The Anesthesia Preoperative Evaluation

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ID

state age, sex, and scheduled surgical procedure including which side if site specific

Past Medical History
(list all medical history with special emphasis on the following)

CV- list past CV history,

• Hypertension – how well controlled and which meds are needed for control
  
• CAD- list if the patient has had an MI, plus report any recent CP or SOB and list any cardiac evaluation including functional studies (P-thal, treadmill, stress echo) and/or cardiac echo.
  

Resp- list past respiratory history, include room air sat and home O₂ requirements

• COPD- list medications needed to control symptoms including any recent steroid use, list any PFT if available
  Asthma- list any recent flares or hospitalizations including steroids use

Endo-

• DM- list how well it is controlled and how it is controlled (diet, meds, insulin), list last HbA1C if available
  

GI-

• GERD- list degree of symptoms including passive reflux symptoms and if it is controlled on medication

Hem/ID- list any history of bleeding disorders and/or any recent anticoagulation including when the patient last received anticoagulation medication, list any recent coagulation studies

Neuro- list any deficits including residual effects of old CVAs

Pain- note pre operative pain score and document any history of chronic pain and list all preoperative pain medication taken by the patient

Other- list all other medical conditions

Past Surgical History

List all past surgeries where the surgeries were performed if known.

Past Anesthetic History

List any problems with anesthesia including difficult airway, PONV, difficult IV access, awareness, or prolonged emergence

Family History

List any problems with anesthesia that runs in the family (MH, pseudocholinesterase deficiency, etc.)         

Social History

• List ETOH history including amount and last drink
  
• List smoking history including duration and when patient last smoked
  
• List any illicit drug use

Medications

List all medications that the patient is taking including over the counter and herbal medications.  List the most important drugs first and give doses for important medication

Allergies

List all allergies including latex and record what happened with each reaction.

Review of Symptoms

List any recent fevers, new productive cough, GERD symptoms, low back pain, chest pain, shortness of breath, and history of motion sickness

Exercise Tolerance

Quantify amount and degree of exercise the patient can do with out developing chest pain or shortness of breath (0-2 flights of stairs)

Physical Exam

            Weight and height, vitals including room air saturation, and general appearance

            Airway exam- complete airway exam
            CV- complete exam with a focus on murmurs or rubs
            Resp- complete lung exam noted wheeze or crackles
            Neuro- complete neuro exam including carotid bruits
Extremities- complete exam including clubbing, deformities, bruising, and venous access

EKG

Full interpretation including rate, rhythm, and ST changes.  Any abnormalities should be compared to an old EKG if available

Labs

Review all recent labs and if any abnormal labs are noted confirm that the findings are not new

Assessment and Plan

           
ASA status

1. healthy
2. mild systemic disease under control
3. severe systemic disease with poor control
4. severe systemic disease with threat to life
5. expect death with in 24hrs with out surgery
6. brain dead (organ donor)

Plan

For example: MAC/Regional/GA with or with out invasive monitors