THE PRE OPERATIVE ASSESSMENT
Goals:
- Improve patient outcome.
- Reduce patient's anxiety.
- Obtain informed consent.
It is relied primarily on accurate history and clinical examination.
History:
Name
Age
Sex
Occupation
Home address
Home phone
Cell phone
Marital status
Referring surgeon
(I)
How would you rate your overall health?
Excellent Good Fair Poor
(II)
Has been a recent change in your health?
Yes No Comment
(III) How physically active are you?
Very active (no restrictions)
Somewhat active (walk upstairs)
Not active (unable to walk)
(IV) Previous hospitalization:
Date (month-year).
Hospital
Type of operation
Type of anesthesia
(V)
Do you have or have you even had any of these problems:
Heart attack or heart failure.
Stroke.
Kidney or bladder problems.
Liver problems or hepatitis.
High blood pressure.
Diabetes.
Bleeding problem.
Cancer.
Seizure or epilepsy.
Rheumatic fever.
Arthritis.
Lung problems e.g. pneumonia, emphysema, bronchitis,
asthma… etc
Others.
(VI) Please name any medicines that you are presently taking;
include all prescription and nonprescription drugs (even
aspirin): type of medication, dosage (amount), number of
times taken each day.
(VII) Are you allergic, or have you had unusual reactions following
the use of adhesive tapes, medicine, or drugs? Please list the
items and the type of reaction you experienced.
(VIII) Have you ever taken steroids such as prednisolone or
cortisone? When? For how long? , if stop it, from which time?
(IX) Do you have any of the following? False teeth, capped teeth,
loose teeth… etc.
(X)
Have you or any of your close relatives encountered problems
or complications with anesthesia? , what?
(XI) At the present time, do you have?
Chest pain.
Blackouts or periods of dizziness.
Palpitations or irregular heartbeats.
Pain in your legs with exercise.
Ankle swelling.
Shortness of breath at night.
Shortness of breath with exercise.
Chronic cough or sputum.
Black or tarry stools or diarrhea.
Frequent nausea and vomiting.
Facial weakness.
Temporary weakness of one or more limbs.
Temporary loss or blurring of vision.
Burning urination or frequent urination.
Arthritis or joint pain.
Back pain.
Excessive bleeding following minor cuts or dental surgery.
(18)Resent weight loss.
Difficulty in walking.
Pregnancy.
(XII) Have you had resent problems with: cold, flu, bronchitis, laryngitis,
sore throat or fever.
(XIII)Do you smoke? How many years? Packs per day?
(XIIII)Do you drink alcoholic beverages? Drinks per day?
(XX) Do you wish to discuss the possible complications of anesthesia?
Physical examination:
(I)
General examination.
(II)
Vital signs.
(III) Concentrate on respiratory and CVS.
(IV) Examination for difficult intubation:
Teeth.
Mouth opening.
Rang of active head extension.
Tung versus pharyngeal size.
(V)
Examination of back.
Investigation:
History and clinical examination are the best measure for screening
for disease.
Laboratory test recommendations for asymptomatic healthy patients
scheduled to undergo non blood loss peripheral surgical procedures:
Age(years)
Tests indicated
Men
Women
40 and bellow
None
Pregnancy test?
-
ECG
Hb or PCV, pregnancy
test?
-
ECG
Hb or PCV, ECG
-
Hb, PCV, ECG, BUN,
glucose, CXR?
Hb, PCV, ECG, BUN,
glucose, CXR?
75 and above
Hb, PCV, ECG, BUN,
glucose, CXR
Hb, PCV, ECG, BUN,
glucose, CXR