Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
) ___________
Age: _________________
Sex: (Female/Male)
Weight: _________
Height: __________
Surgery: (Elective/Emergency)
Surgical diagnosis: (B/L advanced knee osteoarthritis/Left advanced knee osteoarthritis/Right knee
osteoarthritis/Left hip AVN/Right Hip AVN/Left hip osteoarthritis/Right knee osteoarthritis/Fracture
Right Neck of Femur/Fracture Left Neck of Femur/ Fracture Right IT of Femur/ Fracture Left IT of
Femur/Others:__________________)
Proposed Operation: (B/L Total Knee Replacement/Left Total Knee Replacement/Right Total Knee
Replacement/Left Total Hip Replacement/Right Total Hip Replacement/ Left DHS/Right DHS/ Left Bipolar
Hemiarthroplasty/Right Bipolar Hemiarthroplasty/Others :___________________)
Implants: (PFC, LCCK, and Zimmer LPS, Attune, J&J other: _________________________)
Co-morbid: (HTN/DM/CKD/HEP-B/HEP-C/
CVA/EPILEPSY/CA/RA/hypothyroidism/hyperthyroidism/Others: ____________)
Anti-hypertensives (YES/NO), Oral Hypoglycemic (YES/NO), Blood Thinners (YES/NO), Insulin (YES/NO),
Medicines: ______________
Allergy: ______________
Investigations:
CBC:
RBS:
FBS:
HBA1C:
Urea
Creatinine
Electrolytes
ECG:
Chest XRAY:
Hepatitis B: (Reactive/Non-Reactive)
Hepatitis C: (Reactive/Non-Reactive)
ECHO:
PT:
INR:
APTT:
ASA Classifications:
1/2/3/4/5
Anesthesia Plan:
(General/Spinal/Epidural/Regional/Local/Sedation)
Proposed date of surgery:
Assessment date:
Notes: