University of Cape Town Groote Schuur Hospital by wuyunyi

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									                                            Thoracic Surgery
Date of Admission: d                   /m        /200__ date of referral: __/__/200 ___          Hospital number: __________________
                                                                                                 SURNAME: ______________________
Consultant Thoracic Surgeon: ___________________________                                         First Name: _______________________
Referring Physician: __________________Responsible Registrar: ______                             Gender:      Male     Female_______
Age: _______yrs                                                                                  DOB:     ___ /___ / _______
Discharge Home Support:               Yes        No                      Height: _______ m
MARS Trial:                           Yes        No                      Weight: _______ Kg

ALLERGIES:
  Nil   Drug                  Food           Other         Specify: 1):__________________________2):___________________________

DIAGNOSIS: _____________________________________________________________________

INTENDED OPERATION: _________________________________________________________
CURRENT SYMPTOMS: Main Complaint / Duration of Symptoms:___________________________________
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Cough / Sputum          Yes        No ____________________________________________________________
Haemoptysis             Yes        No ____________________________________________________________
Dyspnoea                Yes        No NYHA Grade Now: ___________. NYHA Grade Pre-morbid: ________
Chest Pain              Yes        No Chest wall pain:      Central chest pain suspicious of Angina:
Musclokeletal Pain      Yes        No Pain elsewhere suggestive of Metastases:   _____________________
Weight loss             Yes        No ____________________________________________________________
Dysphagia / G-O reflux: Yes        No ____________________________________________________________

RISK FACTORS:
Smoking                              Yes              No Duration: ________No./ day____(Pack years___), if stopped, when? _________
Exposure to Asbestos                 Yes              No Duration: __________________________________________________________
Substance abuse                      Yes              No __________________________________________________________________
Exposure to carcinogenic chemicals:        Yes        No __________________________________________________________________

MEDICAL HISTORY:                                                          Comments:
Pneumothorax                         Yes              No __________________________________________________________________
COPD                                 Yes              No __________________________________________________________________
Asthma                               Yes              No __________________________________________________________________
TB                                   Yes              No __________________________________________________________________
IHD / Myocardial Infarction          Yes              No __________________________________________________________________
Diabetes                             Yes              No    Diet         OHGD_________________________      Insulin______________
Hypertension                         Yes              No __________________________________________________________________
CVA / TIA /Previous stroke           Yes              No __________________________________________________________________
H/O Increased Bleeding               Yes              No __________________________________________________________________
Rheumatoid Arthritis                 Yes              No __________________________________________________________________
Steroid Therapy                      Yes              No __________________________________________________________________
Alcohol intake                       Yes              No (_____Units / week) _________________________________________________
H/O Surgery                          Yes              No __________________________________________________________________
H/O Cancer                           Yes              No___________________________________________________________________
Others: ____________________________________________________________________________________________________
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Pre-Operative Medication:
                  Drug                            Dose       Frequency                    Drug                   Dose     Frequency
                                                                                                                                      2
DISEASE PATHOLOGY / DIAGNOSTIC GROUP:
   Congenital                     Trauma                 Primary Cancer Lung              Primary Cancer Oesophagus
   Mesothelioma                   Chest Wall tumour      Pulmonary Parenchymal disease    Malignant disease Other or uncertain
   Benign Neoplasms               Empyema                TB                               Other Septic Condition
   Pneumothorax                   Vascular lesion        Mediastinal Tumour / Cyst        Malignant disease secondary or Metastatic
   Pleural Effusion               Thymic Tumour          Mysthenia (No tumour)            Diaphragmatic Hernia
   Hiatus Hernia                  Other:
ASA GRADE:
   1. Normal healthy individual                                            4. Incapacitating systemic disease – Life threateninig
   2. Mild systemic disease                                                5. Patient moribund
   3. Severe systemic disease

PULMONARY FUNCTION :
Measured FEV1         ___________                                       Measured FVC           __________
FEV1 - % Predicted ___________                                          FVC - % Predicted ___________

________________________________________________________________________
CLINICAL EXAMINATION:
   Jaundice   Anaemia      Cyanosis
   Clubbing   Oedema        Muscle wasting  ________________________
    SVC Obstruction         Horner Syndrome ________________________
    Lymphadenopathy (Site: _________________________________________)
Temperature: _____°C HR: ____/min              SR       AF    BP:_____/______mmHg
Heart Sounds:    I------------II---------------------I O Saturation: _____% (On air)
                                                        2

