 CREATININE NA 139 K 4.1 FBS 4.5 CXR O 12 LEAD ECG

66

sr nsttw - o

PT4 95 (N) TSH 0.2657(ARROW DOWN)

OPERATING ROOM RECORD SERVICE CONSULTANT: DR.MALANYAON SURGEON: DR.CARINO ANESTHESIOLOGIST: DR. ABAD SCRUB NURSE: R.ESTONACTOC FIRST ASSISTANT: DR. PADRE ANESTHESIA: General Anesthesia CIRCULATING NURSE: D.S YODICO ANESTHESIOGIST: DR.VICTORINERO SECOND ASSISTANT: DR.LIGOLA DURATION OF ANESTHESIA: 7:3A-2: 50P DURATION OF OPERATION: 8:10A-2: 40P PREOPERATIVE DIAGNOSIS: MULTILOBULAR NODULAR GOITER BILATERAL; COLLOD GOITER BY FNAB POST-OPERATIVE DIAGNOSIS SAME OPERATION: TOTAL THYROIDECTOMY/ GA SPECIMEN: LEFT& RIGHT THYROID LOBES; THYROID ISTHMUS

ANESTESIA AGENTS, MEDICATION AND SUPPLIES USE OF CATHETER CORX PLATE ASEPTO YANKAUEK B.ILBUB PREP-FUU LIDOAINE EPINEPHRINE BLADE-II