History taking Hilary Walsgrove

Chapter 3 History taking

Hilary Walsgrove


This chapter will describe:

the purpose of taking a health history at preoperative assessment

various methods of obtaining a health history

the preoperative assessment history taking consultation

functional assessment and systems inquiry

recording a clinical health history assessment.


The importance of obtaining an accurate and comprehensive patient history should not be under-estimated. It is the baseline upon which appropriate diagnostic reasoning and clinical decision-making can be made in order to optimise the patient’s health prior to surgery and anaesthesia.

History taking should not be viewed in isolation. The communication skills and consultation techniques required to extract relevant information from a patient, and/or relative, should be a core component of the practice of healthcare professionals and need to be considered as essential. A reliable and clear record of the patient’s medical history, to serve as a foundation for creating a plan of care, will ensure that the patient’s surgical journey is effective, reducing the risk of suboptimal management and increasing safety with the least possible distress for the patient and their significant others. For the history taking process to be executed well, a number of essential elements should be considered, such as the environment. The knowledge and expertise of the healthcare professional and the required information should create a complete and thorough assessment.

The essential elements of history taking include a medical, surgical and anaesthetic history; general and focused system review health history; social history, including recreational activities; psychological/emotional issues. This is described in further detail later in this chapter. Details of the information exchange between the patient and the assessor should be recorded and addressed to ensure patients’ expectations are understood and aligned with the anticipated plan of care and course of recovery including discharge from the hospital. There are a number of additional considerations dependent on the individual patient, for example, whether the patient is a child or elderly, their sexual history, any learning disability, as well as cultural and religious considerations (these areas are beyond the scope of this chapter).

Once the history has been obtained, the ensuing clinical examination can be focused accordingly (see Chapter 4). Relevant investigations and observations, including vital signs, can be undertaken depending upon the systemic disease/co-morbidity identified (seeChapters 5–12).

The aims of taking a preoperative assessment history

Preoperative optimisation can decrease the risk to the patient, improve surgical outcomes, and ensure effective and timely use of healthcare resources, whilst also ensuring the implementation of preventative and precautionary interventions prior to surgery for patients who are potentially at risk.1 The patient history is also useful for establishing a baseline for postoperative evaluation.1 Effective preoperative preparation and education have been shown to aid recovery and reduce postoperative morbidity.2

Methods of preoperative assessment history taking

Preoperative assessment aims to identify level of fitness for surgery and anaesthesia, with particular emphasis on the cardiovascular and respiratory systems and potential airway difficulties. However, a whole systems approach is required to assess and identify disease processes or other factors that may impact on the patient’s surgical and anaesthetic course. The organisation of preoperative assessment varies according to local policies/practices and, therefore, how the patient history is obtained varies accordingly. The assessment should be relevant and effective according to patient need, method of anaesthesia planned and the severity of the surgical procedure.

Preoperative assessment questionnaires

Self-completed questionnaires can be sent by post or electronically3 or completed at the time of the surgical outpatient appointment. In recent years, use of computer-interpreted screening questionnaires has increased.3 Such questionnaires extract information from patients, and are reviewed by appropriately trained clerical, nursing or other members of staff, invariably using a specific protocol. This method identifies patients with problems who may need more formal preoperative assessment within a clinic setting. It enables useful information to be obtained about the patient in a relatively simple manner and is especially useful for fit patients, such as those in ASA 1 and 2 grading categories requiring minor and/or intermediate type surgical procedures.4

Preoperative assessment by direct contact

Obtaining patient information for preoperative assessment via telephone interview can decrease visits to hospital. It can be performed in the community such as by the general practitioner or other community care practitioner or at a designated preoperative assessment clinic based in the community or hospital. This model of care enables more comprehensive information to be gathered about the patient by a healthcare professional experienced in undertaking consultations of this type (rather than by the self-reporting method identified above) and allows patients to ask questions and share concerns on a more personal level. These more direct methods of preoperative assessment will provide the main focus for the rest of this chapter. There is an increasing trend towards optimisation by the primary care provider, prior to referral for surgery for the patient undergoing an elective procedure.

The preoperative assessment consultation

Setting the scene

The creation of the right environment can play a vital part in the success of a consultation.5 Ideally a quiet, private, comfortable place should be allocated for this purpose, where patient privacy, confidentiality and dignity can be maintained throughout and where interruptions are kept to a minimum. It is suggested that extraneous noises may distract, intrude and raise stress levels for the patient as well as the assessor.6 If possible, seating should be arranged in a non-confrontational manner. If a computer is used, the screen and keyboard should not get in the way or create a distraction/barrier.7 Within a more open area, such as a hospital ward, this may be very difficult to achieve. The assessor within the ward environment should pull up a chair next to the patient’s bed or bedside chair and sit level with the patient so that they can clearly see them and maintain eye contact.

Preparation for the consultation

First impressions play an important role, with the assessor’s demeanour, attitude and dress having an influence.8 The maintenance of a professional, neutral attitude and showing concern and understanding for the patient’s situation are key to the conduct of the consultation.7 A supportive, encouraging approach that is unbiased and non-judgemental will make the patient more forthcoming in terms of sharing personal information.9 Establishing contact with the patient by shaking their hand during the opening of the consultation may help to establish a rapport and put them at ease,10 as well as addressing the patient by name and the assessor introducing him/herself and explaining what is going to happen during the consultation.