Chest:______________________________________________________
____________________________________________________________                                                  Anterior
Abdomen:___________________________________________________
____________________________________________________________
____________________________________________________________
Others: __________________________________________________________________

____________________________________________________________
____________________________________________________________                                                  Posterior
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INVESTIGATIONS:                        _______________________________________________________________________
Blood Investigations:
 Hb:               WBC:               Plt:            Na+:           K+:               Urea:             Creat.:_           Ca++:

 Alk. Ph.          SGPT:              AST             Alb.:          Bilirubin:        PT:               INR:               APTT:

 Fib.
ECG: _______________________________________________________________________
ABG: _______________________________________________________________________
Bronchoscopy: _______________________________________________________________
____________________________________________________________________________
Echocardiography: ___________________________________________________________
____________________________________________________________________________
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Exercise Tolerance Test (ETT): ________________________________________________
____________________________________________________________________________
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PRE-OPERATIVE DIAGNOSTIC IMAGING:
CXR: _____________________________________________________
__________________________________________________________
CT SCAN: ________________________________________________
__________________________________________________________
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MRI SCAN: _______________________________________________
__________________________________________________________
PET SCAN: _______________________________________________
Bone Scan:________________________________________________
Others:___________________________________________________________________________________________
__________________________________________________________________________________________________
PRE-OPERATIVE TISSUE DIAGNOSIS: _____________________________________________________________
__________________________________________________________________________________________________
HISTOLOGICAL DIAGNOSIS: ____________________________________________________________________________
LUNG CANCER TYPE:                        (Not to be completed if not applicable)
   1 – Small Cell Lung Cancer                       3 – Small cell & Non-small cell
  2 – Non-Small Cell Lung Cancer                  Lung Cancer

NSCL – PREDOMINANT TYPE:
       1 – Squamous cell                                 3 – Bronchiolo-alveolar             5 – Mixed
       2 – Adenocarcinoma                                4 – Large cell                      6 - Other

PRE-OPERATIVE LUNG CANCER STAGING:
T STAGE:
       1 – T1: < 3 cm tumour surrounded by lung parenchyma
       2 – T2: > 3 cm tumour >2 cm from Carina – May invade visceral pleura
       3 – T3: Involves main Bronchus < 2cm from Carina – and/or invasion of
                chest wall, diaphragm, pericardium or mediastinum.
       4 – T4: Invasion of Mediastinal organs – oesophagus intrapericardial
                pulmonary vessels – nerves etc.
       5 – Tis: Carcinoma in situ

N STAGE:
     0 – N0                                              2 – N2
     1 – N1                                              3 - NX

M STAGE:
       0 – M0
       1 – M1


MESOTHELIOMA TYPE:                       (Not to be completed if not applicable)
  1 – Epithelioid
  2 – Sarcomatoid (Fibrous)                         3 – Biphasic (Mixed)

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PLAN:___________________________________________________________________________________________
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SIGNATURE: __________________________________________ BLEEP: _________________________________
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                      OPERATIVE NOTES
                                                                         Hospital number: ______________
                                                                         SURNAME: __________________
                                                                         First Name: __________________
                                                                         DOB:     ___ /___ / _____
                                                                         Gender:      Male    Female___
OPERATIVE PRIORITY:
    1 – Elective                2 - Urgent                3 – Emergency

SURGICAL STRATEGY:
    1 – Diagnostic only                      2 – Staging or assessment               3 – Therapeutic

DATE OF OPERATION: ____/____/200__ (TIME:         :   )   THEATRE: __________________________________
CONSULTANT: _______________________________               SURGEON:__________________________________
ASSISTANT(S):   ______________/_________________          ANAESTHETIST:_____________________________

           OPERATION: ______________________________________________________________________
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INCISION: _________________________________________________________________________________________
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FINDINGS: ________________________________________________________________________________________
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PROCEDURE: ______________________________________________________________________________________
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CLOSURE: _________________________________________________________________________________________
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DRAIN(S): _________________________________________________________________________________________
SUCTION:                        YES               NO
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ANTIBOTICS:                     YES               NO
COMMENTS:_______________________________________________________________________________________
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________________________________________________           SIGNATURE: ________________________________

								
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