1144 E. Home Road, Suite B • Springfield, Ohio 45503-2797
Phone (614) 504-5705 • Fax (614) 504-5707
www.osotc.org
HEART-LUNG CANDIDATE SUMMARY
OSOTC Patient Number:
PATIENT DEMOGRAPHICS
Initials:
Gender:
Birth Date:
M
F
ABO:
A
Institutional Approval Date:
B
AB
City/State of Residence:
Height:
O
Race:
Marital Status:
County if Ohio:
Weight:
BMI:
UNOS Status:
Transplant#:
PATIENT STATUS
MEDICAL DIAGNOSIS:
NY CHF Functional Class:
MEDICAL HISTORY (Please indicate nutritional status, infection, ascites, variceal hemorrhage, encephalopathy, etc.):
Laboratory Data
Renal
BUN
Creatinine
Hepatic
AST (SGOT)
ALT (SGPT
Alk Phos
Bilirubin
Albumin
Protein
Patient
Lab Date
Normal Range
Patient
Lab Date
Normal Range
Cardiac Catheterization
Right Atrium
Right Ventricle
Pulmonary Artery (sys/dias/mean)
Pulmonary Artery Wedge (mean)
Woods Units
Left Ventricle
Left Ventricular end diastolic pressure
Aortic Pressure
Cardiac Output
Cardiac Index
LV Ejection
Pressures:
Baseline:
With Vasodilators:
(v15.0528)
Heart-Lung Candidate Summary
Page 2 of 2
Previous CABG
Yes
No
Coronary Artery Disease
Yes
No
Pertinent ECHO or MUGA Results
Pertinent Chest X-Ray Results
Electrocardiogram
Pulmonary Function Test
6 Minute Walk Test
Quantitative Perfusion Scan
Cancer Screenings (PSA, colonoscopy, mammogram, pap)
Smoking History & Length of Abstinence
PSYCHOSOCIAL EVALUATION/QUALITY OF LIFE
(Support system, informed consent, attitude about transplant, aftercare, complications, etc.):
Performed by:
Social Worker
Psychiatrist
Other:
Insurance:
(v15.0528)