The preoperative medical report is a medical-legal document. It is an integral part of the medical record. The use of a pre-established checklist helps to avoid omissions with sometimes serious consequences. A self-questionnaire does not replace the consultation but can provide significant help by specifying important antecedents. The purpose of this visit is to verify the absence of new medical elements since the preanesthetic consultation.
Clinicians are often asked to examine patients before surgery. A medical advisor can be a primary care physician who sees patients at the surgeon's request or evaluates patients before considering surgical referral. The goal of evaluating healthy patients is to identify undetected diseases and risk factors that may increase surgical risk above baseline and suggest strategies to reduce this risk.
- Knowledge of the pathology that motivates the interventional procedure
- Knowledge of the medical, surgical and obstetrical history, of the treatments usually taken (nature, dosage) and detinition of the significant drug interferences requiring an adaptation (cf. Adaptation of treatments)
- Assessment of the allergic risk (see Allergic risk in anesthesia)
- Assessment of cardiovascular risk in non-cardiac surgery:
- Search for glycemic imbalance (HbA1c assay), cardiac autonomic neuropathy in diabetic patients (see Anesthesia and diabetes)
- Evaluation of the risk of difficult intubation (see Difficult intubation) and full stomach (see Anesthesia and full stomach)
- Assessment of the risk of postoperative nausea and vomiting (e.g. Apfel score) (see PONV in adults)
- Assessment of the risk of bleeding and transfusion (cf. patient blood management sparing strategy)
- Search for sleep apnea syndrome (STOP-BANG Score) (cf. Sleep apnea syndrome in adults)
- At the end of this first part of the consultation, the ASA score is define:
- Planning of the chosen anesthesia strategy and the required monitoring, possible transfusion (or transfusion sparing strategy), postoperative pain management, prevention of PONV, standard examinations (if necessary) and specialized examinations and advice (see Preoperative examinations)
- Prescription of a possible premedication (cf. Premedication of the adult) and antibiotic prophylaxis (cf. Antibioprophylaxis).
- Discussion of risks, information, and consent of the patient on the chosen strategy
- Answers to questions
- A document with additional information can be given on this occasion
Clinicians are often asked to examine patients before surgery. A medical advisor can be a primary care physician who sees patients at the surgeon's request or evaluates patients before considering surgical referral. The goal of evaluating healthy patients is to identify undetected diseases and risk factors that may increase surgical risk above baseline and suggest strategies to reduce this risk.