Pre-Anaesthetic Evaluation (Preoperative Assessment Note)

Pre-Anaesthetic Evaluation (Preoperative Assessment Note) Patient Identification: Full Name: Ms. Amelia Sharma Hospital Number: 7890123 Date of Birth: 15/03/1978 Gender: Female Procedure Details: Planned Procedure: Laparoscopic Cholecystectomy Expected Date: 1 November 2024 Hospital/Clinic Location: General Hospital Surgical Ward Responsible Surgeon/Proceduralist: Dr. Eleanor Vance (General Surgeon) Medical History: Chronic Illnesses: Hypertension (controlled with medication), Type 2 Diabetes Mellitus (managed with oral hypoglycaemics), history of seasonal asthma (well-controlled, last exacerbation 3 years ago). Previous Surgical History: Appendectomy at age 12, wisdom teeth extraction at age 25. Known Diagnoses: Essential Hypertension, Type 2 DM, well-controlled asthma. Comorbidities: No acute comorbidities affecting anesthetic risk at present. Medication History: Current Medications: Ramipril 5mg daily, Metformin 1000mg twice daily, Salbutamol inhaler as needed (rarely used). Supplements: Multivitamin daily. Recent Changes: No recent changes in treatment. Allergies: Drug Allergies: Penicillin (rash, itching). Food Allergies: None. Latex Allergies: None. Physical Examination: General Clinical Assessment: Well-nourished, alert, and oriented female. Weight: 70 kg Height: 165 cm Vital Signs: BP 130/85 mmHg, HR 72 bpm (regular), RR 16 breaths/min, SpO2 98% on room air. Cardiovascular Exam: S1 S2 heard, no murmurs, gallops, or rubs. Peripheral pulses present and equal. Respiratory Exam: Clear to auscultation bilaterally, no wheezes or crackles. Good air entry. Airway Assessment: Mallampati Score: Class II Mouth Opening: Adequate (3 fingerbreadths) Thyromental Distance: >6 cm Neck Movement: Full range of motion Loose/Missing Teeth or Dentures: No loose teeth, no dentures. Other Airway Predictors: None identified. Laboratory and Diagnostic Results: Hb: 13.5 g/dL (normal) Creatinine: 70 µmol/L (normal) Glucose: 6.8 mmol/L (controlled) ECG: Normal Sinus Rhythm, no ischaemic changes or arrhythmias. Risk Stratification: ASA Physical Status Classification: ASA II Identified Risk Factors: Controlled hypertension and type 2 diabetes mellitus. No other significant risk factors. Anesthetic Plan: Proposed Anesthetic Technique: General Anaesthesia with LMA insertion. Induction Strategy: Propofol induction, Fentanyl for analgesia, Rocuronium for muscle relaxation if required for LMA insertion. Maintenance Strategy: Sevoflurane in air/oxygen mixture. Monitoring Plans: Standard ASA monitoring (ECG, NIBP, SpO2, EtCO2). Postoperative Care Needs: Standard post-operative recovery, routine pain management with paracetamol and ibuprofen, antiemetics as per protocol. Discharge to ward. Consent: Informed consent discussion for anaesthesia was conducted. Patient understands the risks (e.g., nausea, vomiting, sore throat, dental damage, awareness, allergic reaction) and benefits (pain relief, loss of consciousness). Alternatives were discussed (regional anaesthesia not suitable for this procedure). Patient had ample opportunity to ask questions and expressed understanding and agreement. Special Considerations: NPO Compliance: Patient is compliant with NPO guidelines (6 hours for solids, 2 hours for clear fluids). Planned Surgical Position: Supine. Blood Availability: Group and Save requested, no cross-match indicated. Cultural Needs: None specified. Interpreter Involvement: Not required. Multidisciplinary Referrals: None indicated for pre-operative optimisation. Clinician Signature: Dr. Marcus Thorne, Anaesthetist, 1 November 2024