Pre-Operative Anaesthetic Assessment Note

Pre-Operative Anaesthetic Assessment Note Patient 68 years, female Planned Procedure Elective Total Hip Arthroplasty (right side) Background and Functional Status Patient is independently mobile with a walking stick for longer distances. She manages all activities of daily living without assistance. Estimated functional capacity is 4 METs. No overt frailty indicators noted. Past Medical History Hypertension well-controlled on medication, Type 2 Diabetes Mellitus managed with diet and metformin (HbA1c 6.8%), osteoarthritis affecting multiple joints, and a history of well-controlled anxiety. No known cardiovascular disease, respiratory disease, or renal impairment. Previous Anaesthetic History Previous uncomplicated anaesthetic for laparoscopic cholecystectomy 5 years ago. No reported airway difficulties, postoperative complications, or PONV. Medications Lisinopril 10mg OD, Metformin 500mg BD, Atorvastatin 20mg OD, Paracetamol 1g QDS PRN. No anticoagulants, antiplatelets, steroids, or biologics. Allergies Penicillin (rash) Airway Assessment Mallampati Class II, good mouth opening (>3 fingerbreadths), intact dentition, thyromental distance >6cm, full neck mobility, good jaw protrusion. Cardiorespiratory Review No reported chest pain, dyspnoea, orthopnoea, or syncope. Good exercise tolerance (can walk 2 flights of stairs without stopping). No wheeze or history of sleep apnoea. Investigations Full Blood Count: WNL. Urea & Electrolytes: WNL. Liver Function Tests: WNL. ECG: Sinus rhythm, no ischaemic changes. HbA1c: 6.8%. Peri-Operative Risk Assessment ASA Physical Status II. Peri-operative risk is low. Main drivers of risk are well-controlled hypertension and Type 2 Diabetes. Using the Revised Cardiac Risk Index (RCRI), the patient has 0 risk factors, indicating a low risk of major cardiac events. SORT score also indicates a low risk for elective hip arthroplasty in this demographic. Estimated peri-operative mortality risk is <1%, and significant morbidity risk (e.g., major cardiac events, stroke) is also low (1-5%). Optimisation Required No further investigations or specialist referrals are immediately required. Continue current medications. Advised to take usual morning medications with a small sip of water on the day of surgery, excluding Metformin which should be omitted on the morning of surgery. Postoperative Care Anticipated ward-based care with standard enhanced recovery pathway. No anticipated HDU/ICU requirements. Final Impression Low peri-operative risk. Patient is suitable for elective total hip arthroplasty from an anaesthetic perspective following routine pre-operative preparation.