Medical Assessment

Prior to presenting to the Pre-Operative Assessment Clinic (POAC) for their assessment, patients will receive a letter stressing the importance of providing a complete medical history from their GP and a full list of the regular medicines that they take.

Below is an outline of the questions that should be asked, and the information that should be recorded, for each patient who is seen in the clinic, and the basic examination they should undergo. The airway examination is simplified, given that most incidents in this area are unanticipated1.

History

1) General

  • What procedure is the patient undergoing?
  • What is the indication for the procedure?
  • When is it being performed?
  • What is the severity grading of the procedure?
  • What is the patients height?
  • What is the patients weight?

2) Anaesthetic History

  • Has the patient had a general anaesthetic in the past?
    • If so, when and for what procedure?
    • Did the patient feel nauseous or vomit after their last general anaesthetic?
    • Did they have any unforeseen complications, or have an unplanned admission to the Intensive Care Unit?
    • Was the patient told they had any difficulties with their airway? i.e. were they told ‘you were difficult to intubate’ or ‘you have a difficult airway’?
      • If yes, what details do they have?

3) Medical history overview

  • Does the patient have any chronic and ongoing medical conditions for which they receive treatment or surveillance?
    • If they do, find out:
      • the condition
      • the treatment (i.e. medical, surgical, etc)
      • who is it managed by (i.e. the GP, a hospital specialist)

4) Surgical History

  • Has the patient had surgery before?
    • If so:
      • what procedure
      • when
      • was any metalwork implanted?
        • if so, where is the metalwork?
        • does the patient have any functional limitations due to this metalwork, or the pathology that led to their placement?
  • Does the patient have any implanted devices or pins/metalwork in their body?

5) Medications and allergies

Note that when documenting medicines, GENERIC rather than BRAND names should be recorded (e.g. record ‘LERCANIDIPINE’ rather than ‘ZANIDIP’)

  • What regular medicines does the patient take?
  • Does the patient have a true allergy to any drugs or substances?
    • If so, what is the nature of the allergic reaction?
  • Does the patient take any herbal remedies?
  • Does the patient take any recreational drugs?

6) Assessment of functional capacity

For further details on the vital importance of this, see here.

  • Can the patient comfortably climb a flight of stairs without having to stop because of pain in their chest or because they are out of breath?
    • If the answer is no or uncertain, the patients exercise tolerance must be more formally quantified using the Duke Activity Status Index
    • Note and document the Metabolic Equivalents (METS) for the patient.
    • This question can be correlated with the patient being capable of ‘4 METS’. This suggests their body can handle the stresses involved in a ,major surgery.
    • If this is ≤4, the patient will likely need functional testing of their cardiorespiratory systems
  • Has the patients exercise tolerance declined recently (e.g. in the past six months)?

7) Social

  • Does the patient smoke currently? How much, and for how long?
  • Does the patient drink alcohol? How many units per week?
  • Does the patient live independently?
    • Record the patients Clinical Frailty Scale (CFS)
  • Assess the patient’s nutrition:
    • Has the patient lost weight recently without intending to?
    • Has the patient’s appetite decreased recently?
  • Is the patient a Jehovah’s Witness, or do you they hold any beliefs that might affect what treatments or drugs they are willing to receive?

8) Final screening

These are slightly tailored to each patient depending on whether the issue has been uncovered during earlier steps.

  • Can the patient lie flat?
  • Does the patient get pain in their chest when engaging in activity?
  • Does the patient faint frequently?
  • Does the patient have any ongoing fevers, productive cough, or pain when urinating?
  • Has the patient ever been diagnosed with sleep apnoea or told to use a CPAP mask while they sleep?
  • Has the patient had a hospital admission in the past year? Did this involve intensive care?
  • Does the patient suffer from any chronic infective diseases (e.g. heptitis, HIV, etc.)?
  • Does the patient take:
    • blood thinners?
    • medicines for diabetes?
    • anti-seizure medications?

Examination

1) Vital signs

  • Heart rate
  • Blood Pressure
  • Respiratory rate
  • Oxygen saturations
  • Palpate pulse to assess regularity

2) Airway assessment

  • determine if the patient can fully open their mouth
  • determine if the patient’s neck has a full range of movement
  • does the patient have any physical abnormality with their jaw or neck?

3) Cardiorespiratory

  • auscultate the heart and lung fields, paying particular attention to note the presence of murmurs or added sounds

References

1.
Nørskov AK, Rosenstock CV, Wetterslev J, Astrup G, Afshari A, Lundstrøm LH. Diagnostic accuracy of anaesthesiologists’ prediction of difficult airway management in daily clinical practice: a cohort study of 188 064 patients registered in the Danish Anaesthesia Database. Anaesthesia. 2015;70(3):272-281. doi:10.1111/anae.12955