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AS3.1-6 | Preoperative Evaluation and Medication — Assignment

Instructions

1. Read the provided patient case (attached scenario: 68-year-old man with hypertension, type 2 diabetes, stable COPD GOLD II, and a remote history of ischaemic heart disease, now scheduled for elective right hemicolectomy under general anaesthesia).
2. Compile a structured pre-anaesthetic assessment using the following headings: (a) Presenting complaint and planned surgery; (b) Past medical and surgical history; (c) Drug history — list all current medications with perioperative plan (continue/withhold/bridge) and note any allergies; (d) Family history — specifically ask about and document anaesthetic-relevant family history; (e) Social history — document smoking, alcohol, and any recreational drug use with anaesthetic implications; (f) Airway examination findings — document Mallampati class, mouth opening, thyromental distance, neck mobility, and dentition; (g) Cardiovascular and respiratory examination — relevant positives and negatives; (h) ASA classification with explicit justification; (i) Preoperative investigations — list each test ordered, the clinical indication, and your interpretation of results provided; (j) Fitness determination — declare fitness with any conditions (optimisation required? specialist input?); (k) Anaesthetic plan summary — type of anaesthesia, monitoring level, anticipated challenges; (l) Premedication prescription — write a complete prescription (drug, dose, route, timing, indication) for at least two agents appropriate for this patient.
3. Each section must include clinical reasoning — do not list data without interpretation.
4. The document should read as a formal clinical record that another anaesthesiologist could act upon.

Length: 700–1000 words (excluding tables and prescription charts)

Grading Rubric — Preoperative Evaluation and Medication Assignment Rubric

Criterion	Points	Full-marks descriptor
History completeness and anaesthetic relevance: The report covers all seven history domains with appropriate emphasis on anaesthetic-relevant information (airway history, prior anaesthesia, medications, family history of anaesthetic problems, and GORD/aspiration risk factors).	20 pts	All domains covered; medication history includes perioperative plan for each drug; family history explicitly asks about anaesthetic reactions/MH; anaesthetic relevance of each finding is explained.
Airway examination and risk classification accuracy: Mallampati correctly assigned and documented; other airway predictors assessed; ASA classification correctly applied and distinguished from Mallampati.	20 pts	Mallampati class correctly assigned with examination method described; at least three other predictors documented; ASA correctly stated with justification; ASA and Mallampati clearly described as distinct scales.
Investigation selection and interpretation: Investigations are clinically justified (not ordered as routine checklist); results are interpreted with clinical implications stated.	20 pts	Every investigation has a named clinical indication; results are interpreted with implications (e.g., 'HbA1c 8.9% — poor glycaemic control; target <8.5% met/not met'); no unjustified blanket testing.
Fitness determination and anaesthetic plan: Fitness decision is explicitly stated with reasoning; anaesthetic plan specifies type of anaesthesia, monitoring level, and anticipated challenges.	20 pts	Fitness declaration uses explicit language (fit/conditionally fit) with reasons; anaesthetic plan specifies GA vs regional, monitoring (standard vs invasive), and at least one specific anaesthetic challenge addressed.
Premedication prescription accuracy: At least two appropriate premedicants prescribed with correct drug, dose, route, timing, and stated goal; doses are in mg/kg or standard adult dose with rationale.	20 pts	Two or more premedicants with complete prescription (drug, dose, route, timing, indication); doses correct for the clinical profile (e.g., PONV prophylaxis for COPD patient using volatiles); no contraindicated agents prescribed.