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Demographic history detail

Collected data for the systematic literature review
“Data Collection Variation in Preoperative Assessment”
Leila Ahmadian, Ronald Cornet, Wilton A van Klei, Nicolette F. De Keizer Department of Medical Informatics Corresponding Author: L.ahmadian@amc.uva.nl Date: July 21, 2008 Version 1.0 Page count: 16 Introduction
This technical report contains collected data from a systematic review with the objective to
identify data collected in the preoperative assessment. Extracted data from included articles
in this review study is categorized into the 13 categories: demographic history detail;
functional finding; ; procedure behavior finding; past history of clinical finding; laboratory
test; diagnostic procedure; physical examination procedure; review of medication;
preoperative evaluation, anesthesia; family history; patient status observation and
administrative information.
Extracted preoperative assessment data from literature review
1. Demographic history detail
patient name sex age social security number assigned identification number height weight/BMI right handed or left handed occupation habits insurance coveragecultural and ethnic assessment 2. Functional finding
Difficulty in communication
- difficulty in speaking
- difficulty in hearing
- dialect (language barrier)
- difficulty in eyesight
emotional assessment
socioeconomic assessment
Functional Finding
- ability to walk up one flight of stairs without stopping/ exercise tolerance
- ability to perform daily activities
- ability to lie flat for at least one hour
- prosthesis
- physical impairment
3. Procedure
purpose of the operation/ diagnosis planned proceduresdate and time of surgery type of surgery(elective, emergency,.)site and side of surgery NPO status surgeons type of anesthesia expected anesthesia duration expected blood lossrisk of surgery/anesthesia 4. Behavior finding
cigarette smoking and use of tobaccoalcohol drinking illicit drugs signs of abuse and neglect 5. Past history of clinical finding
chief complaint
present illness
severity and stability of the conditions
general health status
prior treatment for the problem
past hospitalizations
- when
- transfer to ICU/being in ICU
- nosocomial status
endocrine diseases
- thyroid diseases
- diabetes
- prostate disease
- adrenal suppression/insufficiency
- Cushing’s syndrome
- Addison’s disease
- hyper/hyperparathyroidism
- hypoglycemia (low blood sugar)
GI diseases
- stomach problem
- abdominal mass
- constipation
- visceromegaly
- (hiatal) hernia
- peptic ulcer
- indigestion
- bowel problem
- emesis
- anorexia
- nausea
- motion sickness
- capped or loose teeth
- gastrointestinal reflex disease
liver diseases
- cirrhosis
- hepatitis
- jaundice
- alcohol/drug induced hepatic disease
- hepatic failure
- gallbladder or biliary tract disease
- abnormal liver function test
renal diseases
- kidney diseases
- bladder diseases
- cystitis
- infection
- stones
- failure
- polyuria/oliguria/anuria/ hematurai
- hyper uremic
- dialysis
- renal transplant
cardiovascular diseases
- coronary artery disease
- myocardial infarction
- hypertension/high blood pressure
- hypotention
- peripheral vascular disease
- vascular heart disease
- cerebral vascular disease
- chest pain or angina
- heart attack
- abnormal EKG
- heart murmur
- palpitation/ irregular heartbeat
- arrhythmias
- deep venous thrombosis
- venous thromboembolism
- phlebitis
- (congestive) heart failure/disease
- ischemic heart disease
- congenital heart diseases
- shock/ syncope
- valvular heart disease
-- stenosis
-- aortic or mitral regurgitation
-- (chronic) atrial fibrillation
-- aortic aneurysm
-- artificial heart valve
- cardiomegaly
- cor pulmonale
- dextrocardia
- systolic and diastolic ventricular disfunction
- use of pacemaker
blood disorders
- anemia
- polycythemia
- leukemia
- sickle cell disease
- clotting disorder or bleeding/ coagulation disorder
- transfusions
-- date
-- reactions or problems related to transfusion
- intravascular hemolysis
vitamin B12 deficiency
pulmonary diseases
- COPD
- airway obstruction
- respiratory tract infection
- lung disease
- respiratory failure
- shortness of breath (dyspnea)
- dyspnea on exertion
- paroxysmal nocturnal dyspnea
- emphysema
- bronchitis
- asthma
- abnormal chest X-ray
