History (AS3.2)

History-taking during the preoperative period is required to obtain information about the patient’s medical, surgical, and medication details, which guide the anesthetic management during the perioperative period. The history-taking should focus on:

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  Demographic details including the age, weight, and body mass index (BMI).

  
  
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  Comorbid illnesses such as diabetes mellitus, hypertension, thyroid disorders, seizure disorder, and coronary artery disease.

  
  
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  Medication history (types and duration of each drug the patient is taking).

  
  
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  Personal history (smoking, alcoholism).

  
  
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  History of allergy (including allergy to any food items or any medication).

  
  
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  History of previous surgery (regional anesthesia [RA] or general anesthesia [GA], complications, etc.) is taken.

  
  
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  Family history: The unexpected death of a first-degree relative under GA makes the probability of malignant hyperthermia high.

Examination (AS3.3)

Head-to-toe examination of the patient is done, with an emphasis on the cardiorespiratory system. Abnormal findings in any organ system should be properly evaluated and optimized before taking the patient for elective surgery. The important head-to-toe findings that require further evaluation are as follows:

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  Central nervous system:

  
  
  
  
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    Altered sensorium and behavior.

    
    
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    Sensory and or motor deficit.

    
    
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    Abnormal gait and cranial nerve palsy.

  
  
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  Cardiovascular system:

  
  
  
  
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    Irregular heart rate (except for sinus arrhythmia).

    
    
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    The difference in blood pressure of two limbs.

    
    
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    Presence of carotid bruit and murmurs on auscultation.

  
  
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  Abdomen:

  
  
  
  
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    Any lump or swelling.

    
    
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    Presence of tenderness.

  
  
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  Musculoskeletal system:

  
  
  
  
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    Limitation of movement at any joint may complicate patient positioning during transfer and under anesthesia.

    
    
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    Limitation of movement at the cervical spine makes laryngoscopy and intubation difficult.

  
  
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  Respiratory system:

  
  
  
  
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    Altered thoracic spine curvature suggests scoliosis.

    
    
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    Presence of wheeze/crepitation (may be due to lower respiratory tract infection).

Breath-holding time is commonly done to assess the cardiorespiratory reserve of the patients. The patients are instructed to hold breath after deep inspiration and the time is noted (till the patients are able to hold the breath) in the following manner:

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  ≥25 seconds: Good reserve.

  
  
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  25 to 15 seconds: Borderline.

  
  
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  <15 seconds: Poor reserve.

The detailed examination of upper respiratory tract along with its clinical implication has been described later on in this chapter.

After history-taking and physical examination, risk stratification is done, based on the American Society of Anesthesiologists (ASA) classification system. Patients are classified under increased risk of morbidity and mortality by this classification (Table 3.1).