Pre-Operative assessment

Age: ‍ years old

Gender: ‍malefemale



HISTORY:

Presents for a pre-operative assessment

Planned procedure: ‍, ‍electiveurgent

Last meal: ‍ ‍ ‍dayshours ago

Last drink: ‍ ‍ ‍dayshours ago

Scheduled date: ‍ ‍not yet decided



Current complaints: ‍none



Past medical history: ‍ ‍none



Past surgical history: ‍ ‍none



Medications: ‍ ‍none



Allergies: ‍ ‍NKDA



Family history: ‍none, ‍



Social history:

Smoking: ‍neversmokerformer smoker, ‍ pack-years

Alcohol: ‍nonereasonableexcessive, ‍ drinks per ‍dayweek

Recreational drugs: ‍none ‍cannabis, ‍IVDU

Diet: ‍goodaveragepoor, ‍high in salt, ‍high in carbs, ‍high in fat, ‍vegan

Physical activity: ‍adequateaveragesedentary

Occupation: ‍





EXAM:

General appearance: ‍well-appearing, ‍apparent distress

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Metrics: weight: ‍ ‍kglbs, height: ‍ cm, waist: ‍ cm, BMI: ‍

Neck: ‍normal, ‍lymphadenopathy, ‍, c-spine ‍

Heart: ‍RRR, ‍MRG, ‍normal S1 and S2

Lungs: ‍clear bilaterally, ‍abnormal sounds, ‍retractions

Abdomen: ‍soft, ‍non-tender ‍, ‍non-distended, ‍

Anorectal: DRE ‍normal, prostate ‍normal, ‍blood, ‍mass, anus ‍

Extremities: ‍warm, ‍dry, cap refill ‍< 3> 3 sec, pulses ‍intact, ‍edema ‍bilaterally, ‍

Musculoskeletal: joints ‍ ‍normal, ‍limited ROM

Neurologic: cranial nerves ‍intact, strength ‍intact 5/5, sensation ‍intact, reflexes ‍intact 2+, cerebellar function ‍intact, gait ‍steady





ASSESSMENT:

‍Medically cleared for surgery

DDx: cardiac risk factors, pulmonary risk factors, renal risk factors, endocrine risk factors, infectious risk factors, hematologic risk factors, nutritional deficiencies, anemia, electrolyte imbalances, coagulopathy, substance abuse issues, medication interactions, allergies to anesthesia or medications, psychological readiness, social support systems, postoperative care planning





PLAN:

Investigations:

- Blood work: ‍CBC, ‍lytes, ‍creatinine, ‍glucose, ‍coagulation profile, ‍liver function tests

- Urinalysis

- ECG

- Chest X-ray

- Pulmonary function tests

- Cardiac stress test if cardiac disease or high-risk surgery

Treatments:

- Anticoagulation: stop ‍ days before surgery

- Clopidogrel: stop 7 days before surgery

- NSAIDs: stop 2 days before surgery

- Diabetic medications: ‍continueadjuststop ‍ days before surgery

- Anti-hypertensives: ‍continueadjuststop ‍ days before surgery

- Smoking cessation counseling

- Alcohol moderation counseling

Further care:

- Referral to dietitian

- Referral to anesthesiologist

- Follow-up in ‍ ‍daysweeks