What should be included in a preoperative visit template for a patient with chronic conditions and current medications?

Preoperative Visit Template for Patients with Chronic Conditions and Current Medications

A comprehensive preoperative evaluation must be completed prior to the day of surgery for patients with high severity of disease or undergoing high-risk procedures, focusing on cardiovascular risk stratification, medication optimization, and functional capacity assessment. 1

Timing of Preoperative Assessment

• High-risk patients or high-invasiveness procedures: Complete the initial record review, patient interview, and physical examination prior to the day of surgery 1
• Low-risk patients with low-invasiveness procedures: The evaluation may be performed on or before the day of surgery 1
• Medium-risk scenarios: Prioritize completing the assessment before surgery day when feasible 1

Medical Record Review

Review all readily accessible pertinent medical records before the patient encounter, including: 1

• Current diagnoses and their severity 1
• All treatments and medications (including dosages) 1
• Alternative therapies, herbal supplements, and over-the-counter medications 1
• Previous surgical and anesthetic history, including complications 1
• Recent consultations and specialist evaluations 1

Cardiovascular History

Identify active cardiac conditions that require evaluation and treatment before proceeding with elective surgery: 1, 2, 3

• Unstable coronary syndromes: unstable or severe angina, myocardial infarction within the past 30 days 2, 3
• Decompensated heart failure: NYHA class IV, worsening or new-onset heart failure 2, 3
• Significant arrhythmias: high-grade AV block, Mobitz II, third-degree heart block, symptomatic ventricular arrhythmias, supraventricular arrhythmias with uncontrolled ventricular rate 2, 3
• Severe valvular disease: severe aortic stenosis, symptomatic mitral stenosis 2, 3

Document cardiovascular risk factors and comorbidities: 1, 2, 3

• History of coronary artery disease, prior angina, or previous myocardial infarction 1, 2
• History of heart failure 3
• Cerebrovascular disease 3
• Peripheral vascular disease 1
• Diabetes mellitus (especially insulin-requiring) 1, 3
• Renal impairment or insufficiency 1, 3
• Hypertension and current blood pressure control 3
• History of pacemaker or implantable cardioverter defibrillator 1, 2
• History of orthostatic intolerance 1, 2

Assess for recent changes in cardiac symptoms in patients with established cardiac disease 1, 2

Pulmonary History

• Chronic pulmonary disease and current symptom control 1
• Obstructive sleep apnea screening: snoring, witnessed apneas, sleep disruption, daytime somnolence, CPAP use 3
• Tobacco use history and current smoking status 1

Functional Capacity Assessment

Determine the patient's ability to perform specific daily activities, as this correlates with maximum oxygen uptake and perioperative risk: 1, 2, 3

• Can the patient walk up one or two flights of stairs without stopping? 3
• Can the patient run a short distance? 3
• Can the patient perform activities requiring ≥4 METs (metabolic equivalents)? 2, 3
• High-risk indicator: A sedentary patient with poor functional capacity (<4 METs) and clinical risk factors requires more extensive evaluation 1, 3
• Lower-risk indicator: An asymptomatic patient who exercises regularly (e.g., runs 30 minutes daily) may need minimal additional evaluation despite age or known coronary disease 1, 2

Complete Medication History

Document exact medications with specific dosages, not just medication classes: 1, 2, 3

Cardiovascular Medications

• Beta-blockers (specific agent and dose) 3
• ACE inhibitors and ARBs (note: should be held the morning of surgery to prevent intraoperative hypotension) 3
• Antiplatelet agents (aspirin, clopidogrel) 3, 4
• Diuretics 3
• Statins 3
• Antihypertensives 3

Anticoagulation

• Warfarin: Document current dose, indication, recent INR values, and plan for perioperative management 1, 4
• Direct oral anticoagulants: Document specific agent and timing of last dose 1
• Antiplatelet agents: Aspirin, clopidogrel, and timing of discontinuation 1, 3
• For elective surgery: Anticoagulation drugs should be discontinued before surgery and the procedure delayed until anticoagulation effects wear off 1

Other Critical Medications

• Herbal supplements and nutritional products (many affect coagulation, including garlic, Ginkgo biloba, ginger, ginseng, St. John's wort) 1, 4
• Diabetes medications (especially insulin) 1
• Corticosteroids 1
• Alcohol, tobacco, and illicit drug use 1