The assessor should ensure that they are consulting with the correct patient. A prior review of the patient’s medical notes and/or screening questionnaire is valuable, as it allows the assessor to build up an initial picture of the patient.11 If the patient senses that the assessor has some knowledge of them at the outset, this can inspire confidence and demonstrate that the assessor has a personal interest in them. It is suggested that lack of interest in a patient, remoteness or a distant manner or a superior professional attitude are unhelpful in a relationship, such as one that is built between preoperative assessor and patient.12

Communication skills

Non-verbal communication, as well as verbal communication can be used to gain further information pertaining to the patient’s health status. It is the medium through which relationships begin and develop, and the quality of the communication directly influences the quality of the relationship between the assessor and the patient. Thus barriers to the communication process should be kept to a minimum.13 The lack of active participation in listening has been described as a key barrier in this process. Egan14 uses the acronym SOLER as a prompt to encourage active listening by health professionals, which would be useful in a preoperative assessment (see Box 3.1).

Box 3.1 SOLER14
    Sitting Squarely in relation to the patient
    with an Open stance
    Leaning slightly forward and maintaining
    Eye contact in a
    Relaxed manner indicates attention to what the patient is saying

Other points to note, in relation to non-verbal communication, include the assessor’s use of reassuring gestures, ensuring he/she is not crossing his/her arms, looking bored or rushed. Observing the patient for non-verbal cues will elicit important information within the consultation. For example, if the patient is uncomfortable or unsure about answering a question, they may lower their voice or glance around uneasily.9

Verbal communication skills should be considered and used appropriately, e.g. silence, facilitation, confirmation, reflection, clarification, summary and conclusion.9 Open-ended questions allow the patient to respond freely and to express feelings, opinions and ideas and to provide more detailed information. Closed questions help to gain clear, concise feedback on specific points. It may be pertinent to alternate between both questioning styles.

A skilled healthcare professional will adapt to the patient’s style of communication and the use of broad questions followed by more focused questions will elicit as much information as possible in the patient’s own words.15 Any questions need to be asked in a manner the patient understands and in the language they speak. Patients are often not familiar with healthcare terminology and jargon, which should be avoided, as it can lead to confusion and misinterpretation of information.16 The accuracy and completeness of the patient’s answers largely depend on the skills of the assessor.9

The content of the history taking episode should give consideration to the following areas, in a structured approach:

Presenting complaint and its symptoms

Diagnosis (if relevant)

Past medical history

Previous surgical experiences

Anaesthetic history, including problems experienced and family history of anaesthetic problems



Family history

Social and psychological history

Activities of daily living

Systems enquiry

There is evidence to suggest that the patient’s history contributes to approximately 60–80% of data required for focused examination and any subsequent clinical decision-making and diagnosis.17

Biographical data

Biographical data is usually gathered at the start of the patient’s surgical journey and may be recorded by a member of clerical staff, such as the clinic receptionist or by a healthcare assistant. This is vital information to help ensure that the patient’s surgical journey runs smoothly and efficiently, that channels of communication are maintained and the patient is cared for in accordance with individual, religious and cultural needs.

Presenting complaint

When obtaining information about the presenting complaint, it is useful to ask the patient to discuss the issue in their own words, using open-ended questions. This will ascertain their knowledge and understanding of the situation and of the planned surgery and guide the assessor with regard to the focus of the remainder of the consultation. The assessor is thus able to ensure that the patient’s interpretation of the situation is accurate and to check that the patient is presenting for the correct procedure, depending on the nature of their presenting problem/s. If the preoperative assessment appointment is not ‘one-stop’, at the same time as the patient’s consultation with the surgeon when the decision to treat has been made, the assessor needs to check whether the patient’s symptoms have altered since the initial consultation with the surgeon.

Most patients will have been through an initial healthcare consultation, leading to a diagnosis of for the presenting complaint which, in turn, led to the decision to operate and the proposed surgical procedure. Other patients will be presenting at preoperative assessment for an investigative procedure to ascertain the nature of their problem. It is important for the preoperative assessor to ensure the patient is fully aware of the planned procedure, to check this with the patient, and to ensure that this information correlates with the medical notes. This corresponds with initiating the process of informed consent for the patient, in relation to the surgery and/or anaesthetic technique that will be employed.

The assessor has the opportunity to discuss the patient’s symptoms, the impact on their life and ability to function.9 All of this information will help with the organisational aspects involved in planning the patient’s surgery, i.e. operating theatre scheduling, equipment required and the patient’s perioperative and postoperative care needs.

The acronym OLDCART (Box 3.2) is a useful tool to aid assessment of the patient’s physical complaint/s.

