High Risk Anaesthesia Clinic

Subjective: - Reason for Visit: Pre-operative assessment for elective coronary artery bypass grafting (CABG). - History of Presenting Illness: The patient reports increasing chest pain over the past month, now occurring with minimal exertion. This has significantly impacted his ability to perform daily activities, such as walking to the shops. He also reports shortness of breath and occasional palpitations. - Past Medical History: - Ischaemic Heart Disease, diagnosed 2018, treated with percutaneous coronary intervention (PCI) in 2019. - Hypertension, managed with Ramipril 5mg daily. - Type 2 Diabetes Mellitus, controlled with Metformin 1000mg twice daily. - Previous Myocardial Infarction in 2018. - Ejection Fraction 45%. - Current Medications: - Ramipril 5mg daily. - Metformin 1000mg twice daily. - Aspirin 75mg daily. - Atorvastatin 40mg nocte. - Social History: The patient lives with his wife and is independent in all activities of daily living. He is a retired engineer and enjoys gardening, but has had to reduce this activity due to his chest pain. He does not smoke and drinks alcohol occasionally. He has good social support from his family. - Mobility and exercise tolerance; The patient can walk one block on flat ground, equivalent to 4 METS. - Family History: Father died of a myocardial infarction at age 65. Review of Systems: - Cardiovascular: Reports chest pain on exertion, orthopnoea, and palpitations. - Respiratory: Reports mild shortness of breath on exertion. - Gastrointestinal: Reports occasional heartburn. - Genitourinary: No significant symptoms. - Musculoskeletal: Reports mild joint pain. - Neurological: No significant symptoms. -Fraility: No signs of frailty. Objective: Examination: - Oral cavity: Dentition appears adequate. - Heart: Regular rhythm, no murmurs auscultated. - Lungs: Clear to auscultation bilaterally. - Vitals: Blood pressure 130/80 mmHg, heart rate 78 bpm, SpO2 98% on room air. - No jugular venous pressure or ankle oedema noted. - Stair climb test: The patient was able to climb one flight of stairs without significant symptoms. Investigations: - Blood tests (date not specified): - Haemoglobin: 14.5 g/dL. - White cells: 7.2 x 10^9/L. - Potassium: 4.2 mmol/L. - EGFR: 65 mL/min/1.73m2. - ECG: Shows evidence of previous inferior myocardial infarction. Impression & Plan: 1. Coronary Artery Bypass Grafting: - Risk of death with surgery: 2-3%. - Risk of significant complication: 10-15%. - Potential complications: Infection, myocardial infarction, stroke, respiratory failure, renal impairment, and deep vein thrombosis. - Treatment planned: Coronary artery bypass grafting. - Recovery: Expected hospital stay of 5-7 days, with full recovery in 6-12 weeks. 2. Cardiac History: - Investigations planned: - Repeat ECG. - Echocardiogram. - Cardiac catheterisation. - Troponin levels. - Relevant referrals: Cardiology review planned. 3. Renal Impairment: - Impression: Stable renal function. - Investigations planned: Repeat creatinine and urea. - Relevant referrals: No referral required. 4. Anaesthesia plan discussed, with benefits, risks, alternatives, and risks, complications of the each technique as discussed.