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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.

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

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 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).

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.

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 - Light touch C5–T1 Intact Intact - Biceps reflex 2+ 2+ Lower limbs: RIGHT LEFT - Hip flexion 5/5 5/5 - Hip extension 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 - Light touch L2–S1 Intact Intact - Knee reflex 2+ 2+ - Plantar reflex Flexor Flexor

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 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, wheeze: Cardiovascular – Chest pain, palpitations, orthopnoea, PND, oedema, syncope: Gastrointestinal – Abdominal pain, nausea, vomiting, constipation, diarrhoea, reflux: Haematological – Easy bruising/bleeding, frequent infection, PHx/FHx VTE: Constitutional – Fever, chills, sweats, rigors, loss of weight, loss of appetite: Exercise tolerance: _ ? DASI -> 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

A - Own, patent. No dental trauma. No neck bruising or laceration. B - Saturating on room air. Speaks full sentences, nil work of breathing. Breathes deeply, symmetric chest expansion, no paradoxical movement. No chest wall bruising or laceration. No tenderness or deformity of clavicles/ribs. No subcutaneous emphysema. No tracheal deviation. Chest clear. C - Haemodynamically stable. No exsanguinating external haemorrhage. Warm peripheries. Heart sounds dual, no murmur. D - GCS 15 No scalp/facial bruising or laceration No mastoid/periorbital ecchymosis No otorrhoea/rhinorrhoea/haemotympanum No tenderness or deformity of skull 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 No abdominal bruising or laceration Abdomen soft, non-tender No pulsatile mass No tenderness or deformity of large bones of upper/lower limbs No pelvic instability No hip irritability Able to actively straight leg raise bilaterally Normal upper/lower limb power and sensation Palpable radial and dorsalis pedis pulses No back bruising or laceration No tenderness or deformity of C/T/L-spine Unrestricted neck flexion/extension/rotation

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.