- chronic cough
- pneumonia
- atelectasis
- mediastinal or pulmonary masses
- trachea deviation
- pulmonary edema
psychiatric diseases
- dementia
- cognitive decline
- delirium
neurological diseases
- central nervous system diseases
- CNS tumor
- spinal cord injury disease
- (peripheral) neuropathy
- stroke
- transient ischemic attack
- seizures
- epilepsy or fits
- multiple sclerosis
- Parkinson’s disease
- dizziness
- migraines
- confusion
- convulsion
- blackout/ consciousness
- brain vascular disorders/aneurysms
- Increased ICP( intracranial pressure)
- use of brain stimulators
- chronic pain
- movement disease
-- tremor
musculoskeletal diseases
- myopathy
- Myasthenia gravis
- kyphoscoliosis
- scoliosis
- muscle weakness/disease
-- leg weakness
-- arm weakness
- neck problems
- back problems
- pain and stiffness in jaw
- arthritis (rheumatoid)
- osteoporosis
- systematic lupus erythematosus
- spondyloarthropathies
- broken bones
- bone diseases
- dystrophy
- artificial joint
allergies
- allergies to medications
- allergies to latex
- allergies to food
- allergy to cleansers
- allergy to adhesive or taped dressings
- other allergies
- kind of reactions
malignancy
- chemotherapy
- radiotherapy
infections
- sepsis
- HIV
- TB
- HSV (herpes simplex virus)
- prolonged antibiotic therapy
- carrier of contagious diseases
- rheumatic fever
metabolic diseases
- electrolyte acid-base imbalanced
- gout
- dehydration
- increased fluid overload/ fluid imbalance
- hyperlipidemia
- acute porphyria
autoimmune disease
- immunosuppression
Other conditions
- edema
- fatigue
- skin condition
- glaucoma
- ascites
- malnutrition
- connective tissue disorders
- down syndrome
- organ transplantation
- swollen ankle
surgical history
previous operations
- approximate dates of previous operations
- nose surgery
- neck surgery
- throat surgery
- history of high risk surgeries
- history of emergency surgeries
- prolonged surgical procedure
- CABG
- revascularization
- pneumonectomy
- thyroidectomy
surgical-related complications
6. Laboratory test
- hematology tests
- CBC
- WBC
- lymphocytes
- hemoglobin
- hematocrit
- MCH (mean corpuscular hemorrhage)
- MCV (mean corpuscular volume
- MCHC (mean corpuscular hemoglobin concentration)
- mean platelet volume
- chemistry profile
- pregnancy test or β-HCG
- coagulation profiles
-- platelets
-- PT
-- PTT
-- thrombin
- fibrinogen test
- bleed time
- thyroid tests
- liver function tests
-- transaminase (AST/ALT)
-- ALP(alkaline phosphatase)
-- bilirubin
- CPK (creatine phosphokinase)
- lactic dehydrogenase
- factors for likelihood of a blood transfusion
- ABG (arterial blood gases)
- electrolytes
-- Mg
-- Ca
-- PO4
-- K
-- Na
-- chloride
-- carbon dioxide
- hormone level
- HIV
- cholesterol
- drug levels
- toxicology tests
- renal function test
-- renal clearance time
-- BUN
-- creatinine
-- urinalysis
- urine culture
- albumine
- protein
- glucose
- other test
7. Diagnostic Procedure
- electrocardiogram - echocardiogram - cardiac stress test- pulmonary function test - chest X ray - other radiological tests - sonography - carotid duplex ultrasound 8. Physical examination procedure
abnormal findings
vital signs
- blood pressure
- pulse rate
- JVP
- respiratory rate
- temperature
- oxygen saturation
respiratory examination
- auscultation of the lung
-- wheezing
-- breath sounds
- cyanosis
- clubbing
- effort of breathing
- thoracic inspection
- palpation
- percussion
chest diameter
cardiovascular examination
- auscultation of the heart
-- murmurs
-- thrills or gallops
-- rhythm disturbances
-- volume overload
-- carotid bruit
-- s3
- palpitation or irregular of the pulses
- orthostatic hypotension
- peripheral circulation
- precordial inspection
- palpation
- percussion
- venous thromboembolism risk
renal examination
gastrointestinal examination
- abdominal examination
-- percussion
-- inspection
-- asculation
-- palpation
- liver evaluation
- bowel routine
- risk for ileus and constipation
- gum abscesses
psychological examination
- cognition examination
- determining fear and anxiety
neurological examination
- Alert, oriented, cooperative and awake
- central nervous system
- sensory examination
-- loss of hearing
-- loss of vision
-- loss of taste
musculoskeletal examination
- mobility status
- -range of motion in the neck, head, vertebrae, shoulders
