Pre-Operative Assessment Case Sheet - Components Explained

1. Patient Identification

• Name, age, sex, date of admission
• Unit/bed number, hospital registration number
• Date of surgery, name of operating surgeon and anaesthetist

2. Chief Complaint (CC)

• The primary reason the patient is presenting for surgery, stated in the patient's own words, with duration
• Example: "Swelling in the right lower abdomen for 3 months"

3. History of Presenting Illness (HPI)

• Onset, duration, character, and progression of symptoms
• Aggravating and relieving factors
• Previous episodes and treatment received
• Symptoms relevant to likely diagnosis (e.g., for a bowel case - change in bowel habit, blood in stool, weight loss)

4. Past Medical History (PMH)

• Known comorbidities: hypertension, diabetes mellitus, ischemic heart disease, COPD, renal disease, liver disease
• Previous hospitalizations
• Prior surgeries and any complications during those surgeries (bleeding, anaesthetic problems)
• History of deep vein thrombosis or pulmonary embolism (relevant for VTE risk)

5. Drug History

• Current medications with doses - especially:
  • Anticoagulants (warfarin, heparins, NOACs) - need bridging or reversal
  • Antiplatelet agents (aspirin, clopidogrel) - may need to be stopped
  • Insulin and oral hypoglycaemics - perioperative glucose management protocols
  • Antihypertensives, ACE inhibitors, ARBs
  • Steroids - need stress dosing
  • Herbal supplements - many affect bleeding (garlic, ginseng, ginkgo)

6. Allergy History

• Documented drug allergies with the nature of the reaction (rash vs. anaphylaxis)
• Latex allergy (important for OT preparation)
• Food allergies (especially shellfish if iodine-based contrast is planned)

7. Personal History

• Smoking: pack-year history (impacts pulmonary risk and wound healing)
• Alcohol use: chronic use affects anaesthetic dosing and liver function
• Substance use: opioids, benzodiazepines affect anaesthetic management
• Occupation and activity level (used to estimate functional capacity)

8. Family History

• History of anaesthetic complications in family: malignant hyperthermia, pseudocholinesterase deficiency
• Bleeding disorders (haemophilia, von Willebrand disease)
• Cardiovascular disease, diabetes, malignancy

9. Menstrual and Obstetric History (in females)

• Last menstrual period (LMP) - rule out pregnancy before surgery and anaesthesia
• Parity, previous caesarean sections (relevant for pelvic/abdominal surgery)
• Oral contraceptive pill use (thromboembolism risk)

10. Review of Systems (Systemic Enquiry)

11. Physical Examination

General

• Build, nutrition, pallor, icterus, cyanosis, clubbing, lymphadenopathy, oedema
• Weight, height, BMI - important for drug dosing and VTE risk

Vital Signs

• Blood pressure (both arms if cardiovascular history)
• Heart rate, respiratory rate, SpO2 on room air
• Temperature

Airway Assessment (mandatory pre-op)

• Mallampati classification (Class 1-4 based on visible oropharyngeal structures)
• Mouth opening (normal >4 cm or 3 finger-breadths)
• Thyromental distance (normal >6 cm - less than 6 cm predicts difficult intubation)
• Neck mobility and circumference
• Presence of large overbite, small mandible, limited jaw protrusion
• Obesity is an independent risk factor for both difficult intubation and difficult mask ventilation

Mallampati classification: Class 1 = soft palate, fauces, uvula, pillars visible; Class 4 = hard palate only visible - Schwartz's Principles of Surgery, p. 2062

Cardiovascular Examination

• JVP, pulse character, cardiac auscultation (murmurs, added sounds)
• Peripheral vascular status

Respiratory Examination

• Chest expansion, percussion, auscultation

Abdominal Examination

• Specific to the surgical problem plus general assessment (hepatosplenomegaly, ascites)

Neurological Examination

• Baseline motor and sensory function (especially for spine/regional anaesthesia cases)

12. ASA Physical Status Classification

13. Functional Status Assessment

• Measured in METs (Metabolic Equivalents)
• Patients who cannot achieve 4 METs are considered poor functional status and may need further cardiac workup before surgery
• 4 METs = walking up a flight of stairs, climbing a hill, or walking at 3-4 mph on level ground
• This directly determines whether further pre-operative cardiac investigations are needed (ACC/AHA guidelines)

14. Investigations

Routine / Baseline

Targeted / Specialty-Based

• Echocardiogram - if cardiac murmur or reduced functional status
• Pulmonary function tests - for thoracic surgery or significant lung disease
• Serum albumin - marker of nutritional status and wound healing risk
• Pregnancy test (urine beta-hCG) - all women of reproductive age
• Imaging relevant to the planned procedure (CT, MRI, ultrasound)

15. Cardiac Risk Assessment

1. History of ischaemic heart disease
2. Congestive cardiac failure
3. Cerebrovascular disease
4. Insulin-dependent diabetes mellitus
5. Chronic kidney disease (baseline creatinine >2 mg/dL)
6. High-risk surgery: major vascular, intraperitoneal, or intrathoracic

16. Thromboembolism Risk Assessment

• Caprini or Wells score for DVT/PE risk
• Determines whether pharmacological prophylaxis (low-molecular-weight heparin) and/or mechanical prophylaxis (compression stockings, sequential compression devices) are needed

17. Preoperative Fasting Status (NPO Status)

• Patients at high aspiration risk (GORD, gastroparesis, achalasia, bowel obstruction) need rapid sequence induction regardless of fasting status.