Comorbidity Assessment

• Diabetes mellitus: Type, control, complications, current medications 1
• Renal disease: Baseline creatinine, estimated GFR 1
• Liver disease: Baseline function, coagulopathy risk 1
• Anemia: Baseline hemoglobin/hematocrit (anemia increases perioperative ischemia and complications) 1, 2
• Obesity: Document BMI 3
• Nutritional status: Consider preoperative nutritional support for malnourished patients 1

Physical Examination

At minimum, perform a focused examination including airway, lungs, and heart with vital signs documentation: 1

Vital Signs

• Blood pressure in both arms 1, 2, 3
• Heart rate 1
• Orthostatic blood pressure measurements when indicated 1, 3

Cardiovascular Examination

• Carotid pulse contour and bruits 1, 2, 3
• Jugular venous pressure and pulsations 1, 2, 3
• Precordial palpation and auscultation for murmurs 1, 3
• Peripheral pulses and vascular integrity 1, 2
• Peripheral edema 1, 2, 3
• Confirm presence of pacemaker or ICD by physical examination 1, 2

Pulmonary Examination

• Auscultation of lungs for rales, wheezing, or decreased breath sounds 1
• Assessment for signs of acute heart failure (rales correlate with elevated pulmonary pressure) 1

Airway Examination

• Mallampati score 3
• Neck circumference (for obstructive sleep apnea risk) 3
• Tonsillar size 3
• Mouth opening, thyromental distance, neck mobility 1

General Appearance

• Cyanosis, pallor, dyspnea at rest or with minimal activity 1
• Cheyne-Stokes respiration 1
• Nutritional status and obesity 1
• Skeletal deformities 1
• Tremor and anxiety 1

Additional Examination

• Abdominal palpation 1, 2
• Skin examination for acanthosis nigricans, insulin injection sites, lipodystrophy 1

Laboratory and Diagnostic Testing

Order preoperative tests only when results will change the surgical procedure, alter medical therapy or monitoring, or lead to postponement until the cardiac condition is stabilized—avoid routine testing without clinical indication: 1, 2, 3

Indicated Tests Based on Clinical Condition

• Hemoglobin/hematocrit: Review if available; order if anemia suspected or significant blood loss expected 1
• Coagulation profile: Review for patients on anticoagulation or with history suggesting coagulopathy 1
• Serum creatinine and estimated GFR: For patients with renal disease or risk factors 1
• Electrocardiogram: Not routine; order based on cardiac risk factors and surgical invasiveness 1
• Avoid redundant testing: Do not reorder tests that will not change management 2, 3

Surgical Risk Stratification

Determine the cardiac risk of the planned surgical procedure: 3

• Low-risk surgery: Patients can proceed without further cardiac testing regardless of risk factors 3
• Intermediate-risk surgery: Further evaluation based on functional capacity and clinical risk factors 3
• High-risk surgery: More extensive preoperative evaluation required 1

Patient Counseling and Education

• Provide oral and written information about the surgical procedure, expected hospital stay, and discharge criteria 1
• Discuss potential risks versus benefits of blood transfusion and elicit patient preferences 1
• Provide stoma education if applicable (ostomy is an independent risk factor for delayed discharge) 1
• Set realistic expectations for postoperative recovery 1

Preoperative Optimization

Implement these measures well in advance of surgery when possible: 1

• Smoking cessation: Recommend cessation at least 4 weeks before surgery 1
• Alcohol reduction: Cessation 4 weeks prior to surgery 1
• Medical condition optimization: Hypertension, diabetes, anemia 1
• Nutritional support: Consider for malnourished patients 1
• Physical exercise: Encourage preoperative conditioning 1

Communication and Documentation

Never use phrases such as "clear for surgery" in consultation notes: 1, 2

Ensure clear communication includes: 1, 2, 3

• Direct communication with surgeon, anesthesiologist, and other physicians (not just documentation) 1, 2, 3
• Frank discussion with patient and family when appropriate 1
• Documentation of cardiovascular stability 3
• Optimal medical condition assessment 3
• Specific medication recommendations 3
• Need for enhanced perioperative monitoring 3
• Clear documentation in the medical record 1, 2

Critical Pitfalls to Avoid

• Do not order tests that will not change management decisions 2, 3
• Do not focus only on short-term perioperative risk—address long-term cardiac risk management 2
• Do not perform routine testing in the absence of specific clinical indications 1
• Do not delay necessary consultations until the last minute—optimize patients well in advance 1
• Do not forget to document herbal supplements—many affect coagulation and interact with anesthetics 1, 4