Anesthesia Summary · what matters in the next 30 minutes
Airway
Mallampati IV · TMD 5cm
Limited mouth opening
Entered by me
Entered by me
Aspiration risk
GERD · obese · NPO 8h
RSI consider
From EHR
From EHR
Anticoag
None active
ASA held 7d
From EHR
From EHR
OSA
STOP-BANG 5 · high risk
No CPAP at home
From EHR
From EHR
ASA · functional
III · METs ≥ 4
Walks 2 flights
Entered by me
Entered by me
Active blockers
Anesthesia consent
Not on chart yet
Needs confirmation
Needs confirmation
Allergies & Reactions 3 entries · 1 anaphylaxis
Penicillin
Anaphylaxis · ED admit, epinephrine, intubated 6h
2014 · self-report + ED record
Latex
Contact rash · self-reported, no formal testing
2018 · self-report
Codeine
Nausea · intolerance only, not immune-mediated
2009 · self-report
Last time I had penicillin I went to the ER. I couldn't breathe and they put a tube in.
— Pt, pre-op interview · 10:34 · transcribed via voice capture
Active Problems 7 active · 2 anesthesia-significant
Cardiac
HTN — well-controlled on lisinopril 20 mg. Last echo 2024: EF 58%, no regional wall motion abnormality. From EHR
Pulmonary
OSA · home study STOP-BANG 5. No CPAP — declined trial. From EHR
GI
GERD on omeprazole 40 mg daily. Cholelithiasis — index admission. From EHR
Endo
T2DM · A1c 7.1% (Mar 2026) · metformin 1000 mg BID, last dose Fri PM. From EHR
Renal
eGFR 78. From EHR
Hepatic
No known dysfunction. AST/ALT WNL Mar 2026. From EHR
Home Medications 5 active
| Medication | Dose · Schedule | Indication | Last Dose |
|---|---|---|---|
| Lisinopril HOLD AM | 20 mg PO daily | HTN | Held this AM |
| Metformin HOLD AM | 1000 mg PO BID | T2DM | Fri 8 PM |
| Omeprazole | 40 mg PO daily | GERD | Sat 5 AM |
| Atorvastatin | 40 mg PO QHS | Hyperlipidemia | Fri QHS |
| Aspirin HELD ×7d | 81 mg PO daily | Primary prevention | Apr 18 (7d) |
Anesthesia Hx 3 prior cases · no MH family hx
2019 · GA
Lap appendectomy · uneventful induction, easy mask. Per OR record, single-attempt DL grade I. From EHR · prior op note
2014 · sedation
Screening colonoscopy · propofol/fentanyl. PONV in PACU. From EHR
2008 · GA
C-section under spinal. Adequate block, no conversion. From EHR
Family
No personal or family history of malignant hyperthermia or pseudocholinesterase deficiency reported. Entered by me
STOP-BANG · OSA
S
SNORE
T
TIRED
O
OBSV
P
BP
B
BMI
A
AGE
N
NECK
G
SEX
Score 5/8 · high risk. Plan considerations: minimize long-acting opioid; PACU continuous SpO₂; consider CPAP post-op.
Airway Exam From me · 10:34
Mallampati IV
TMD 5 cm
Mouth opening 3 cm · limited
Neck extension full · no tracheal deviation
Dentition intact, no loose teeth
Beard / facial hair: none
Difficult-airway preparation: video laryngoscope as primary, fiberoptic adjunct ready, two-provider induction. Entered by me
Labs Sat AM
Hgb
12.8 g/dL
Plt
228 K
INR
1.0
K+
4.1
Cr · eGFR
0.9 · 78
Glu (fasting)
142
Coding · pre-case prep
ASA III+1 unit
OSA · STOP-BANG ≥5documented
Anesthesia consentmissing
Allergy: severerequired
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