High Risk Anaesthesia Clinic

Subjective: - Reason for Visit: [describe the primary reason for the patient's visit, including the type of assessment being conducted and the planned surgical procedure] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a concise sentence.) - History of Presenting Illness: [detail the patient's current symptoms, their impact on daily activities, and the progression of the condition necessitating the visit] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a paragraph of full sentences.) - Past Medical History: [list the patient's diagnosed medical conditions, including relevant details such as ejection fraction, specific vessel involvement, and management specialists] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a list of bullet points.) - Current Medications: [enumerate all medications the patient is currently taking, including those for specific conditions and any special monitoring requirements] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a list of bullet points.) - Social History: [describe the patient's living situation, support systems, daily self-care capabilities, assistance received, and any other relevant social factors affecting their health] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a paragraph of full sentences.) - Mobility and exercise tolerance; [describe the patient's exercise tolerance and convert them into metabolic equivalents or METS in terms of their exercise capacity] - Family History: [document any significant medical conditions present in the patient's immediate family members] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a concise sentence.) Review of Systems: - Cardiovascular: [document the presence or absence of cardiovascular symptoms such as chest pain, paroxysmal nocturnal dyspnoea, dyspnoea on exertion, orthopnoea, claudication, oedema, or palpitations] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a concise sentence.) - Respiratory: [document the presence or absence of respiratory symptoms such as breathlessness, cough, sputum production, wheezing, smoke exposure, or dyspnoea, including specific contexts where they occur] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a concise sentence.) - Gastrointestinal: [document the presence or absence of gastrointestinal symptoms such as nausea, vomiting, diarrhoea, constipation, abdominal pain, heartburn, anorexia, dysphagia, haematochezia, melaena, flatulence, or jaundice] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a concise sentence.) - Genitourinary: [document the presence or absence of genitourinary symptoms such as dysmenorrhoea, dysfunctional uterine bleeding, dyspareunia, dysuria, urinary frequency, haematuria, urinary incontinence, urgency, flank pain, or changes in urinary flow/hesitancy] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a concise sentence.) - Musculoskeletal: [document the presence or absence of musculoskeletal symptoms, specifically focusing on pain and its impact on mobility] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a concise sentence.) - Neurological: [document the presence or absence of neurological symptoms such as weakness, numbness, paraesthesias, loss of consciousness, syncope, dizziness, headache, coordination changes, or recent falls] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a concise sentence.) -Fraility: [document an assessment fo fraility based on their musculoskeletal systems, mobility] Objective: Examination: - Oral cavity: [describe findings related to the oral cavity, including dental status and any observations relevant to anaesthetic assessment] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a concise sentence.) - Heart: [describe auscultatory findings related to the heart sounds] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a concise sentence.) - Lungs: [describe auscultatory findings related to the lung sounds] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a concise sentence.) - Vitals: [report vital signs, including blood pressure] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a concise sentence.) - [document findings related to jugular venous pressure and ankle oedema] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a concise sentence.) - Stair climb test: [describe the patient's performance and any observed symptoms during a stair climb test] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a concise sentence.) Investigations: - Blood tests (date not specified): - Haemoglobin: [report the haemoglobin level] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a concise sentence.) - White cells: [report the white blood cell count] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a concise sentence.) - Potassium: [report the potassium level] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a concise sentence.) - EGFR: [report the estimated glomerular filtration rate] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a concise sentence.) - ECG: [report the findings of the electrocardiogram] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a concise sentence.) Impression & Plan: 1. [planned surgical procedure]: - Risk of death with surgery: [state the estimated risk of death associated with the planned surgery] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a concise sentence.) - Risk of significant complication: [state the estimated risk of significant complications associated with the planned surgery] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a concise sentence.) - Potential complications: [list potential complications related to the surgery, including infection, cardiovascular events, respiratory issues, renal impairment, and deep vein thrombosis] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a list of bullet points.) - Treatment planned: [specify the planned surgical intervention] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a concise sentence.) - Recovery: [describe the expected recovery timeline and potential variations based on patient factors] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a concise sentence.) 2. Cardiac History: - Investigations planned: - [list specific blood tests planned for cardiac assessment] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a list of bullet points.) - [list specific imaging or diagnostic tests planned for cardiac assessment] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a list of bullet points.) - Relevant referrals: [document any planned referrals to specialists for cardiac evaluation] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a concise sentence.) 3. Renal Impairment: - Impression: [summarize the current status and any recent changes in renal function] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a concise sentence.) - Investigations planned: [list any further investigations planned to assess kidney function prior to surgery] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a concise sentence.) - Relevant referrals: [document any planned referrals to specialists for renal evaluation, including the specialist's name and reason for referral] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a concise sentence.) 4. [document discussed anaesthesia plan, with benefits, risks, alternatives, and risks, complications of the each technique as discussed] (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.)