What comprehensive medical history, including both positive and negative findings, should a provider take before assessing a patient's preoperative fitness for surgery?

Preoperative History and Physical Assessment Checklist

A comprehensive preoperative assessment must systematically document both positive findings (present abnormalities) and negative findings (explicitly documented absence of risk factors) across cardiovascular, pulmonary, functional, and surgical risk domains to identify patients requiring optimization before surgery. 1, 2

Active Cardiac Conditions (Document Presence or Absence)

These conditions mandate postponement of elective surgery:

• Unstable or severe angina (CCS Class III or IV) - document chest pain patterns, frequency, triggers, and recent changes 3, 1, 4
• Recent myocardial infarction (within 30 days) - document exact date and treatment 3, 1, 4
• Decompensated heart failure (NYHA Class IV, worsening symptoms, new-onset failure) - document orthopnea, paroxysmal nocturnal dyspnea, weight gain, edema 3, 2, 4
• Significant arrhythmias (high-grade AV block, Mobitz II, third-degree block, symptomatic ventricular arrhythmias, uncontrolled supraventricular arrhythmias) - document palpitations, syncope, presyncope 3, 2, 4
• Severe valvular disease (severe aortic stenosis, symptomatic mitral stenosis) - document murmurs, dyspnea, syncope, angina 3, 2, 4

Cardiac History (Positive and Negative Findings)

Document the following risk factors explicitly as present or absent:

• Prior coronary artery disease - history of MI, PCI, CABG with dates and current symptoms 3, 1, 2
• Prior angina - stable vs unstable, frequency, CCS class 3, 2
• Heart failure history - NYHA class, ejection fraction if known, recent hospitalizations 3, 2, 4
• Cerebrovascular disease - stroke, TIA with dates and residual deficits 1, 2
• Peripheral vascular disease - claudication distance, prior revascularization 3, 1
• Pacemaker or ICD - type, indication, date of last interrogation 3, 2
• Orthostatic intolerance - lightheadedness, syncope with position changes 3, 2

Functional Capacity Assessment (Critical for Risk Stratification)

Assess ability to perform specific activities measured in METs:

• Can climb one flight of stairs or walk up a hill? (4 METs) 3, 1, 2
• Can walk on level ground at 4 mph? (4 METs) 3, 1
• Can run a short distance? (>4 METs) 3, 1
• Can do heavy housework like scrubbing floors or moving furniture? (4 METs) 3, 1
• Can participate in moderate recreational activities like golf, bowling, or doubles tennis? (4 METs) 3, 1
• Can participate in strenuous sports like swimming, singles tennis, or skiing? (>10 METs) 3, 1

Document if patient is sedentary vs regularly exercises - a patient running 30 minutes daily may need no further evaluation despite risk factors 3, 2

Pulmonary History (Positive and Negative Findings)

Document presence or absence of:

• Chronic obstructive pulmonary disease - severity, recent exacerbations, home oxygen use 3, 5
• Asthma - control status, recent exacerbations, emergency visits 6
• Obstructive sleep apnea - snoring, witnessed apneas, daytime somnolence, CPAP use and compliance 1
• Recent upper respiratory infection - within 2 weeks 5

Metabolic and Renal History (Positive and Negative Findings)

Document presence or absence of:

• Diabetes mellitus - type, insulin requirement, HbA1c if available, complications (neuropathy, nephropathy, retinopathy) 3, 1, 2
• Renal insufficiency - creatinine, dialysis status 1, 2
• Hepatic disease - cirrhosis, hepatitis, coagulopathy 6

Medication History (Exact Drugs and Dosages)

Document all medications with specific dosages:

• Beta-blockers - exact drug and dose 1, 2, 4
• Antiplatelet agents - aspirin, clopidogrel, ticagrelor with last dose 2, 4
• Anticoagulants - warfarin, DOACs with last dose 2
• ACE inhibitors/ARBs - note these should be held morning of surgery 1
• Diuretics - type and dose 1
• Statins - should be continued perioperatively 1, 4
• Antihypertensives - all agents and doses 1, 4
• Insulin or oral hypoglycemics - regimen and control 1, 2
• Herbal supplements - specific products 3, 2

Substance Use History (Positive and Negative Findings)

Document presence or absence of:

• Tobacco use - pack-years, current vs former, quit date 3, 2
• Alcohol use - drinks per week, history of dependency 3, 2
• Illicit drug use - specific substances 3, 2, 6

Physical Examination Findings (Positive and Negative)

Cardiovascular examination:

• Blood pressure in both arms - document if discrepancy >10 mmHg 3, 1
• Heart rate and rhythm - document bradycardia <60 or tachycardia >100 3, 1
• Jugular venous pressure - elevated vs normal 3, 2
• Carotid bruits - present vs absent 3, 1, 2
• Heart murmurs - grade, timing, radiation 3, 2
• Peripheral edema - location and severity 3, 2
• Peripheral pulses - diminished vs normal 3, 2

Pulmonary examination:

• Lung auscultation - wheezes, crackles, or clear 3, 2
• Respiratory rate - tachypnea >20 5

Airway and body habitus:

• Body mass index - calculate from height and weight 1, 6
• Neck circumference - if >17 inches (men) or >16 inches (women), increased OSA risk 1
• Mallampati score - for airway assessment 1

Surgical Risk Stratification

Document the cardiac risk of planned surgery:

• Low-risk surgery (<1% cardiac event rate) - superficial procedures, cataract, breast, ambulatory 1, 4
• Intermediate-risk surgery (1-5% cardiac event rate) - intraperitoneal, intrathoracic, orthopedic, prostate 1, 4
• High-risk surgery (>5% cardiac event rate) - vascular, major emergency procedures 1, 4

Preexisting Neurologic Conditions (For Peripheral Neuropathy Risk)

Document presence or absence of:

• Preexisting neurologic symptoms - numbness, tingling, weakness in extremities 3
• Arthritis - limiting joint mobility 3
• Body habitus extremes - obesity or cachexia 3

Mental Status and Capacity Assessment

Document:

• Ability to cooperate and position for surgery 3
• Cognitive function - oriented vs confused 5
• Language barriers - need for interpreter 3
• Hearing impairment - communication challenges 3
• Caregiver availability - for postoperative care and transportation 3

Critical Pitfalls to Avoid

• Never use the phrase "cleared for surgery" - this oversimplifies risk and fails to communicate nuanced assessment 2, 4
• Never order tests that won't change management - testing should only occur if results will alter surgical approach, medical therapy, monitoring, or timing 3, 1, 4
• Never assume negative findings - explicitly document absence of risk factors, not just presence 3
• Never fail to assess functional capacity - this is the single best predictor of perioperative risk 3, 1, 2