— year-old — with a PMH of — comes in for preoperative risk assessment.
Surgery type:
Date:
Social support they will need to recover:___
Negative history of diseases of the heart, lungs, kidneys, or any bleeding diathesis. Specifically,
-No angina (chest pain), dyspnea, palpitations, syncope, presyncope, or claudication.
-No hx of heart disease–no prior MI, angina, cardiomyopathy, valvular heart disease, arrhythmia, heart failure, aortic stenosis, pacemaker, implantable cardioverter-defibrillator, or past orthostatic intolerance.
-No prior diagnostic heart testing or therapeutic interventions.
–No hx cardiovascular risk factors: No hx of hypertension, diabetes, chronic kidney disease, dyslipidemia, tobacco use, peripheral vascular disease, and cerebrovascular disease.
–No Asthma, COPD, OSA, pulmonary hypertension, or another lung disease.
-No obstructive sleep apnea symptoms (snoring, apneic episodes, gasping, choking).
–No hx of kidney disease.
-No hx of Bleeding problems. No hx of easy bruising, prolonged or profuse bleeding from minor wounds, family history of bleeding diathesis, nosebleeds, bleeding gums, etc.
*No hx of Rheumatoid arthritis, ankylosing spondylitis, chronic steroids, or Down syndrome (which could cause atlantoaxial instability and increase the risk of C-spine injury during intubation).
–No previous adverse reaction to anesthesia. No previous surgeries. Never been intubated.
-No Family hx of bleeding disorders
–Denies smoking, alcohol, or drug/opiate abuse.
-Patient doesn’t think she is pregnant.
Medications: List reviewed (not taking blood thinners).
Allergies:
ROS:
Functional Capacity:
—-/END/—-
Notes and additional resources
- *If any of these are present, there is a risk of C-spine injury during intubation 2/2 to atlantoaxial instability; consider flex/ext C-spine films.
Down syndrome? Consider atlantoaxial instability. - Diseases associated with an increased risk for surgical complications include respiratory and cardiac disease, malnutrition, and diabetes mellitus.
- If the patient is smoking: Recommend quitting smoking eight or more weeks before surgery to minimize the surgical risk associated with smoking.
- Review medications and decide which ones need to be stopped prior to the surgery, when that should occur, and when they should be resumed. Do any new meds like Statins or BB need to be started?
A sample of Negative History: “Patient denies symptoms of CP at rest or with exertion, PND, LE edema, claudication, and palpitations. The patient has no history of ischemic heart disease, CHF, CVD, DM, tobacco abuse, alcohol/drug abuse, recent anticoagulant or antithrombotic use, personal or family history of coagulopathy, or CKD.
Patient denies a history of undergoing a stress test, cardiac cath, or coronary revascularization either percutaneously or surgically)”
“Routine laboratory studies are rarely helpful except to monitor known disease states. Patients with good functional capacity do not require preoperative cardiac stress testing in most surgical cases. Unstable angina, myocardial infarction within six weeks and aortic or peripheral vascular surgery place a patient into a high-risk category for perioperative cardiac complications. Patients with respiratory disease may benefit from perioperative use of bronchodilators or steroids. Patients at increased risk of pulmonary complications should receive instruction in deep-breathing exercises or incentive spirometry. Assessment of nutritional status should be performed. An albumin level of less than 3.2 mg per dL (32 g per L) suggests an increased risk of complications. Patients deemed at risk because of compromised nutritional status may benefit from pre- and postoperative nutritional supplementation.” AAFP
Am Fam Physician. 2000 Jul 15;62(2):387-396.
http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/preventive-medicine/perioperative-evaluation/