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Asymptomatic hypertension

The current evidence base suggests that intensive treatment of asymptomatic hypertension in noncardiac inpatients is likely to do more harm than good. See e.g. Anderson TS et al. JAMA Internal Medicine 2023;183(7):715–23.

Consent for Iron Infusion Y Li (Intern) Discussion with the patient regarding proposed [iron polymaltose/ferric carboxymaltose] infusion for [iron deficiency anaemia/iron deficiency/low iron stores] (Hb _, ferritin _). Procedure was discussed. Oral replacement is not preferred as duration is longer and gastrointestinal side effects are frequent. Discussed risks of bleeding, infection, allergy including anaphylaxis, iron leak including permanent staining, chest pain/fever/GI upset/malaise. All questions answered. Pt verbally consented for infusion.

Mental state examination (MSE)

MSE A: B: S: M: A: Tf: Tc: P: C: I: J:

Montreal Cognitive Assessment (MoCA)

Montreal Cognitive Assessment (MoCA) Y Li (Intern) [General comment] Visuospatial/executive . . . _/5 Naming . . . . . . . . . . . . . _/3 Memory (registration) . . . N/A Attention . . . . . . . . . . . . _/6 Language . . . . . . . . . . . . _/3 Abstraction . . . . . . . . . . . _/2 Delayed recall . . . . . . . . . _/5 Orientation . . . . . . . . . . . _/6 Total score . . . . . . . _/30 Scoring sheet filed in patient folder.

My Health Record access

My Health Record access Pt has a My Health Record but does not remember the access code. Verbal consent was obtained from the patient to access the My Health Record. My Health Record was accordingly accessed pursuant to the My Health Records Act 2012 s 66 (Collection, use and disclosure with healthcare recipient’s consent).

Neurological exam, cranial nerves, brief

Pupils equal, round, reactive. Full range of eye movement, no diplopia/nystagmus. CN 5 normal power/sensation. CN 7/11 normal power. Tongue, uvula midline.

Neurological exam, peripheral, brief

Upper limbs: RIGHT LEFT - Shoulder abduction 5/5 5/5 - Shoulder adduction 5/5 5/5 - Elbow flexion 5/5 5/5 - Elbow extension 5/5 5/5 - Finger flexion 5/5 5/5 - Sensation grossly intact all dermatomes Lower limbs: RIGHT LEFT - Hip flexion 5/5 5/5 - Knee flexion 5/5 5/5 - Knee extension 5/5 5/5 - Ankle plantarflexion 5/5 5/5 - Ankle dorsiflexion 5/5 5/5 - Sensation grossly intact all dermatomes

Rowland Universal Dementia Assessment Scale (RUDAS)

Rowland Universal Dementia Assessment Scale (RUDAS) Y Li (Intern) [General comment] Memory (registration) . . . . . . . N/A Visuospatial orientation . . . . . . _/5 Praxis . . . . . . . . . . . . . . . . . . . _/2 Visuoconstructional drawing . . . _/3 Judgement . . . . . . . . . . . . . . . _/4 Memory recall . . . . . . . . . . . . . _/8 Language . . . . . . . . . . . . . . . . _/8 Total score . . . . . . . . . . . __/30 Scoring sheet and drawing filed in patient folder.

Surgical preadmission clinic

Surgical Preadmission Clinic Y Li (Intern) Operation: _ Indication: _ Category: _ Surgeon: _ PMHx _ ? asthma/COPD, hypertension, myocardial infarction, atrial fibrillation, heart failure, diabetes, kidney disease ? COVID Surgical/Anaesthetic Hx _ ? Previous general anaesthetic/issues ? FHx Medications _ ? antiplatelets/anticoagulants/oral hypoglycaemics Allergies _ SHx Home with _ ? Occupation ? Independent ADLs, nil mobility aid ? Drives ? Smoker ? Alcohol ? Immunisations: COVID/flu Systems Review Respiratory – Dyspnoea, cough, haemoptysis, wheeze, sore throat, coryza: Cardiovascular – Chest pain, palpitations, orthopnoea, PND, oedema, syncope: Gastrointestinal – Abdominal pain, nausea, vomiting, constipation, diarrhoea, haematochezia/melaena, reflux, jaundice, pruritus: Genitourinary – Dysuria, frequency, recurrent UTIs: Haematological – Pallor, easy bruising/bleeding, frequent infection, VTE history: Constitutional – Fever, chills, sweats, rigors, loss of weight, loss of appetite: Exercise tolerance: _ ? DASI 58.2 -> METS 9.89 STOP-BANG _ O/E HR _, BP _ RR _, SpO2 _ Height: _ cm Weight: _ kg -> BMI: _ ? Heart sounds dual, no murmur. Chest clear. Abdomen soft, non-tender. No pedal oedema. ? Dentition Mallampati _ ? Full range of neck movement Thyromental distance ≥ _ cm Investigations Bloods: _ ECG: _ Imaging: _ Impression _ ASA _ Plan ? Signed consent sighted ? Blood transfusion consent ? Request for bloods and ECG ? Perioperative medications: antiplatelets, anticoagulation, hypoglycaemics ? Imaging to request ? Anaesthetic referral

Urinary catheterisation

Urinary Catheterisation Y Li (Intern) Discussion with the patient regarding insertion of indwelling urinary catheter for _. Procedure was discussed. Discussed risks of bleeding, infection, failure, allergy, trauma. Pt verbally consented for catheterisation. _ as chaperone. Chlorhexidine/cetrimide prep, drape, lidocaine gel. Two way _Fr silicone catheter inserted under aseptic technique. Balloon inflated with 10 mL water for injection. [If applicable:] Foreskin replaced. Pt tolerated the procedure well. Catheter draining _ urine.