- rheumatologic evaluation
integument examination
- existing tearing or shearing
- oxygenation and hydration
endocrine evaluation
metabolic conditions
hematologic evaluation
- petehciae
extremities examination
Other physical examination
- inspection for edema
- organomegaly
- visual examination of the planned incision site
- active infection
- nutritional assessment
- palpable masses
- eyelid closure
9. Review of medication
dose and how often use of medications
anticoagulant medications
- clopidogrel
- warfarin
- heparin
over-the-counter medications
- aspirin-containing medications
- nonsteroidal anti-inflammatory medications (NSAIDs)
herbal medications
- ginko biloba
- ginseng
- garlic
- St Johan's wort
- saw palmetto
- kava
- echinacea
- valerian
- ephedra
health/dietary supplements
- vitamin E
- fish oil
steroids and retinoid compounds
- isotretinoin
- corticosteroid
- prednisone
bronchodilators
- Theophylline
- inhalers
- asthma drugs
-- metered dose inhalers
cardiovascular drugs
- antihypertensive
- antiarrhythmic
- antianginal
- cardiac glycosides
- beta blocking agents
- ACE inhibitor
- HMG CoA reduction
- gemfibrozil
- digoxin(digitalis)
- diuretics
- dipyridamole
diabetic medication
- hypoglysemic agents
- metformin
- chloropropamide
- insulin
immunosuppressive agents
- glucocorticoids
- antineoplastic
endocrine drugs
- tyroid replacement
- estrogen
antianexity
- monoamine oxidase inhibitors
- antidepressants
gastrointestinal drugs drugs affected renal function anticonvulsant/anti-epileptic antiparkinson sedative narcotics/opioids hypnotics antibiotics (postoperative) analgesia psychotropes potassium supplement contraceptive non prescription medications drug averse effect recreational drugs 10. Preoperative evaluation, anaesthesia
anesthesia history
- anesthesia-related problem or complications
-- malignant hyperthermia
-- poorly controlled pain
-- persistent nausea and vomiting
airway examination
- Mallampati classification
- measurement of thyromental distance
- measurement of sternum-mental distance
- mouth opening
- tongue size
- narse examination
- mandibular space
- craniofacial abnormalities
- maxillofacial and airway trauma
- airway tumors, abscesses and soft tissue enlargement
- teeth and oropharynx examination
risk factors for difficult intubation
risk of aspiration
past history of difficult intubation
obesity
sleep apnea or snoring
need for post operative mechanical ventilation
potential for an adverse reaction to anesthesia
ASA class
anesthesia team/ name of anesthetist and performer of intubation
anesthesia duration
monitors
pain assessment
hypothermia assessment
hyperthermia assessment
11. Family history
surgical-related complications
anesthesia- related problems
- malignant hyperthermia
- pseudocholinesterase
deficiency
- allergy to succinylcholine
- postoperative nausea or vomiting
bleeding disorders
heart diseases
12. Patient status observation
do you need to take antibiotics before dental cleaning
pregnancy
- LMP
are your menstrual periods regular
birth control method
do you have your period
are you wearing a tampon
current menstrual cycle status
exposure to measles, mumps, chicken pox, or TB
are you ill now or were you recently ill with:
- cold
- chills
- flu
- (productive) cough
- fever
- acute tonsillitis
- gingivitis
- vomiting and diarrhea
- weight loss
visiting primary care doctor recently
co morbidities
do you have sensitive skin
blood donor
immunization status
13. Administrative information
family/ other support after surgery/ during hospitalization information about how to contact with family's patient after surgery documenting patient or family questions and concerns accompanied to hospital by information obtained from date of assessment number of days in hospital before surgery delays due to requests for additional tests name of referring doctor possibility for transfer to ICU additional consultations admitted to transfer from… cardiologist have you been in this hospital physical environment of patient home (stairs, throw rugs, bathroom) determining that patient or its family understand the proposed procedure Informed consent competency of patient before informed consent written permission to leave postoperative follow- up

Source: http://kik.amc.uva.nl/KIK/reports/TR2008-01.pdf

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