[Dr. Eleanor Vance]
Consultant Anaesthetist
MBBS, FRCA
Practice Number: 1234567
PERI-OPERATIVE RECORD
1. PRE-OPERATIVE ASSESSMENT
Patient information:
• Name: John Smith
• Age: 68
• Sex: Male
• Weight: 85 kg
• Height: 178 cm
• Date of assessment: 1 November 2024
• Procedure: Right Total Hip Replacement
• Surgeon: Mr. David Jones
• Hospital: City General Hospital
Medical history:
• Previous medical history: Hypertension, controlled with medication. Mild osteoarthritis.
• Medications: Lisinopril 20mg daily, Paracetamol as needed.
• Previous surgical history: Appendectomy 20 years ago.
• Previous anaesthetic complications: None known.
• Allergies: No known drug allergies.
• Social: Non-smoker, occasional alcohol consumption.
• Effort tolerance: Able to walk 100 meters without significant shortness of breath.
Examination:
• Airway:
- Fasting: 8 hours
- Mallampati score: Class I
- Mouth opening: 4 cm
- Neck mobility: Full range of motion.
- Teeth/ dentition: Dentures, upper and lower.
- Other airway concerns: None anticipated.
• Cardiovascular: Regular heart rate, no murmurs.
• Respiratory: Clear lung sounds bilaterally.
• Other: Nil.
Special investigations:
• Bedside: Nil.
• Laboratory: Hb 14.2 g/dL, Creatinine 88 umol/L, Na 140 mmol/L, K 4.1 mmol/L.
• Radiological: Chest X-ray clear.
• Other: Nil.
• Summary: Fit for surgery. Controlled hypertension. No significant anaesthetic risks identified.
• ASA classification: ASA II
• Concerns: Risk of post-operative pain.
• Anaesthetic plan: General anaesthesia with peripheral nerve block for post-operative analgesia.
2. INTRA-OPERATIVE ANAESTHESIA
General:
• Date of surgery: 1 November 2024
• Surgeon: Mr. David Jones
• Hospital: City General Hospital
• Anaesthetic start time: 09:00
• Anaesthetic end time: 12:00
• Total time: 3 hours
Intravenous lines, monitoring and other:
• Intravenous line: 18G in left forearm.
• Other lines (Central line/ Arterial line): Nil.
• Standard ASA Monitors applied (ECG, SpO2, NIBP, Capnography): Yes
• Other monitors: Temperature probe.
• Eyes taped shut: Yes
• Pressure points padded: Yes
• Warmer: Forced air warmer used.
• Calf compressors: Yes
Induction:
• Pre-oxygenation: 3 minutes with 100% oxygen.
• Drugs administered: Fentanyl 100 mcg, Propofol 150mg, Rocuronium 50mg.
• Airway management (NPO2, MASK, LMA, ETT): Endotracheal intubation, size 7.0 ETT.
• Positioning: Supine.
Maintenance:
• Anaesthetic technique (Sedation/ GA/ RA): General Anaesthesia
• Regional anaesthetic technique: Femoral nerve block performed.
• Ventilation: Volume-controlled ventilation, Vt 500ml, RR 12/min, FiO2 0.4.
• Drugs administered: Sevoflurane 1.5%, Rocuronium top-ups.
• Fluids administered: Hartmann's solution 1500ml.
• Blood loss: 300ml.
• Urine output: 200ml.
Emergence:
• Extubation: Awake and breathing spontaneously.
Intra-operative events:
• Complications/ interventions: Nil.
• Notes: Patient stable throughout the procedure.
3. POST-OPERATIVE CARE
Immediate recovery:
• Vital signs: BP 130/80 mmHg, HR 80 bpm, SpO2 98% on room air.
• Pain score: 3/10.
• Nausea/ Vomiting: Nil.
• Other complications: Nil.
Further care:
• Transfer (Back to ward/ ICU): Back to ward.
Ward prescription:
• Medication: Paracetamol 1g qds, Morphine 2.5mg PRN for pain, Ondansetron 4mg PRN for nausea, Enoxaparin 40mg daily.
Discharge prescription:
• Medication: As per ward prescription, to continue for 24 hours post-operatively. Review pain control and discharge with appropriate analgesia.