Box 3.2 Physical Complaint/Pain Assessment: ‘OLDCART’ acronym
o = Onset
     When did it start?
L = Location
     There may be multiple sites
D = Duration
     How long does the complaint/pain last?
     Is it constant?
     Is it intermittent?
C = Characteristics/causative factors (e.g. of pain)
     Neuropathic or nerve (sharp, shooting, burning, electrical)
     Somatic – bone pain is one example (dull, aching)
     Visceral (cramping, squeezing)
A = Aggravating factors

     Moving, walking, sitting, turning, chewing, swallowing, breathing, defecating, urinating

R = Relieving factors
     What makes the problem better?
     What medical and non-medical interventions relieve the complaint/pain?
T = Treatment

     Non-pharmacological interventions (e.g. heat, cold, massage, distraction, etc.)

Past medical history

The medical history should comprise all medical problems the patient has experienced to date, including any chronic and episodic illnesses.18 Any relevant medical history should be explored with the patient to ascertain whether or not it is likely to have an impact on the patient’s surgical experience. Previous serious illnesses, treatments and any consequences, hospitalisations or frequent visits to a healthcare professional should be recorded. Patients often underestimate their morbidity, particularly if there has been a gradual deterioration over time, or they may consider their condition to be a part of the normal ageing process. For example, a patient who is being treated for an under-active thyroid may not consider that they have a medical condition and may not see the importance of informing the preoperative assessor of this issue. The availability of a current medication list from the GP can provide some insight into their current, as well as past, health history.

Surgical history

Any surgical procedure the patient has undergone, both major and minor, including dates performed should be recorded, including the type of anaesthesia involved if applicable. It should also be ascertained whether the patient experienced any complications or had any bad experiences from undergoing the surgery and anaesthetic. Any reactions or complications should be explored and considered in future planning of care, e.g. postoperative nausea and vomiting, suboptimal pain control. Knowledge of such problems can help with planning the treatment and care of a patient to ensure that the experience that they have this time is as satisfactory as possible.

This will also assist the assessor to gauge the patient’s level of anxiety and any particular fears they may have. A comprehensive surgical history provides information about previous pathology and potential problems that may be encountered such as presence of scar tissue that may hinder the procedure to be undertaken.

Anaesthetic history

An anaesthetic history is more focused on specific aspects of relevance to perioperative management than a general medical history as outlined in (see Box 3.3).19

Box 3.3 Anaesthetic history pertinent to preoperative assessment
    Cardiac disease: cardiac failure, angina
    Respiratory disease: breathlessness, stridor, wheeze, smoking history
    Exercise tolerance: on flat surfaces and stairs
    Renal disease
    Liver disease
    Gastric reflux
    Dental conservation work: Bridges, crowns, false teeth
    Pregnancy or the use of oral contraception

    Drug/food allergy or intolerance: nature of food allergy, possible latex allergy

    Potential airway concerns such as facial surgery

Risk assessment tools

The American Society of Anaesthesiologists (ASA) Physical Status Classification is an established scoring tool and is useful for determining patient risk in relation to existing conditions. It can be used as a guide for the patient undergoing anaesthesia and is strongly predictive of peri- and postoperative complications20 (see Box 3.4). The classification system subjectively categorises patients into five groups by preoperative physical fitness. Originally devised in 1961, it does have limitations; for example, it does not allow for adjustment regarding age, sex, weight or pregnancy or reflect the nature of the planned surgery.20 Further analysis of risk assessment can be found in Chapter 2.

  Box 3.4 ASA grade
Class Physical status Example
I A completely healthy patient A fit patient with an inguinal hernia
II A patient with mild systemic disease Essential hypertension, mild diabetes without end organ damage
III A patient with severe systemic disease that is not incapacitating Angina, moderate to severe COPD
IV A patient with incapacitating disease that is a constant threat to life Advanced COPD, cardiac failure
V A moribund patient who is not expected to live 24 hours with or without surgery Ruptured aortic aneurysm, massive pulmonary embolism
E Emergency case  

As outlined above, in the United Kingdom patients are usually coded according to their ASA grade but the NCEPOD21 (National Confidential Enquiry into Peri-operative Deaths) scores can be used to assess the severity of the planned surgery, with the NCEPOD banding denoting the urgency of the surgery (see Box 3.5).

  Box 3.5 NCEPOD grades
Immediate Immediate life- limb- or organ-saving intervention – resuscitation simultaneous with intervention. Normally within minutes of decision to operate.
A) Life-saving
B) Other, e.g. limb- or organ-saving.
Urgent Intervention for acute onset or clinical deterioration of potentially life-threatening conditions, for those conditions that may threaten the survival of limb or organ, for fixation of many fractures and for relief of pain or other distressing symptoms. Normally within hours of decision to operate.
Expedited Patient requiring early treatment where the condition is not an immediate threat to life, limb or organ survival. Normally within days of decision to operate.
Elective Intervention planned, or booked, in advance of routine admission to hospital. Timing to suit patient, hospital and staff.

Cardio-pulmonary exercise testing (CPX), is increasingly the investigation of choice used to stratify the risk of patients undergoing major surgery by measuring their anaerobic threshold.19 This can be used as an aid in decision-making in consultation with the patient to determine whether surgery should proceed and to predict patient management decisions, such as intensive care requirement postoperatively. It is discussed in detail in Chapters 2 and 5.

