preoperative care

1. ERIC WILLIAMS MEDICAL SCIENCES COMPLEX PART 1
PRE-OPERATIVE ASSESSMENT FOR ANAESTHESIA CHECKLIST
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DATE: ________________ TIME____________ SURGEON: ______________________________________
MEDICAL RECORD #: __________________
SURNAME: ________________________________ OPERATION: ____________________________________
FIRST NAME: _____________________________________
WARD: _________________ ANAESTHETIST:__________________________________
AGE: ________ WEIGHT: _______ HEIGHT: _________ BMI:________kg/m2
BLOOD GROUP: __________
CONSENT FORM SIGNED: YES □ NO □ HEALTH SURVEY QUESTIONNAIRE COMPLETE:YES □NO □
DATE OF LAST MENSTRUAL PERIOD: _____________ BP. / P R T
ILLNESS HISTORY: ______________________________________________________________________________________________
TRAUMA YES□ NO□ LOC YES□ NO□DURATION_________ TIME OF LAST MEAL/DRINK: _____________
VOMITING YES□ NO□ DIARRHOEA YES□ NO□ BLEEDING YES□ NO□ OTHER FLUID LOSSES _______
CHRONIC ILLNESS:
DIABETES YES□ NO□ TYPE IDDM□ NIDDM□ DURATION______ TREATMENT_____________________
HYPERTENSION YES□ NO□ DURATION______ TREATMENT__________________________________________
ISCHAEMIC HEART DISEASE YES□ NO□ DURATION ______ TREATMENT_____________________________
SCD YES□ NO□ TREATMENT__________ THALASSEMIA YES□ NO□ BLEEDING DISORDER YES□ NO□
ASTH MA YES□ NO□ PREV ADMISSION□ PREV ICU□ LAST ATTACK_______ TREATMENT_______________
EPILEPSY YES□ NO□ LAST ATTACK________ TREATMENT__________________________________________
CONGENITAL HEART DISEASE YES□ NO□ RHEUMATIC HEART DISEASE YES□ NO□
OTHER ILLNESSES _______________________________________________________________________________________
PERINATAL HISTORY:
TERM□ PRETERM□ ____/40 COMPLICATIONS DURING PREGNANCY YES□ NO□ SCBU/ NNU YES□NO□
RELEVANT INFO:________________________________________________________________________________
REVIEW OF SYSTEMS:
RECENT URTI (WITHIN LAST 3 WEEKS) YES□ NO□ RUNNY NOSE□ FEVER□ PRODUCTIVE COUGH□
DYSPNOEA YES□ NO□ CHEST PAIN YES□ NO□ PALPITATIONS YES□ NO□ PND YES□ NO□
EXERCISE TOLERANCE ______________________________________ ORTHOPNOEA NO□ YES□______PILLOWS
GASTRO-OESOPHAGEAL REFLUX YES□ NO□ SNORING YES□ NO□ SLEEP APNOEA YES□ NO□
DRUG HISTORY:
ANTIHYPERTENSIVES________________ ANALGESICS_______________ ORAL CONTRACEPTIVE PILL_____________
ANTIDIABETICS ______________________ DIURETICS_________________ ANTICOAGULANTS _____________________
CORTICOSTEROIDS ___________________ ANTIBIOTICS ______________ OTHER_______________________________
HERBAL MEDICINE _________________ BUSH TEAS________________ OTC DRUGS____________________________
SOCIAL HISTORY: SMOKER NO□ YES□________/ DAY MARIJUANA NO□ YES□ COCAINE NO□ YES□
ALCOHOL USE NO□ YES□ OCCASIONAL□ MILD□ MODERATE□ HEAVY□______________
ALLERGIES: NO□YES□_____________ RASH□ URTICARIA□ AIRWAY OEDEMA□ ANAPHYLAXIS□
ANAESTHETIC HISTORY: PREV SX NO□ YES□_____________ PREV HOSPITALISATION NO□ YES□_______________
PREV GA NO□ YES□ DATE_____________ PROBS WITH GA NO□YES□_________PONV □PAIN □
