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CARD SURG Assessment Cardiac Transplant (Page 1 of 3) DATE _____/_____/_______ DD MM YYYY WEIGHT:_________ KG TIME _________ BSA __________ M2 HEIGHT:_________ CM ALLERGY CAUTION sheet reviewed Status/Admit/Transfer/Discharge Cardiologist: ____________________ Cardiac Surgeon: ____________________ Nurse Practitioner: ____________________ Patient Care Measure weight Measure height Measure head circumference Obtain a copy of the patient's immunization record Mantoux Test (PPD) (*read 48hrs after) Laboratory Urinalysis (UA) with microscopy Urine culture and sensitivity Urine, albumin:creatinine ratio Nuclear glomular filtration rate (GFR) Routine Patient Bloodwork regular lab req: Complete blood cell count (CBC) differential, peripheral blood smear, reticulocyte count Sodium level, serum Potassium level, serum Chloride, serum Carbon dioxide, total (bicarbonate plus dissolved carbon dioxide) Glucose, serum, random Magnesium (Mg) level, serum Calcium level, serum, total Calcium level, ionized Phosphate Urea (BUN) Creatinine (Cr), serum Group and Screen Ferritin Iron Transferrin saturation Partial thromboplastin time (PTT) International normalized ratio (INR) Fibrinogen Thyroid stimulating hormone (TSH) Parathyroid hormone (PTH) 25-OH Vit D Aspartate aminotransferase (AST) Signature:_______________________________________ Print Name:____________________________________ College ID:______________________________________ Pager:________________________________________ PTN Review Date: November 15 2016 PTN# CTAv1 Exp Date: November 15 2019 Page 1 o f 3 CARD SURG Assessment Cardiac Transplant (Page 2 of 3) DATE _____/_____/_______ DD MM YYYY WEIGHT:_________ KG TIME _________ BSA __________ M2 HEIGHT:_________ CM ALLERGY CAUTION sheet reviewed Alanine aminotransferase (ALT) Alkaline phosphatase, total Gamma-glutamyl transferase (GGT) Lactate dehydrogenase (LDH), serum Bilirubin, total unconjugated and conjugated Albumin Cholesterol, total Fasting Triglycerides Cholesterol, HDL Cholesterol, LDL Brain natriuretic peptide (BNP) Serology screening req: Syphilis screen (TPS) HIV (HIVB) - non-nominal reporting requested Hepatitis B Screen - HBsAg, Anti-HBs, Anti-HBc Total (HBSAG) Anti-hepatitis A Total (HAAT) Anti-HCV (HEPCB) Measles IgG (MIGB) Mumps IgG (MUIGB) Rubella IgG (RUBEB) EBV IgG (EBGSB), EBV IgM (EBVSP) EBV IgM (EBVSP) EBV IgG (EBGSB) CMV IgG (CMVIGB) CMV IgM (CMVSP) Varicella IgG (VZIGB) HSV IgG (HSVIGB) HTLV I/II (HTLVB) Toxoplasma gondii IgG (zoonotics & emerging pathogens req) VGH Histocompatability assessment booking form and req: sent to VGH immunology lab HLA antibody screen (PRA) and HLA typing and ABO Optional Bloodwork (Select all that apply) Maternal Serology: For patients LESS than 6 months or breatfeeding: Maternal serology Culture, cytomegalovirus (CMV), blood Epstein-Barr virus (EBV) Hepatitis B (surface and core antibody) HIV Hepatitis A Hepatitis C Culture, herpes simplex virus (HSV) Varicella Signature:_______________________________________ Print Name:____________________________________ College ID:______________________________________ Pager:________________________________________ PTN Review Date: November 15 2016 PTN# CTAv1 Exp Date: November 15 2019 Page 2 o f 3 CARD SURG Assessment Cardiac Transplant (Page 3 of 3) DATE _____/_____/_______ DD MM YYYY WEIGHT:_________ KG TIME _________ BSA __________ M2 HEIGHT:_________ CM ALLERGY CAUTION sheet reviewed For females: Beta-HCG, serum (post-menarche) PAP testing (sexually active) For patients less than 3 years: Isohemagglutinin titre For patients at risk for being carriers of Sickle Cell Anemia or Thalassemia: Hb HPLC and Hemoglobin electrophoresis For patients with obesity or at-risk for diabetes based on family history: Glucose, serum, fasting Oral glucose tolerance test (OGTT) HbA1C Medical Imaging Chest xray (AP/LAT) Abdominal and renal ultrasound Echocardiogram Ultrasound, head Cardiac magnetic resonance imaging (MRI) OR computed tomography (CT) Bone mineral density (DEXA scan) and Bone Age (Left hand x-ray) Diagnostic Tests/Procedures 12-lead ECG Holter monitor Exercise test - bicycle ergometer with oxygen consumption OR treadmill OR 6 minute walk Non-invasive cardiac output 24-hr ambulatory blood pressure monitoring (AMBP) MIBI (stress, rest) Multi gated acquisition study (MUGA) Doppler - jugular, subclavian, femoral arteries and veins Pulmonary function testing AND/OR V/Q scan Consults Standard Consults Nephrology Infectious Disease Dentistry Multi-organ transplant Dietitian Multi-organ transplant psychosocial assessment (Social Work, Psychology, Psychiatry) Occupational Therapy Physiotherapy Multi-organ transplant Pharmacist Optional Consults (Select all that apply) Neurology Immunology Metabolics Adolescent medicine Child life Respirology Hematology Genetics Dermatology Spiritual care Ophthalmology Canuck place Signature:_______________________________________ Print Name:____________________________________ College ID:______________________________________ Pager:________________________________________ PTN Review Date: November 15 2016 PTN# CTAv1 Exp Date: November 15 2019 Page 3 of 3