Exercise tolerance

The patient’s degree of exercise tolerance provides an indication of their fitness for surgery and anaesthesia. Evidence demonstrates that patients with poor exercise tolerance have more perioperative complications.22 In the absence of formal exercise testing, the preoperative assessor can ascertain the patient’s exercise tolerance from the patient history. Questions regarding the nature and frequency of their physical activities, alongside other available information, for example their Metabolic Equivalent Task Score (METs), can assess the patient’s ability to undergo surgery safely.

Questioning to establish a patient’s exercise tolerance can include the following:

How far can you walk on the flat?

How far can you walk uphill?

How many stairs can you climb before stopping?

Could you run for a bus?

Are you able to do the shopping?

Are you able to do the housework (e.g. hoovering)?

Are you able to care for yourself?

One way of making questioning more objective is through the use of the New York Heart Association (NYHA) Classification.23 This specific activity scale grades common physical activities in terms of their MET score and classifies patients according to how many ‘METS’ they can achieve (Box 3.6). A detailed comparison of risk and METS is also made in Chapter 2.

  Box 3.6 New York Heart Association Classification – METS
Class I Can perform activities requiring more than 7 METS
Class II Can perform activities requiring more than 5 METS but less than 7 METS
Class III Can perform activities requiring more than 2 METS but less than 5 METS
Class IV Patient cannot perform activities requiring more than 2 METS

Previous anaesthetic issues

If difficulty with previous anaesthesia is noted, detail of such events should be obtained from the patient or from the anaesthetic record. Individual needs should be identified, particularly issues such as problems with either mask ventilation and/or endotracheal intubation, as this would indicate concern with regard to the patient’s airway. Adverse respiratory events are a major cause of injury in anaesthetic practice, with inadequate ventilation being the largest category of adverse events.2 This can lead to an unplanned admission to a critical care facility, which may be traumatic for the patient who is not expecting it, as well as causing organisational and planning difficulties for the hospital.

Airway assessment

Protection of the airway throughout anaesthesia is essential. Thus a detailed airway assessment should be made, based on information from the patient, their records and a thorough examination. Predictive factors for a potential difficult airway include a past history of a ‘difficult airway’ and any congenital, acquired or anatomical features. The Mallampati scoring system allows assessment of the oropharyngeal structures including the size and position of the tongue in relation to that of the soft palate, while the tongue rests on the floor of the mouth.24 Further information on airway assessment can be found in Chapter 7.

A patient who meets the criteria for a potential ‘difficult airway’ may be less of a challenge to the anaesthetist than the patient with an unrecognised difficult airway, highlighting the importance of accurate and comprehensive history taking in relation to airway management issues.2

There are some rare medical conditions that can cause life-threatening anaesthetic problems. Identification at preoperative assessment can decrease the risk and ensure appropriate management is planned.

Malignant hyperthermia (MH)

Malignant hyperthermia is a genetic condition where individuals are predisposed to a potential life-threatening condition when exposed to either volatile anaesthetic agents such as halothane or isoflurane or certain drugs such as succinylcholine (suxamethonium). Individuals in whom no response is triggered initially may develop malignant hyperthermia with subsequent anaesthetic administration.2 Clinical features of hypermetabolism, such as tachycardia, hypertension, metabolic acidosis, muscle rigidity are indicative and hyperthermia and death may occur if the condition remains untreated.2,25

Pseudocholinesterase deficiency

This condition affects the quality or quantity of plasma cholinesterase, an enzyme responsible for metabolism of certain muscle relaxants used in general anaesthesia, such as succinylcholine and mivacurium. It can lead to prolonged apnoea in the anaesthetised patient. Pseudocholinesterase deficiency can be genetically determined or acquired in association with various disease processes, such as liver failure, acute myocardial disease, malnutrition, myxoedema or by certain drugs, such as oral contraceptives, phenylzine, cyclophosphamide and chlorpromazine.2,25 A line of questioning that may be useful when ascertaining whether the patient has this deficiency would include the following.26

What type of anaesthetic has the patient had (i.e. general or local)?

Did the patient have any adverse reactions?

Does the patient have a family history of adverse reactions to anaesthetic?

Did the patient require mechanical ventilation during postoperative period?

Was the patient unable to lift their head postoperatively?

Has the patient been tested for this deficiency (blood sampling for pseudocholinesterase levels)?

Family history

Details of the health of family members can assist in identifying risk factors that may or may not become apparent during the rest of the history taking process. If the patient does not have any previous history of anaesthesia and surgery it may provide an indication of underlying genetic conditions such as those discussed above. A family history of cardiovascular and respiratory disease may also be of significance.

Medication history

Past and current consumption of medications, including prescription, over-the-counter, vitamins/supplements, lotions and alternative remedies as well as recreational drug use should be explored and recorded, including any recently stopped medication. Most medicines taken for chronic conditions should continue as usual, up to and including the day of surgery. However, it may be necessary to omit certain medications or amend the dose of others, such as anticoagulant therapy or steroids. There is a risk of drug interactions with certain medications. Thus drugs used during anaesthesia, peri- and postoperatively should be considered in the light of the patient’s regular medication use, including any medication that may be required in an emergency or rescue situation.