FAMILY HISTORY: ADVERSE REACTION TO PREV ANAESTHETIC NO□ YES_________________________ICU ADMISSION□

2. PRE-OPERATIVE ASSESSMENT FOR ANAESTHESIA CHECKLIST
PART 2
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PHYSICAL EXAMINATION
MUCOUS MEMBRANES: MOIST□ DRY□ PINK□ PALE□ CYANOSIS YES□ NO□ ICTERUS YES□ NO□
AIRWAY ASSESSMENT: EDEMA YES□ NO□ BEARD YES□ NO□ THYROID / AIRWAY MASS YES□ NO□
TEETH CARIES□ LOOSE TEETH□ BUCK TEETH□ CAPS□ CROWNS□
INTERDENTAL DISTANCE: <3FB□ >3FB□ THYROMENTAL DISTANCE: <6.5cm□ >6.5cm□
NECK MOBILITY GOOD: NO□ YES□ STERNOMENTAL DISTANCE: <12.5cm□ >12.5cm□
TMJ MOBILITY: UNABLE TO PROTRUDE JAW□ TEETH JUST TOGETHER□ CAN PROTRUDE JAW□
MALLANPATI SCORE: I II III IV EDENTULOUS: YES□ NO□
LIKELY DIFFICULT VENTILATION YES□ NO□ LIKELY DIFFICULT INTUBATION YES□ NO□
RESIRATORY SYSTEM: TRACHEA CENTRAL YES□ NO□ AIR ENTRY R=L YES□ NO□ CREPITATION□ RHONCHI□
EXPANSION_____________________ PERCUSSION__________________ VOCAL FREMITUS _________________
FINDINGS ON AUSCULTATION_______________________________________________________________________
CARDIOVASCULAR SYSTEM: PULSE RATE ___________regular□ irregular□ BLOOD PRESSURE _______/_______
HEART SOUNDS S1 S2 S3 S4 THRILLS_____________ MURMURS_______________
SIGNS OF CARDIAC FAILURE _________________ FUNCTIONAL DIAGNOSIS __________________________
ABDOMEN: THIN□ NORMAL□ OBESE□ DISTENSION YES□ NO□ ASCITES YES□ NO□
SITE FOR REGIONAL BLOCK: THORACO-LUMBAR SPINE _____________________ UPPER / LOWER LIMB ___________________
VENOUS ACCESS: LIKELY DIFFICULT YES□ NO□ IV IN SITU: FUNCTIONAL YES□ NO□ ADEQUATE YES□ NO□
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INVESTIGATIONS ORDERED & RESULTS
Hb __________ Hct ____________ WBC _________ Platlets __________ PT______________ PTT____________
Na ___________ K _____________ Cl ____________ Urea ____________ Creat ____________ Glu_____________
ECG_____________________________ CXR_________________________________ ECHO_____________________________
Lung Fcn Tests_____________________ PEFR___________________ ABG_____________________________________________
BLOOD GROUPED AND CROSS MATCHED YES□ NO□ OLD REPORTS/NOTES AVAILABLE YES□ NO□
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ASA STATUS: I II III IV V Emergency / Urgent / Scheduled Fit for Day Surgery YES□ NO□
STARVATION ORDERS ________________________________________________________________________________________
PREMEDICATION ORDERED: ___________________________________________________________________________________
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ADVICE:
WITHOLD DIABETIC MEDICATION; ON MORNING OF SURGERY, DO FBS & ELECTROLYTES, START SLIDING SCALE INSILIN
STOP ASPIRIN 2/52 BEFORE SURGERY CONTINUE: ANTIHYPERTENSIVES ON MORNING OF SURGERY
GIVE ASMATHICS SALBUTAMOL BEFORE SURGERY GIVE STEROID TO PTS ON STEROIDS FOR ≥2/52 IN LAST 2 YRS
CONSIDER DVT PROPHYLAXIS AND H2 BLOCKERS FOR OBESE PATIENTS
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ANAESTHETIC OFFICER: ___________________________________