Southern Philippines Medical Center

Department of Anesthesia
Enhanced Pre-op Form
in response to CoViD-19 Crisis

PREOPERATIVE PREPARATION
(to be endorsed by the Surgeon to the Anesthesiologist)

Name of Patient: PANILAG, ANTONIO M. Patient HRN: 3092343

Diagnosis: IMPENDING AIRWAY COMPROMISE SECONDARY TO GLOTTIC MASS PROBABLY MALIGNANT
Planned Procedure: Emergency Tracheostomy, Direct Laryngoscopy with Biopsy, Tracheoscopy, Esophagoscopy

AGE: 66 years old WEIGHT: _____ kg

SEX Male HEIGHT: _____ cm
NPO STATUS: Last Meal 12:51PM

PATIENT’S HISTORY
CHIEF COMPLAINT: Hoarseness
HISTORY OF PRESENT ILLNESS: 2 years PTA, noted onset of hoarseness with no associated symptoms. Patient self medicated with lemon
juice drinks and herbal ginger conconctions with partial relief. No consult done. No meds taken. Tolerated
condition.
In the interim, noted gradual worsening of hoarseness. Still continued to self-medicate with herbal drinks with
partial relief. No consult done. No meds taken. Tolerated condition.
10 months PTA, symptoms persisted now with dysphagia to solid foods. Sought consult to a private ENT
where indirect laryngoscopy revealed laryngeal mass, probably malignant. He was advised for a biopsy but
was not amenable. Tolerated condition.
9 months PTA, symptoms persisted. Sought 2nd opinion at our institution where x-ray and sputum geneXpert
was requested, showing no clinical evidence of pulmonary tuberculosis. An endoscopy was done and
subsequently, a biopsy was requested, but the patient lost to follow-up.
In the interim, symptoms persisted now with onset of difficulty of breathing. still no consult done. No meds
taken. Tolerated condition.
On the day of admission, symptoms persisted now with recurrent bouts of cough with hemoptysis and
sudden weight loss. Patient advised for surgery and biopsy and now amenable, thus this admission.

PAST MEDICAL HISTORY: +) HPN, Meds: Telmisartan 40mg OD (-) DM (-) PTB (-) Thyroid Disorders (-) Food and drug allergies
(+) Previous surgeries or hospitalizations: Inguinal Hernia (S/P Hernioplasty, 2016, SPMC)

FAMILY HISTORY: (+) HPN both parentage (+) Breast Cancer (Sister)

PERSONAL-SOCIAL HISTORY: 23.5 pack-years smoker; Occasional alcoholic beverage drinker

REVIEW OF SYSTEMS
General: No change in weight and Respiratory: No hemoptysis, Psychiatric: no change in mood Hematologic: no anemia, easy
appetite, weakness, fatigue or wheezing, pleuritic pain bruising or bleeding, excessive
fever bleeding or past blood transfusion
and/or transfusion reactions
Skin: No puritus on the face, GIT: No heartburn, heartburn, Endocrine: no polyuria, polydipsia MSK: no joint pain, stiffness, or
sores, dryness, changes in hair or nausea, change in bowel habits, swelling, muscle cramps, stiffness,
nails, changes in size or color of rectal bleeding, constipation, low back pain
moles diarrhea or jaundice
HEENT: (+) CLADs, bilateral level CVS: No high BP, heart murmur, GUT: no urinary frequency, Neurology: no changes in mood,
1b-2, trachea midline and palpable chest pain or discomfort, urgency, dysuria, frequent attention, or speech, changes in
palpitations, orthopnea or urination at day or night, orientation, memory, insight,
paroxysmal nocturnal dyspnea hematuria, urinary infection or judgment, headaches, fainting,
incontinence blackouts
RAPID PHYSICAL EXAMINATION
Latest Vital Signs: BP: ______mmHg Temp: ____C Chest & Lungs: Effort of Breathing: [✓] Normal [✗] Labored
HR: ____bpm O2 Sat%: ___% at Shape of Chest: [✗] Flail [✗] Pigeon [✗] Funnel
Room air Ausculation Findings: [✓] Clear [✗] Rhonchi
RR: 20 cpm [✗] Crackles [✗] Wheezing [✗] Stridor
General Survey: GCS15 [✓] Awake [✓] Coherent [✗] Distress Lower Extremities: [✗] Swelling – Description: ______________
HEENT: [✗] Facial asymmetry – Description: ________ [✗] Limb shortening – Description: _________
[✗] Facial disfigurement – Description: ______ [✗] Limited active ROM – Description: ______
[✓] CLADs, level Ib-II [✗] Limited passive ROM – Description: _____
[✗] Muscle bulk and symmetry
Description: _________
[✗] Edema – Description: ________________
[✓] CRT – Description: less than 2 seconds
[✓] Pulses – Description: full
Cardiovascular: [✗] Thrills [✗] Heaves Neurological: [ ] General muscle tone – Description: _____
[✗] Jugular venous distension: ____________ [ ] Reflexes – Description: _______________
Abdomen: [✗] Asymmetry – Description: _____________ [ ] Gait – Description: ___________________
[✗] Masess – Description: ________________
[✗] Abdominal distension – Description: _____
[✗] Costoverebral angle tenderness
[✗] Guarding – Description: _______________
LABORATORY RESULTS
Complete Blood Count: Hgb __, Hct ___, RBC ___, WBC ___,
[__/__/____] N __, L __, M __, E __, B __, Plt ___,

Chemistry: [__/__/____] Crea _____, Na _____, K _____, Bleeding Parameters: PT 16.8 INR 1.27 % ACT 71 APTT 26.70
Mg _____, Total Ca _____ [10/27/24]
HbA1C _____
ABG: [10/29/24, 8:24 AM] pH ____, pCO2 ____, pO2 ___, BE ___,
HCO3 _____, O2sat _____
Chest X-ray: [10/22/24] UNREMARKABLE CARDIO- ECG:
PULMONARY FINDINGS,
ATHEROSCLEROTIC AORTA ,
THORACIC SPONDYLOSIS
DEFORMANS

CT Scan: Ultrasound:
Other Ancillary Test:

CLEARED for OR by other services (as needed):

[ ] Cardio-pulmonary [ ] Pediatrics [ ] Neurology [ ] Trauma [ ] Hematology [ ] Obstetrics-Gynecology
[ ] Infectious Disease Services

Comments:

Medications:
1. Cefuroxime 750mg IVTT 1hr PTOR
2. Dexamethasone 8mg IV 1hr PTOR
3. Omeprazole 40mg IVTT now then OD