A comprehensive medication history should also include use and potential abuse of over-the-counter and prescription medications, the use and abuse of alcohol and other recreational substances, whether legal or illegal and a past and current smoking history. This can be a challenging route of questioning but it is important to stress the value of gaining such information in relation to maintaining their safety during the surgical/anaesthetic process. The patient should be reassured that information remains confidential and withholding information may be detrimental to their health or may delay treatment.18 More detail of medications management can be found specifically in Chapter 12, and other clinical systems in Chapters 5–11.


Establishing a patient’s allergy status is key to maintaining patient safety and should include allergies to medications, foods and animals as well as environmental allergens, such as latex.18 It may be necessary to provide a latex-free environment within the ward and theatre areas and to avoid the use of certain medications or products in order to prevent an adverse event caused by an allergic reaction. A record should be made of the type and severity of the reaction the patient has experienced and any local guidance should be followed.27

Functional assessment and activities of living

The patient’s perception of their general state of health, including questions about a patient’s usual lifestyle and activities of daily living, can provide a baseline for determining their overall health status, exercise tolerance and suitability for surgery and anaesthesia. Details of the patient’s home life, such as housing, economic situation, living arrangements and so on, particularly if they live alone or have dependants to care for, should be obtained. This will inform the discharge planning process which should commence at the time of preoperative assessment. An enquiry about occupation, if they are employed, is also important. This may identify areas of risk in their occupation which may influence their recovery and daily activity in the future. Social and sporting activities should also be considered, as they may impact on the patient’s recovery postoperatively.

By establishing the patient’s normal self-care practices, a plan of care can be developed to optimise the patient’s health status and level of independence and to identify realistic health outcomes, relating to their surgical pathway and recovery.28 Exploration of the patient’s activities of living including diet and fluid intake, activity and exercise, sleep patterns, elimination, sexuality, menstrual cycle (if relevant), communication patterns and difficulties, mood and behaviour, coping and stress management, will help build up a picture of the patient’s functional capacity and expectations.27 It will provide a guide for the preoperative assessor of how well the patient will cope postoperatively and any arrangements that may be required for safe and effective discharge from hospital.

System review

This section provides an overview of the system review. Greater depth is available in the relevant chapters.


Review of the cardiovascular system requires an understanding of the extent and stability of any disease factors and specific questions regarding cardiovascular status are important for planning perioperative management. Identification of any unstable symptoms, associated with high perioperative risk will influence the decision-making process. Pre-existing cardiovascular conditions, such as previous myocardial infarction, ischaemic heart disease, angina, arrhythmias, heart murmurs, hypertension and heart failure, increase morbidity and mortality from anaesthesia and surgery. Key symptoms of cardiac malfunction to look out for during cardiovascular history taking include breathlessness, chest pain, palpitations, fatigue, syncope and claudication.

Shortness of breath on exertion or lying flat (orthopnoea), is indicative of heart failure. Paroxysmal nocturnal dyspnoea is suggestive of pulmonary oedema.

Questions to be asked with regard to breathlessness include: Do you ever feel short of breath? Does this happen on exertion? How much can you do before getting breathless? Do you ever wake up gasping for breath? If so, do you have to sit up or get out of bed? How many pillows do you sleep on? (If more than two pillows, establish if this is for comfort or due to breathing difficulties.) Are you able to lie flat?

Do you cough or wheeze when you are short of breath?

When cardiac output fails to provide adequate delivery of oxygen to the tissues, the patient may experience otherwise unexplained fatigue and weakness. Chest pain due to cardiac disease is typically brought on by exertion, cold weather or anxiety and may be relieved by rest or the use of nitrates. It is usually experienced in the retro-sternal region as crushing, squeezing or constricting in nature.23

Useful questions to ask include:

Do you get pain in your chest on exertion (e.g. climbing stairs)?

Where in the chest do you feel it?

Is the pain referred anywhere else? For example your left arm, jaw?

Is it worse in cold weather?

Is it worse if you exercise after a big meal?

Is it bad enough to stop you exercising?

Does it go away when you rest?

Do you ever get similar pain when you get excited or upset?

If a patient has had a previous myocardial infarction, specific information is required:

when the attack occurred

its severity and complications

treatment received

duration of hospital stay.

Studies have shown an increased incidence of re-infarction if a patient has had a myocardial infarction within 3 months, or even 1 month of surgery.29

Palpitations can be an indicator of the presence of arrhythmias and episodes of syncope can be indicative of heart block. Questions to ask include:

Is it regular or irregular?

Is there anything that sets off an attack?

Can you do anything to stop an attack?

What do you do when you have an attack?

Are there any foods that seem to make symptoms worse?

What medications are you taking?

It can be useful to ask the patient to tap out rate during an attack.

A patient who has a pacemaker in situ is likely to have underlying pathology, usually ischaemic heart disease or arrhythmia. Details of the type of pacemaker, the reason for pacemaker insertion and date of last pacemaker check should be obtained. The check should have been within the last year and a record of the settings noted.

