H & P / DOCUMENTATION   describe co-morbidities, studies, current plan/meds

 

Names/Numbers of all subspecialty providers involved in patient’s care  

 

Cardiac:   CAD/HF:  recent symptoms, most recent studies (Echo, pharmacologic stress imaging, ecg), prior revascularization/stenting, diuretics/changes, if NOT on beta-blocker, reason Arrhythmias:  type, frequency, onset, pacemaker/AICD date, manufacturer and indication—dual vs. single chamber, Holter or other rhythm monitoring studies, AFib/flutter—if not on anticoagulation, reason  Valvular Disease:  Aortic stenosis, mitral regurgitation, last echo results, type of prosthetic valve (dates, anticoagulation?)

 

Neurologic: stroke, defects, treatment, cognitive impairment, decision making capacity, psych

 

Pulmonary:  new symptoms, OSA risk, treatment, most recent studies (PFTs, CXR, CT), baseline O2 saturation

 

DM: nephropathy, neuropathy, BG control / hypoglycemia risk, recent HgbA1c and med changes

 

Hematologic:  anemia, thrombocytopenia/leukopenia and other blood dyscrasias/ causes & workup, history of bleeding/clotting, transfusion reactions

 

Anesthesia:  any prior patient or family history of complications with anesthesia, provide records and dates

 

Steroid/ opiate use: doses, use in past year, risk for adrenal insufficiency, pain provider

 

CKD:  causes, baseline GFR/Cr, recent changes in meds, If ESRD/ dialysis schedule & type

 

Rheum:  stability of disease/flares, immunosuppressive regimen, rheum recs

 

Anticoagulation/antiplatelet use:  Indication, duration, history of DVT, CVA, PE—dates & prior treatment

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When to Refer    Most consults indicated only for intermediate risk surgery (TJA, NOT scopes)

 

Anticoagulation         Contact local anticoag provider for patients taking DOACs, warfarin, heparin products prior to surgery for guidance on preoperative bridging and risk of withholding anticoagulation in the perioperative period.  If on anticoagulation/antiplatelet through cardiology or neurology, these services must make decisions about safety of holding such agents

 

Cardiology      Complex cardiac history (severe AS/CHF/CAD, refractory arrhythmias), pulmonary hypertension, recent procedures (stent, CABG) and/or new or progressive symptoms of ischemia or heart failure, management of antiplatelet/anticoag prescribed by cardiologist   NOT REQUIRED FOR ROUTINE ‘CARDIAC CLEARANCE’

 

Heme  If patient has VTE or other complicated bleeding / clotting history  (SFVA Anticoag/ Thrombosis service may be consulted ONLY for patients with primary care through San Francisco VA & CBOC)

 

GI/Liver  Inflammatory bowel disease requiring chronic immunosuppression, cirrhosis requiring diuretics, or with prior hepatic encephalopathy, GI bleed, SBP, impaired renal function

 

Nephrology     CKD 1-3 if progression in past 6 months, CKD >4, ESRD on PD/HD        

 

Pulmonology  Severe pulmonary disease (COPD, IPF, ILD, severe persistent asthma, pulm HTN) or new/progressive symptoms in previously stable pulmonary disease.  High risk OSA (STOP-BANG > 5) for sleep study/Bipap, Rarely are new pulm studies (PFTs, CXR, CT chest) indicated as part of a preoperative evaluation

 

Rheumatology  Any patient managed by this service for autoimmune inflammatory disease and on chronic immunosuppression should have input regarding periop medication management, risk for disease progression