Preoperative Assessment

Preoperative Assessment: Anaesthetic Assessor: Dr. Emily Carter Anaesthetic Assessor: Anaesthetist Patient Information: Patient Medical Record Number: 123456 Mr: John Doe Patient Date of Birth: 1975-06-15 Age: 48 Patient Gender: Male Surgery: State Surgery: Total Knee Replacement Reason for Surgery: The patient is experiencing severe osteoarthritis in the right knee, causing significant pain and mobility issues. Medical History: Past Medical History: Hypertension, Type 2 Diabetes, Asthma Heart disease including pacemaker: No Myocardial Infarction: No Hypertension: Yes Angina: No Stroke: No Diabetes: Yes, Type 2, managed with Metformin Epilepsy: No Jaundice: No GORD/ Hiatus hernia: No Kidney Disease: No Arthritis: Yes Asthma: Yes Chronic respiratory disease: No Thyroid disease: No Sickle cell status: Negative Pregnancy status: N/A Current Medications: Metformin, Lisinopril, Albuterol inhaler Allergies: Penicillin Disabilities or communication needs: None Problems with previous anaesthetics: None Social History: Social History: Non-smoker, occasional alcohol use, retired teacher Baseline observations: Pulse: 78 beats per minute, regular Temperature: 36.7°C Conscious level: Alert Blood Pressure: 130/85 mmHg ECG: Normal sinus rhythm Respiratory rate: 16 breaths per minute Oxygen saturations: 98% on air Weight: 85 kg Height: 1.75 m BMI: 27.8 kg/m2 MRSA status: Needs screening National Early Warning Score (NEWS2) Assessment: Respiration Rate (RR): [ ] 0 - 12-20 Scale 1: Oxygen Saturation (SpO2): [ ] 0 - ≥ 96% Scale 2: Oxygen Saturation (Sp02): [ ] 0 - 88% - 92% or ≥ 93% on air Any Supplemental Oxygen: [ ] 0 - No Air Temperature (°C): [ ] 0 - 36.1-38.0 Systolic Blood Pressure (SBP): [ ] 0 - 111-219 Heart Rate (HR): [ ] 0 - 51-90 Level of Consciousness (AVPU): [ ] 0 - A (Alert) Total NEWS Score: 0 Summary: Patient has a respiratory rate of 16, oxygen saturation of 98%, and a heart rate of 78, receiving a total NEWS score of 0. Family History: Family History: Father had hypertension Review of Systems: Review of Systems: No abnormalities noted in cardiovascular, respiratory, or gastrointestinal systems. No risk of obstructive sleep apnoea. Patient ASA status: II Mallampati score: II Condition of teeth: No false teeth, no loose caps, crowns, or teeth Laboratory and Diagnostic Tests: Blood Test Results: Normal Date: 2023-10-01 Technique explained and Agreed: General Anaesthetic including type: General Anaesthetic planned Admission and Plan: Plan for surgery: Scheduled for 2023-10-15 at 8:00 AM, patient to arrive at 6:00 AM. Preoperative instructions include fasting from midnight and stopping aspirin 5 days prior. DVT Prophylaxis: TEDS Consent: Informed consent has been obtained from the patient. Other Information: Infection risks: None Multiple consultant cases: No Specialist equipment required: None