The automatic implantable cardioverter defibrillator (AICD) is now more frequently used for patients with refractory malignant ventricular arrhythmias.30 Preoperative assessment of patients with an AICD includes details of the underlying cardiac disease (ischaemic or valvular heart disease, cardiomyopathy), and the status of the patient’s ventricular function. Such patients should be receiving optimal medical therapy; thus preoperative investigations should focus on detecting any electrolyte imbalance or drug toxicity. Knowledge of the model of AICD is important, as there is wide variation in the functional characteristics of different models.

The presence of coronary artery disease is higher in patients with diabetes mellitus than non-diabetics and there is a higher incidence of both silent myocardial infarction and myocardial ischaemia.

Most hypertensive disease is idiopathic but approximately 10% of patients suffer from hypertension caused by renal, endocrine or pregnancy-related disease. Hypertension needs to be viewed within the context of the patient’s general medical condition to determine the need for further evaluation of the cardiac status. Liaison with the primary care team is necessary, particularly if the patient is receiving ongoing management of their hypertension or if a newly diagnosed hypertension is detected at the time of preoperative assessment.

Hypertension is usually symptomless but, if untreated, it may result in enlargement of the heart and failure, renal dysfunction and cerebrovascular accidents. It is important to look for such problems, as they may influence the choice of anaesthetic technique. Patients with untreated or inadequately treated hypertension developed marked swings in blood pressure with situations such as anaesthesia, blood loss or pain.

Management of hypertension should concentrate on methods to reduce perioperative risk. Determinants of risk include the level of the blood pressure, duration of treatment, degree of end organ damage and the type of surgery planned. In relation to the level of hypertension, severe hypertension increases the risk of perioperative blood pressure lability, myocardial ischaemia and myocardial infarction, pulmonary oedema, arrhythmias, renal failure and neurological damage. Patients with any form of preoperative hypertension, treated or untreated, have an increased risk of postoperative hypertension.

Methods to reduce perioperative risk include adequate preoperative blood pressure control. The patient should be advised to continue all hypertensive medications up to and including the day of surgery, with the exception of diuretics. Local guidelines outlining medicine management in relation to continuing and discontinuing medications preoperatively should be referred to. Elective surgery should be delayed if the systolic blood pressure is above 200mmHg or if the diastolic BP is above 120mmHg, preferably lowered to 140/90mmHg over several weeks. Acute control within hours of surgery is inadvisable. Again, local guidelines for the accepted parameters for blood pressure readings and surgery/anaesthesia, should be adhered to.


Lung disease can complicate anaesthesia and influence the postoperative outcome following surgery. Perioperative complications include intubation difficulties, a need for re-intubation, laryngospasm, bronchospasm, aspiration, hyperventilation and hypoxia. The frequency of postoperative respiratory problems necessitates the identification of those patients who are particularly at risk. Patients who present with respiratory problems may need referral to a respiratory physiotherapist preoperatively, depending on the nature and severity of their disease and in relation to the planned surgery and anaesthesia.

It is possible to observe the patient for signs of respiratory distress during the consultation, particularly while talking. Assessment of exercise tolerance, using the ‘METS’ system described in Box 3.6(see page 42), can be a helpful indicator of the extent of the disease process and risk factors with regard to surgery and anaesthesia.

The presence of key symptoms such as dyspnoea, cough, sputum production and wheeze should be explored in greater detail as discussed below.


Dyspnoea is subjective but can indicate the severity of the respiratory disease in terms of exercise tolerance. Dyspnoea at rest represents a serious anaesthetic challenge. The preoperative assessor should enquire about shortness of breath using the line of questioning outlined as part of the cardiovascular system enquiry above (see pages 45–6).


Cough may indicate a hyper-responsive respiratory tract with increased susceptibility to laryngeal spasm and coughing during induction of anaesthesia. Cough after exercise or at night may be indicative of asthma; a cough following meals may indicate aspiration of gastric contents due to oesophageal abnormalities and a barking cough may be a sign of laryngeal nerve injury. A cough accompanied by sputum may indicate the presence of infection and/or inflammation and may contraindicate elective surgery or require a regional anaesthetic technique, as this enables the preservation of the cough reflex. Some medications, such as ACE inhibitors can induce a cough, due to the bradykinin pathway and it may be appropriate to change these to angiotensin II receptor blockers, which block the bradykinin pathway so a cough is avoided.


Asthma can present a number of risks during the perioperative period. Variable airway obstruction, accompanied by a wheeze, can be precipitated by anaesthesia. Manipulation of the airway can cause bronchospasm. Drugs used in anaesthesia release histamine, which can further complicate the management of asthmatic patients. Details of current management of the patient’s asthma, along with concordance with any treatments should be obtained. Oral steroid therapy, especially recent changes, periods of hospitalisation and critical care admissions as a result of asthma should be noted and the potential need for additional steroid cover should be assessed. By ascertaining the severity of the patient’s disease process, how it is managed and potential risk factors relating to surgery and anaesthesia, the preoperative assessor can ensure safe and effective care is planned.

Upper respiratory tract infection

Symptoms of upper respiratory tract infection with pyrexia are a contraindication to elective surgery. They can lead to airway obstruction, laryngospasm with the postoperative risk of atelectasis and chest infections.

