AS3.2-3 | Pre-anaesthetic History, Medication Review and Clinical Examination Documentation — Summary & Reflection

KEY TAKEAWAYS

The pre-anaesthetic history, medication review, and clinical examination form the anaesthesiologist's primary diagnostic toolkit. The structured history covers seven domains: current illness and planned procedure, previous anaesthetic history (including family history of malignant hyperthermia and pseudocholinesterase deficiency), past medical and surgical history, drug history and allergies, systems review, social history, and functional capacity in METs. The medication review produces specific perioperative instructions for every drug: beta-blockers and statins are continued; ACE inhibitors/ARBs may be held on the day of surgery; anticoagulants and antiplatelets require a hold or bridge plan; oral hypoglycaemics are held on the morning of surgery; MAO inhibitors require psychiatrist consultation. The clinical examination is focused on three mandatory areas: the airway assessment (Mallampati class, inter-incisor distance, thyromental distance, neck mobility — documented using the LEMON mnemonic), the cardiovascular examination (bilateral BP, rhythm, murmurs, JVP), and the respiratory examination (SpO2, air entry, wheeze). All findings must be documented specifically and actionably in the anaesthetic pre-assessment record.

REFLECT

Arrange to observe or conduct one pre-anaesthetic assessment in the surgical ward or anaesthesia pre-assessment clinic. Before you start, write down the seven domains of the history you intend to cover and the three components of the clinical examination. After the assessment, review your written note: Is the airway description specific enough for a colleague who has never met the patient to plan safe airway management? Are perioperative instructions written individually for each drug on the patient's list? Is there a documented family history of anaesthetic problems? If any element is missing, go back and complete it. Then compare your note with the anaesthesiologist's completed record and identify any gaps in your approach.