Meti HPS User Manual page 158

Using HPS
Mrs. Una
Goodeye
Name, Age and
Gender
History of
Present Illness
Past Medical
History
Past Surgical/
Anesthetic
History
Review of
Systems
Current
Medications
Physical
Examination
Laboratory,
Radiology and
Other Relevant
Studies
Narrative
4.20
Mrs. Una Goodeye, 75-year-old female
Decreased vision left eye due to cataract
Scheduled for extraction and intra-ocular lens placement
Good health
Tonsillectomy as a child under general anesthesia, no complications
No family history of anesthetic problems
CNS: Negative for stroke, seizure, syncope
Cardiovascular: Negative for hypertension, angina, dyspnea on exertion
Pulmonary: Negative for COPD, asthma, recent upper respiratory infection
Renal/Hepatic: Negative for renal failure, jaundice
Endocrine: Negative for diabetes, thyroid disease
Heme/Coag: Negative for anemia, bruising
None
General: Healthy appearing elderly woman
Weight, Height: 52 kg, 5'2"
Vital Signs: HR 78 bpm, BP 130/80 mmHg, RR 16 br/min, Sp O
Airway: Upper and lower dentures, no loose teeth, FROM neck, 3 fb oral
opening, 3 fb mandible, MC 2
Lungs: BS clear and equal bilaterally
Heart: Regular rate and rhythm. N1 S1, S2; no S3, S4, murmur or rub
Chest x-ray: No acute disease. No cardiomegaly
ECG: Normal sinus rhythm at 62 bpm. No ischemic changes
HCT: 39 %
Electrolytes: Within normal limits
The patient is a 75-year-old woman in good health that is to have an ophthalmic
solution cataract operation under monitored anesthesia care. Anesthetic history,
physical examination and lab data are entirely normal. The surgeon takes about
20 minutes for the operation. He usually asks for "a little something" to keep the
patient still and not remember the retrobulbar block. The patient weighs 52 kg
at 5'2", BP 130/80 mmHg, HR 78 bpm, Sp O
The operative field will be draped, covering everything but the left eye. An IV
with Lactated Ringer's is running, 75 mL of 500 mL remaining in the bag. You
decide to use remifentanil with or without midazolam.
You will have available a functional anesthesia machine, the usual monitors and
emergency drugs, syringes, airways, etc.
96%
2
96%, RR 16 br/min, HCT 39%.
2
HPS
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