Obstructive sleep apnoea

Patients with obstructive sleep apnoea are particularly vulnerable during anaesthesia and sedation. They may present with a difficult airway and are at increased risk of developing respiratory and cardiopulmonary complications postoperatively.31 Undiagnosed sleep apnoea is common. An awareness of the symptoms associated with the condition is essential to inform the questioning and history taking process (see Box 3.7).31 The symptoms and physical characteristics associated with sleep apnoea and other respiratory conditions are discussed further in Chapter 6.

Box 3.7 Symptoms and physical characteristics associated with obstructive sleep apnoea


Heavy persistent snoring

Excessive daytime sleepiness (somnolence)

Apnoea as observed by sleeping partner

Choking sensations while waking up

Gastro-oesophageal reflux

Reduced ability to concentrate

Memory loss

Personality changes

Mood swings

Night sweating


Dry mouth in the morning

Restless sleep

Morning headache


Physical characteristics

Nasal obstruction

Oedematous or long soft palate or uvula

Hypertrophic tongue

Narrow oropharynx (large tonsils, redundant pharyngeal arches)

Adiposity or large neck circumference


Maxillary hypoplasia

Opiate analgesia may exacerbate this condition with arterial de-saturation being accompanied by cardiac arrhythmias.

Gastro-intestinal conditions, liver disease, renal disease

Conditions associated with the gastro-intestinal tract can increase risk factors for patients undergoing surgery.

Gastric problems

Patients with a history of dyspepsia, acid reflux and recurrent regurgitation, hiatus hernia or increased intra-abdominal pressure (such as occurs in an acutely distended abdomen, intestinal obstruction, morbid obesity or pregnancy), are more susceptible to pulmonary aspiration of gastric contents. Many drugs, including H2-receptor antagonists, proton-pump inhibitors and antacids have been used to reduce and/or eliminate the risk of pulmonary aspiration by decreasing the acidity and volume of gastric fluid. Thus, management of these susceptible patients, using a preoperative medication, including a proton-pump inhibitor is desirable.

Liver disease

Patients with liver disease are complex and may present significant anaesthetic and surgical risk.25 Liver disease can lead to impaired metabolism of anaesthetic drugs and reduced hepatic clearance of uploads can result in prolonged sleepiness after anaesthesia. Coagulopathies, if unrecognised, may result in unexpectedly heavy intraoperative bleeding or even spinal haematoma after regional block.

Renal disease

The main perioperative risk is deterioration of renal function, which may lead to acute renal failure, which can be fatal if left untreated.25 Renal disease can be exacerbated by anaesthesia and surgery, with the potential reduction of renal blood flow and drug-induced nephrotoxicity. Patients with renal disease are commonly hypertensive and have a hyperdynamic circulation. Increased serum urea level associated with renal conditions can delay gastric emptying and increase acid secretion in the stomach, thus increasing the risk of aspiration at anaesthetic induction. This may be an indication for preoperative intervention, such as the administration of a proton-pump inhibitor. Further detailed assessment is considered in Chapter 8.

Endocrine disorders

Thyroid disease and diabetes mellitus are probably the most common endocrine disorders encountered at preoperative assessment. The difficulty with diseases such as these is that they are likely to lead to the patient having a plethora of systemic problems that may be exacerbated by anaesthesia and surgery, increasing peri- and postoperative risks. Evaluation of the impact of the disease process on the individual patient is crucial and such patients may need to be optimised prior to anaesthesia. Patients with endocrine disease are likely to be taking medications that should not be omitted pre- and postoperatively and need a plan of pre-, peri- and postoperative management of their disease and medication (further details can be found in Chapter 8). Any clinically evident disease needs to be controlled prior to elective surgery.25 Patients presenting with thyroid disease may have a goitre, which may potentially compromise the airway, as well as cardiac arrhythmias.


The scope of neurological diseases and their anaesthetic implications is broad and beyond the scope of this chapter. Each neurological condition requires careful consideration and individual evaluation to ensure the safety of the patient during surgery and anaesthesia. Documentation of preoperative neurological deficits is essential and a full anaesthetic assessment may be required preoperatively. Attention should be paid to a history or presence of cerebrovascular disease, pituitary adenomas, seizure disorders, such as epilepsy, myopathies, multiple sclerosis, myasthenia gravis and dementia.2 These are discussed in more detail in Chapter 9.


Common musculo-skeletal diseases that are autoimmune in nature can have significant implications in relation to surgery and anaesthesia. Such systemic diseases have numerous clinical manifestations that require palliative treatment aimed at suppressing inflammatory or immunological processes to improve symptoms and prevent progressive damage. This group of diseases includes rheumatoid arthritis, ankylosing spondylitis, systemic lupus erythematosus, scleroderma and polymyalgia rheumatica. Significant toxicity is associated with the drug therapies used for their management and this necessitates careful evaluation. The impact of these diseases on perioperative risk and complications relates to the drug therapy used, the type of surgery/anaesthesia planned as well as the disease itself. As a general rule, these patients have a better tolerance of surgery if the disease is optimally controlled preoperatively.2 It is also important to ascertain key factors relating to the patient in general such as lifestyle, degree of disability and exercise tolerance.

