Otolaryngology Preoperative History & Physical

Date/Time: [Date and time of documentation]

Location: [clinic / preadmission / inpatient]

Note Type: [Pre-op H&P / Interval Update]

Encounter Context: [elective / urgent]; [inpatient / outpatient]

Surgery Snapshot

Planned Procedure: [Full procedure name with laterality and approach]

Primary Indication: [One-line diagnosis prompting surgery]

Surgeon: [Primary surgeon and co-surgeons if applicable]

Anesthesia Type: [General / MAC / Local with sedation / Regional / Unknown]

Anticipated Disposition: [Outpatient / Observation / Inpatient admission]

Special Considerations: [Anticipated airway risk, planned implants, anticipated blood loss category, positioning, nerve monitoring, or other relevant factors] (State "None" if no special considerations identified.)

Chief Concern

[One sentence stating why the patient is being evaluated and the planned operation]

History of Present Illness

[Operative indication and clinical context] (Begin with the indication for surgery. Include symptom onset, duration, course, severity, and current functional impact such as sleep, voice demands, swallowing, and work or daily activity limitations.)

[Pertinent positives and negatives] (Document key symptoms that support the indication. Include relevant red flags if present.)

[Prior workup and treatments] (Summarize relevant imaging, endoscopy, biopsy/pathology, audiogram, sleep study, and other tests with key decision-driving findings. List prior therapies with dates, duration, and response.)

[Why now] (State objective basis for surgery: failed conservative management, progression, complications, malignancy concern, or quality-of-life impact.)

Prior Evaluation & Therapies

(Include only when substantial prior workup exists and is not adequately covered in HPI. Otherwise omit this section.)

• [Date]: [Conservative therapy, adherence, duration, and outcome]
• [Date]: [Prior procedures and outcomes]
• [Date]: [Specialist input and recommendations]
• [Devices]: [CPAP/BiPAP use and tolerance], [hearing aids], [tracheostomy history]

Past Medical History

• [Cardiovascular conditions] (CAD, heart failure, arrhythmia, hypertension, valve disease, stents with dates; include control status.)
• [Pulmonary conditions] (Asthma/COPD, home oxygen, recent exacerbations.)
• [Obstructive sleep apnea] (Diagnosis date, severity if known, CPAP use and adherence.)
• [Diabetes] (Type and control.)
• [Renal or hepatic disease]
• [Bleeding disorders or prior abnormal surgical bleeding]
• [VTE history]
• [Immunosuppression]
• [Pregnancy status] (if applicable)
• [Other conditions relevant to perioperative risk]

Past Surgical History

• [Procedure] — [Year] — [Complications if any]
• [Prior ENT surgeries] (Note revision risk.)
• [Prior airway procedures or tracheostomy]
• [Anesthesia complications] (Difficult intubation, severe PONV, malignant hyperthermia, intraoperative awareness.)

Medications

(Reconciled list with dose, route, and frequency. For perioperatively important medications, document last dose and plan.)

• [Medication name] — [dose, route, frequency] — [last dose if relevant]
• Anticoagulants/antiplatelets: [Agent], [indication], [prescriber], [last dose], [holding and resumption plan or "Plan pending coordination with prescriber"]
• Diabetes/weight-loss agents: [SGLT2 inhibitors and GLP-1 agonists with perioperative plan]
• Chronic opioids or sedatives: [Dose and duration; perioperative plan]
• Chronic steroids: [Stress-dose plan if applicable]
• OTC NSAIDs and supplements: [Agents affecting bleeding with hold plan]

Allergies

• [Allergen] — [Type: drug / latex / adhesive / contrast] — [Reaction description]

Social History

• Tobacco/nicotine: [Type, amount, duration, quit date if former]
• Alcohol: [Amount and frequency]
• Other substances: [Details or none]
• Home support: [Postoperative care arrangements]
• Voice/occupational demands: [Professional voice use or other relevant demands] (if applicable)
• Pediatrics: [Caregiver situation and decision-maker] (if applicable)

Family History

(Include only if relevant to perioperative risk; omit section if noncontributory.)

• [Bleeding disorders]
• [Anesthesia complications]
• [Hereditary hearing loss]
• [Head and neck cancers]

Review of Systems

(Focused on perioperative and anesthesia relevance. If not obtained, document reason.)

