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Department of Anesthesiology
Duke University Medical Center
Box 3094
Durham, NC 27710

Office of Medical Education
Duke University Medical Center
Box 3005
Durham, NC 27710

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MS 2 Case Report

 

Medical Student: Date:
Anesthesiology Resident/CRNA: Anesthesiology Attending:

Case Posting
Procedure/Surgeon:
Position:
Duration:
Blood (amt set up):

Preoperative Assessment
Age:

History Pos/Neg Explain Positive

Medications
Hypertension:
Hearth Disease:
Diabetes Mellitus:
Kidney Disease:
Asthma:
Reflux:
Other:
Allergies:
Family History (Malig. H'therm):
Social (tob, EtOH, IVDA):

Exam
V/S:
Height:
Weight:
Airway Mouth Opening:
Uvula:
Teeth:
ROM Neck:
Heart:
Lungs:
Other (regional):

Labs
CBC:
ChemCS:
Coags:
EKG:
CXR:

Questions
1. Do you think this patient should have regional anesthesia
or general anesthesia? Why?

 

 

2. List this patient's problems in order of importance to anesthesia
and surgery. Why are they important?

 

 

3. List this patient's possible perioperative complications. How can
you plan your anesthetic management to avoid these complications?

 

 

 

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