18. Consent

• Documented informed consent for the surgical procedure
• Discussion of the procedure, alternatives, risks (general and specific), and benefits
• Anaesthetic consent (separate in many institutions)
• For patients with DNR/DNI orders, pre-operative discussion must clarify whether these orders apply in the perioperative period

19. Anaesthetic Plan / Pre-operative Orders

• Type of anaesthesia planned: general, regional, local with sedation
• Airway plan including backup plan for anticipated difficult airway
• Blood product orders
• Antibiotic prophylaxis (type, dose, timing - typically within 60 minutes of incision)
• DVT prophylaxis plan
• Glucose management protocol (for diabetics)
• Instructions for regular medications (what to hold, what to give on the morning of surgery)

20. Pre-operative Risk Summary

• ASA class
• Cardiac risk (Revised Cardiac Risk Index)
• Airway classification (Mallampati)
• Key comorbidities and whether they are optimized
• Any outstanding issues (e.g., "cardiology review awaited", "INR to be rechecked")
• Plan: "Proceed / Delay / Optimize and reschedule"

• Schwartz's Principles of Surgery, 11e - Chapter 46 (Anesthesia for the Surgical Patient)
• Miller's Anesthesia, 10e - Chapter 29 (Preoperative)

Types of Fever

Definition

Body temperatures under different conditions - Guyton & Hall Textbook of Medical Physiology

A. Classification by Temperature Degree

B. Classification by Fever Pattern (Most Important Clinically)

1. Continuous (Sustained) Fever

• Temperature remains elevated throughout the day with diurnal variation of less than 1°C (i.e., never touches normal)
• Does NOT touch the normal baseline
• Examples: Lobar pneumonia, typhoid fever (classical), urinary tract infection, rickettsial infections
• Temperature typically 39-40°C throughout

2. Remittent Fever

• Temperature remains elevated throughout the day but diurnal variation exceeds 1°C
• Still does NOT touch normal baseline
• The most common type of fever seen in clinical practice
• Examples: Typhoid fever (more commonly), infective endocarditis, viral fevers, most bacterial infections

3. Intermittent Fever

• Temperature rises above normal and then comes down to normal (or below normal) every day
• The key feature: temperature touches the normal baseline between spikes
• Sub-types based on periodicity:
  • Quotidian - fever spike every 24 hours (daily) - seen in Plasmodium falciparum malaria (also some cases of P. vivax), pyogenic abscesses
  • Tertian - fever every 48 hours (3rd day cycle) - seen in P. vivax and P. ovale malaria
  • Quartan - fever every 72 hours (4th day cycle) - seen in P. malariae malaria

4. Hectic (Septic / Swinging) Fever

• A very wide diurnal variation in temperature (>2°C), with the fever going very high and then coming down to normal or subnormal
• Usually accompanied by rigors (when rising) and profuse sweating (when falling)
• Characteristic of pyogenic (pus-forming) infections
• Examples: Pyogenic abscesses (liver abscess, subphrenic abscess), bacteraemia/septicaemia, tuberculosis (miliary or cavitating), infective endocarditis

5. Relapsing (Periodic) Fever

• Fever present for several days, followed by an afebrile period of several days, then fever returns
• Also called "undulant fever"
• Examples:
  • Borrelia infections (relapsing fever) - fever lasts 3-6 days, then 7 days afebrile, then recurs
  • Brucellosis (undulant fever) - classic undulating pattern
  • Malaria (if untreated, can relapse)
  • Hodgkin's lymphoma (Pel-Ebstein fever - a specific type of relapsing pattern)

6. Pel-Ebstein Fever

• A specific relapsing pattern: days to weeks of high fever alternating with days to weeks of normal temperature
• Classically described in Hodgkin's lymphoma
• Considered pathognomonic (though now recognized as uncommon even in Hodgkin's)

7. Inverse (Reverse) Fever

• Temperature is higher in the morning than in the evening
• The reverse of the normal diurnal pattern (normally, body temp is lowest in early morning and highest in late afternoon)
• Examples: Miliary tuberculosis, gram-negative septicaemia, liver abscess (occasionally)

C. Classification by Duration

D. Special / Named Fever Patterns

E. Fever in the Surgical Context (Post-operative Fever)

F. Fever vs. Hyperthermia - Key Distinction

• Guyton and Hall Textbook of Medical Physiology - Chapter 74 (Body Temperature Regulation and Fever)
• Bradley and Daroff's Neurology in Clinical Practice - Chapter 50 (Fever and Hyperthermia)
• Bailey and Love's Short Practice of Surgery, 28e - Chapter 24 (Post-operative fever)