The pre-operative history follows the same structure as typical Medical history taking, with the addition of some anaesthetic and surgery specific topics.
A brief history of why the patient first attended and what procedure they have subsequently been scheduled for. One should also confirm the side on which the procedure will be performed (if applicable)
There may be aspects of the disease or condition requiring surgery that are important for the anaesthetist to be aware of; for example, head and neck surgery may indicate the presence of abnormal airway anatomy.
A full past medical history (PMH) is required, with the following specifically asked about:
Cardiovascular disease, including hypertension; exercise tolerance is a useful indicator of cardiovascular fitness and, particularly for patients undergoing major surgery, can help predict their risk of post-operative complications and level of care needed post-operatively Screening questions may elucidate undiagnosed disease and prompt further investigation, e.g. the presence of exertional chest pain, syncopal episodes, or orthopnoea Respiratory disease, as adequate oxygenation and ventilation is essential in reducing the risk of acute ischaemic events in the peri-operative period Questions including whether the patient is able to lie flat for a prolonged period or has a chronic cough are key as these may preclude spinal anaesthesia; also screen for symptoms and signs of obstructive sleep apnoea, if the patient has any risk factors Renal disease, including their baseline renal function and any renal-specific medications Endocrine disease, specifically diabetes mellitus and thyroid disease Gastro-oeseophageal reflux (GORD), as the aspiration of gastric contents can potentially be fatal and the presence of GORD will likely alter anaesthetic technique Whilst this may be overlooked as a diagnosis or in their past medical history, particularly if patient managed with over-the-counter medicines, it is important to ask about at the pre-operative assessment Other specific questions it may be useful to ask themselves the following questions:
Pregnancy – as part of the pre-operative checklist on the day of surgery, for females of reproductive age a urinary pregnancy test is mandatory in the majority of hospitals Sickle Cell Disease – could they have undiagnosed sickle cell disease, especially if their country of birth does not have routine screening for sickle cell Past Surgical History
Has the patient had any previous operations? If so, what, when, and why?
If the patient is having a repeat procedure, this can significantly change both the surgical time and ease of operation, and hence influence the anaesthetic technique used
Has the patient had anaesthesia before? If so, for what operation and what type of anaesthesia? Were there any problems? Did the patient experience any post-operative nausea and vomiting?
A full drug history is required, as some medications require stopping or altering prior to surgery. Ask about any known allergies, both drug and non-drug allergies
Whilst most hereditary conditions relating to anaesthesia are extremely rare, such as malignant hyperthermia, it is important to ask about any known family history of problems with anaesthesia
Ensure to ask the patient about smoking history, alcohol intake, and any recreational drug use
Other important social factors to make note of include:
Language spoken and the need for an interpreter Living situation, as the absence of an adult at home may require an admission overnight