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Demographic Data:
Name:
Patient’s code:
Age: ……… Y/O
Unit number:
□ Female□
Sex: Male
Phone 1:
Education: …….. years
Phone 2:
Marital status: Single
□ Married□
Phone 3:
Occupation:
From:
Address:
Date:
Preoperative factors:
Hypertension: Yes
□
□
No
□ No□
Hyperlipidemia: Yes□ No□
Hx of renal dx: Yes□ No□ if yes: ………………………………
Hx of liver dx: Yes□ No□ if yes: cirrhosis□ cancer□ other: …………………………..
Recent MI(MI occurring within 1 week before CABG): Yes□ No□
Smoking: Yes□ No□
Opium user: Yes□ No□
NYHA class: I□ II□ III□ IV□
Diabetes Mellitus: Yes
Body mass index: ………. Kg/m2 (wt. : ……….. kg) (height: ………… cm)
□ Urgent□
CABG: Elective

Medications:

□ No□
Aspirin: Yes□ No□
Plavix: Yes□ No□
Diuretics: Yes□ No□

Potassium channel blocker: Yes

ACE-I: Yes



Statins: Yes




□
□
No
□
No
□


□
Oral nitrates: Yes□
□
No□
Ca channel blockers: Yes□
Metformin: Yes□ No□
Glibenclamide: Yes□ No□
NSAID: Yes□ No□
Contrast: Yes□ No□
Beta blocker: Yes
No
2+
Ejection fraction: ……………%
PA pressure (in echo): ………….. mm Hg
□
Angio: 1vessel dx
2vessel dx
CBC:
 Hb: ……….
Biochemistry:
 Cr: ……….
LFT:
 AST: ………..
 ALT: ………..
 Alk.p: ………..
□
3vessel dx

□

Plt: ……….





T.bili: ……….
D.bili: ……….
T.prot: ……….
Albumin: ……….
RDW: ……….
Uric acid: ……….



PT: ……….
INR: ……….
PTT: ……….
No
□
U/A:

Proteinuria: ……….
Intraoperative factors:
Anesthetic agent: Isoflurane
□
□
Propofol
Bypass time: …………. min
Cross clamp time: …………. min
No. of grafts: ………….
Need to blood transfusion: …………… cc
Lowest hematocrit during CPB: …………. %
Ascending Aorta plaque: Yes
□
No
Decrease in blood pressure: Yes
□
□
□
No
□
□
Arrhythmia: Yes
No
Vasopressor inotrope: ………….
Aprotinin (Trasylol): Yes
□
No
□
□ No□
Epsilon-aminocaproic acid (EACA): Yes
Postoperative factors:
Hypotension( <100/70 or >40 mm Hg drop in SBP): Yes
Hypertension: Yes
□
□
□
No
□
No
□
□
Requiring dialysis: Yes
No
Duration of hospitalization: …………... days ( ICU: ………….. , ward: ………….. )
CBC:
 Hb: ……….
 Plt: ……….
 RDW: ……….
Biochemistry:
 Cr: ……….
LFT (24h post-op):
 AST: ………..
 ALT: ………..
 Alk.p: ………..
U/A: Proteinuria: ……….




T.bili: ……….
D.bili: ……….
T.prot: ……….
Albumin: ……….



PT: ……….
INR: ……….
PTT: ……….