Osteoarthritis does not involve systemic factors in the way that the autoimmune diseases do, but the degree of disability and functional impairment should be noted, especially in relation to the range of movement of the neck and spine with regard to airway management, regional anaesthetic techniques as well as positioning during surgery. Severe functional impairment may mask cardiac and other symptoms that would be significant risks during anaesthesia and surgery.

Completing the history taking process

To conclude, a succinct summary of the main points should be recorded to ensure that the patient is in agreement with the information gathered. The art of history taking is to be thorough without being interrogative and to actively listen to the patient’s responses and encourage them to tell their story. Closure of the history taking component of the preoperative assessment can be followed by transition to relevant physical examination, investigations and observations.


Accurate and comprehensive documentation provides the principal source of information about the patient, a vital source of inter-professional communication for practitioners caring for and treating the patient and acts as a means of ensuring continuity of care and decreased risk to the patient.32 All aspects of the patient assessment should be recorded systematically.25 This should be available to all members of the healthcare team caring for the patient. Comprehensive and accurate documentation aids a smooth process, helping to minimise risks to both patients and staff, as well as being the best form of defence if and when anything goes wrong.28


This chapter has provided an overview of the history taking element of the preoperative assessment consultation and the different aspects involved in this process. Each patient’s history should be considered from an individual perspective. Some key general factors to consider during preoperative assessment history taking have been included. Although it is beyond the scope of this chapter to consider a detailed systems inquiry in relation to all disease processes related to surgery and anaesthesia, the structure and process of history taking in preoperative assessment has been described. The preoperative assessor should consult relevant medical, nursing and anaesthetic texts for further detail of systems evaluation and seek out guidance and advice from clinical colleagues with relevant experience as well as using local guidance and policy to support practice.


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5. H. Paniagua (1997). Consultations in practice. Practice Nursing 8(8): 20–2.

6. R. Newell (1994). Intervention Skills for Nurses and Other Health Professionals. London: Routledge.

7. D. Snadden, R. Laing, G. Masterton and N. Colledge. History taking and general examination (section 1) (available at www.acumedic.com/books/bk3944.pdf last accessed 29 March 2010).

8. T. Foster and J. Hawkins (2005). The therapeutic relationship: dead or merely impeded by technology? British Journal of Nursing 14(13): 698–702.

9. D. Beverage and Margaret Eckman (eds) (2005). Assessment made Incredibly Easy (3rd edn). London, Philadelphia: Lippincott, Williams and Wilkins.

10. B. Hutchisson, M.L. Phippen and M.P. Wells (2000). Review of Peri-operative nursing. Philadelphia: WB Saunders Co.

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12. A. Rogers (1989). Teaching Adults. Milton Keynes: Open University Press.

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20. Anon. (1963). New classification of physical status. Anesthesiology 24: 111.

21. N. Buck, H.B. Devlin and J.N. Lunn (1987). The Report of a Confidential Enquiry into Peri-operative Deaths. London: The Nuffield Provincial Hospitals Trust and Kings Fund.

22. D.F. Reilly, M.J. McNeely, D. Doerner, D.L. Greenberg, T.O. Staiger, M.J. Geist, PA. Vedovatti, J.E. Coffey, M.W. Mora, T.R. Johnson, E.D. Guray, G.A. Van Norman and S.D. Fihn (1999). Self-reported exercise tolerance and the risk of serious perioperative complications. Archives of Internal Medicine 159: 2185–92.

23. C.G. Winnutt (2004). Lecture Notes: Clinical Anaesthesia (2nd edn). Oxford: Blackwell Publishing.

24. O. Langeron, E. Masso, C. Huraux, M. Guggiari, A. Bianchi, P. Coriat and B. Riou (2000). Prediction of difficult mask ventilation. Anesthesiology 92: 1229–36.

25. E. Janke, V. Chalk and H. Kinley (2002). Pre-operative Assessment: Setting a Standard through Learning. Southampton: Southampton University.

26. D.R. Alexander (1997). Pseudocholinesterase deficiency. Anaesthesia 52: 244–60.

27. J.R. Weber (2001). Nurses’ Handbook of Health Assessment (4th edn). Philadelphia: Lippincott.

28. M. Hind and P. Wicker (eds) (2000). Principles of Peri-operative Practice. London: Churchill Livingstone.

29. S.L. Cohn, G.W. Smetana and H.G. Harrison (2006). Perioperative Medicine. Just the Facts. New York: Mc-Graw Hill.

30. P.C.A. Kam (1997). Anaesthetic management of a patient with an automatic implantable cardiovertor defibrillator in situ. British Journal of Anaesthesia 78: 102–6.

31. C. den Herder, J. Schmeck, D.J.K. Appelboom and N. de Vries (2004). Risks of general anaesthesia in people with obstructive sleep apnoea. British Medical Journal 329: 955–9.

32. V. Corben (1997). The Buckinghamshire nursing record audit tool: a unique approach to documentation. Journal of Nursing Management 5: 289–93.

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Mar 21, 2017 | Posted by in ANESTHESIA | Comments Off on History taking Hilary Walsgrove
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