Medical Clearance Form PDF

Medical Clearance Form PDF Date: 01 November 2024 Patient Name: [Sarah Johnson] Date of Birth: [15/03/1980] Reason for Clearance: [Pre-operative assessment for elective cholecystectomy] Referring Physician: [Dr. Emily White] Relevant Medical History: (Include a list of relevant medical history, focusing on conditions that may impact the reason for clearance) * Type 2 Diabetes Mellitus (diagnosed 2010), well-controlled with oral medications. * Hypertension (diagnosed 2015), controlled with daily medication. * Seasonal allergies (pollen, dust). * Previous appendectomy (2005) - uncomplicated recovery. Medications: (List all current medications, dosage, and frequency) * Metformin 500mg BID * Lisinopril 10mg OD * Cetirizine 10mg OD Allergies: (List all known allergies and reactions) * Penicillin (rash) * Codeine (nausea) Physical Examination Findings: (Provide a summary of pertinent physical examination findings relevant to the clearance) * General: Well-nourished, no acute distress. BMI 28. * Cardiovascular: Regular rate and rhythm, no murmurs, rubs, or gallops. Peripheral pulses palpable and symmetrical. * Respiratory: Clear to auscultation bilaterally, no wheezes or crackles. Good air entry. * Abdomen: Soft, non-tender, non-distended. No organomegaly. * Neurological: Alert and oriented x3. Cranial nerves intact. Motor and sensory intact. Relevant Diagnostic Test Results: (Summarise any relevant laboratory or imaging results) * Full Blood Count: WNL (White Blood Cells 7.2 x 10^9/L, Haemoglobin 13.8 g/dL, Platelets 280 x 10^9/L) * Electrolytes: WNL (Sodium 139 mmol/L, Potassium 4.1 mmol/L, Creatinine 78 µmol/L) * Liver Function Tests: WNL * HbA1c: 6.5% (consistent with well-controlled diabetes) * ECG: Normal sinus rhythm, no acute ischemic changes. Assessment and Recommendations: (Provide an overall assessment of the patient's fitness for the requested procedure/activity and any specific recommendations or precautions) * Overall Assessment: Ms. Johnson is a 44-year-old female with well-controlled Type 2 Diabetes and Hypertension, presenting for pre-operative clearance for an elective cholecystectomy. Her current medical status is stable, and she appears to be at low risk for cardiac or respiratory complications during surgery. * Recommendations: * Continue all current medications as prescribed. Diabetes medications should be managed peri-operatively as per anaesthetic protocol. * Anaesthesia consultation is recommended to discuss peri-operative glucose management. * No other specific medical contraindications to the proposed surgery identified at this time. * Patient is medically cleared for elective cholecystectomy. Cleared by: Dr. Marcus Thorne Internal Medicine Specialist Date of Clearance: [01 November 2024]