• ENT: [Nasal obstruction, epistaxis, otorrhea, hearing changes, vertigo, dysphagia, hoarseness, neck mass]
• Cardiopulmonary: [Chest pain, dyspnea, exercise tolerance, orthopnea, wheezing]
• OSA screening: [Snoring, witnessed apneas, daytime somnolence] (if no established diagnosis)
• Constitutional: [Fever, unintentional weight loss]

Physical Examination

• Vitals: BP [value], HR [value], RR [value], SpO2 [value], Temp [value]; Height [value], Weight [value], BMI [value]
• General: [Appearance, work of breathing, voice quality, secretion management]
• ENT Exam:
  • Ears: [Auricles, canals, tympanic membranes] (Specify laterality for abnormalities.)
  • Nose: [External nose, septum, turbinates, mucosa, obstruction source]
  • Oral cavity/oropharynx: [Dentition, mucosa, tonsils, lesions]
  • Neck: [Masses, thyroid, lymph nodes, tenderness, scars, tracheal position]
  • Cranial nerves: [Gross CN assessment relevant to planned surgery]
• Cardiopulmonary: [Heart sounds/rhythm, lung examination]
• Additional findings: [Laryngeal exam, facial nerve function, tuning fork tests, vestibular screening] (Label as "Deferred" with reason if not performed.)

Diagnostics Reviewed

• Imaging: [Modality] — [Date] — [Pertinent findings] (Note if images personally reviewed vs report only.)
• Pathology: [Date] — [Key results]
• Audiogram/Tympanogram: [Date] — [Key findings]
• Sleep study: [Date] — [Severity and AHI]
• Labs: [Date] — [Decision-relevant results] (if applicable)

Assessment

1. [Problem 1]: [One-line synthesis combining symptoms, objective findings, course, and response to therapy. State why surgery is appropriate now. Note risk modifiers.]
2. [Problem 2]: [Additional issues in decreasing order of perioperative relevance]

Preoperative Risk Assessment

Bleeding and Thrombosis Risk:

• Personal bleeding history: [Prior surgical bleeding, easy bruising, epistaxis severity, dental extraction bleeding]
• Family bleeding history: [Present / Absent / Unknown]
• Antithrombotic management: [Agent, indication, prescriber, last dose, holding plan, resumption plan, bridging if applicable]
• Labs planned: [Tests with clinical indication, or "None indicated"]
• Type and screen: [Completed / Ordered / Not indicated]

OSA and Airway Risk:

• OSA status: [Diagnosed with severity / Suspected / Negative]; [CPAP/BiPAP use and adherence] (Instructed to bring device.)
• Airway red flags: [Limited neck extension, trismus, mass effect, prior radiation, prior difficult intubation, or "None identified"]
• Prior anesthesia complications: [Details or "None reported"]
• Planned mitigations: [Anesthesia pre-op evaluation, post-op monitoring level, opioid-sparing strategy, airway plan]

Other Comorbidity Considerations:

• Functional capacity: [METs estimate or description]
• Cardiac device: [Type, last interrogation, perioperative plan] (if applicable)
• Clearance/optimization: [Service, status: requested / completed / pending]

Surgical Plan

• Procedure: [Procedure name(s) with laterality and intended extent]
• Contingencies: [Decision criteria] (e.g., "May perform X if Y found.")
• Specimens: [Pathology handling plan] (frozen vs permanent)
• Postoperative devices: [Drains, packing, splints, tracheostomy plan if contemplated]
• Expected setting: [Outpatient / Planned admission] — [Rationale]

Perioperative Management Plan

• Coordination: [Anesthesia evaluation status, medical clearance requests, specialist coordination]
• Medication instructions: [Continue/hold list with timing]; (Patient verbalized understanding.)
• Pre-op testing: [Tests ordered with clinical indication]
• Prophylaxis: [Antibiotics, steroids, VTE prophylaxis per protocol]
• Postoperative plan: [Pain management approach, diet, activity restrictions, follow-up timing, red-flag return precautions]

Informed Consent Discussion

• Diagnosis and indication: [Diagnosis and expected course without surgery]
• Nature of procedure: [Plain-language description]
• Alternatives discussed: [Non-surgical options including observation]
• Expected benefits: [Key benefits]
• Material risks discussed: [Procedure-specific and patient-specific risks]
• Recovery expectations: [Pain, diet, activity, devices, follow-up]
• Patient questions: [Questions asked and answered] (Note interpreter use if applicable.)
• Decision: [Patient/surrogate affirms understanding and wishes to proceed / declines / undecided]
• Written consent status: [Signed (location) / To be obtained]

Interval Update

(Complete only when Note Type is "Interval Update". Otherwise omit this section.)

• Original H&P: [Date and location]
• Interval history: [No interval changes / New symptoms or events]
• Medications/Allergies: [Changes since original H&P or "No changes"]
• Focused exam: [Key findings relevant to procedure and anesthesia]
• New diagnostics: [Results or "None"]
• Confirmation: Planned procedure and laterality verified as correct.

(For safety-critical fields—allergies, anticoagulant status, prior anesthesia complications, OSA status—use explicit placeholders such as "Unknown (patient unsure)" or "Not obtained (reason)" rather than omitting.)