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It should contain all of the pertinent preoperative information, including the patients medical history, significant laboratory values, time of last food or liquid intake, vital signs, and a record of a focused physical examination.
I. Preanesthesia Evaluation* Patient and procedure identification. Anticipated disposition. Medical history includes patients ability to give informed consent. Surgical History (PSHx) Anesthetic history. Current Medication List (preadmission and postadmission) Allergies/Adverse Drug Reaction (including reaction type)
Case reports should include relevant positive and negative findings from history, examination and investigation, and can include clinical photographs, provided these are accompanied by a statement that written consent to publish was obtained from the patient(s).
These phases can be further divided into the four As of anesthesia planning: anesthesia, analgesia, autonomic stability, and areflexia.
A case report is a detailed report of the symptoms, signs, diagnosis, treatment, and follow-up of an individual patient. Case reports usually describe an unusual or novel occurrence and as such, remain one of the cornerstones of medical progress and provide many new ideas in medicine.
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Start with a story. Describe why youre interested in the specialty. Use your story as a hook. Describe why you should do anesthesiology. Include a theme of adaptability under pressure. Use an active voice to tell a story. Write a paragraph to the programs that you signal about why youre signaling them specifically.
The medical summary should describe diagnoses, treatment, and prescriptions in the order they occurred. The summary writer should include any clinical opinions or recommendations found in visit notes, independent medical examinations, work status reports, or other clinical reports.
An anesthesia record should be devised for record keeping and to track the number of procedures and complications. Ideally, the anesthesia record should remain in the patients permanent medical record and a copy kept for quality assurance and improvement.

anesthesia monitoring sheet veterinary pdf