General Surgery Station 7

 

Station 7

Pre operative assessment

 

Candidate Instructions

Setting:

You are a Foundation Year doctor working in a pre-operative assessment clinic. Please perform a pre-op assessment on Mr Milner, a 64 year old man due to have an elective nephrectomy.


Name: Mr Robert Milner


Tasks:

1. Conduct the pre-op assessment with Mr. Milner and answer any questions.

2. Suggest any physical examinations you would conduct to the examiner.

3. Suggest what investigations you would perform to the examiner.

You are not required to examine the patient.

Simulated Patient Instructions

Briefing

Diagnosis: Renal cell carcinoma: presenting at pre-op assessment for nephrectomy.
You are Robert Milner (age 64).
You have presented to a pre-op assessment clinic for a LEFT sided nephrectomy.

Opening statement

I have had some trouble with my kidney, and the surgeons think it's best to take it out.

Information to Give Freely

I went to the GP because of the blood in my urine, he got me an appointment with the doctors here at the hospital who found it was cancer. They decided it’s best to take it out.

Presenting Complaint

Symptoms – No pain, just blood in urine.
Onset – 2 months ago
Character of urine – Pink/rose coloured urine. Still a normal amount of urine.
Associated symptoms – I’ve been a bit tired since it started. Less energy in the day.

Past Medical History

Previous similar episodes - recurrent blood in urine since diagnosis
Other medical conditions - Anaemia
Previous surgeries - Appendicectomy as a child. The biopsy of the kidney.

Drug History

Prescribed - Iron Tablets, NO blood thinners.
Over the counter - nil
Allergies - nil

Family History

Mother had bowel cancer.

Social History

Smoking - since the age of 16, quit when your doctor linked it to renal cancer risks.
Alcohol/Drugs - Nil
Home - lives with wife, normally fully independent, you can walk miles without issue and enjoy hill walking.
Job - Industrial Plumber. Did work around degreasing chemicals.

Systems Review

General/red flags - Night Sweats
Neuro - Nil
ENT - Nil
Resp - Breathlessness
Cardio - Nil
GI - Nil
GU - Haematuria

Ideas / Concerns / Expectation

Ideas - Nil
Concerns - Anxious +++ about the anaesthetic if asked.
Expectations - that everything will go ahead as planned

Discussion / Questions

Questions to ask: "How long before the operation should I go without eating or drinking?"

Start the Timer and Begin

Intro

 

Presenting complaint

 

Past Medical History

 

Drug History

 

Family History

 

Systems Reviews

 

ICE & Questions

 

Examiner Instruction

 

At this point please allow the candidate to give you their suggested examinations and investigations.

Suggested physical exams

 

Suggested investigation

 

Note: Candidates may also consider ASA scoring or urinalysis. However, for urinalysis there are no lower urinary symptoms, and the blood is explained by renal cancer. This test is not done routinely so no mark has been given. Mentioning ASA scoring would impress most examiners at this level.

Case Summary

 

There are a handful of practical tips when thinking about pre-operative status. Complex patients will often be discussed between surgical and anaesthetics teams but the main thoughts are based upon:

  1. Airway management - how easy will intubation be? e.g. dental issues, obesity, reflux due to increased risk of vomitting on induction, current airway compromise, and jaw problems can all make intubation more complex.

  2. Cardiovascular health - will this patient survive the stresses of surgery/anaesthesia? A practical quantification of fitness is asking how far someone can walk before they become breathless.

  3. Medications which interact with surgery - what needs to be optimised prior to surgery? These often must be stopped with notice e.g. COCP, blood thinners, ACE inhibitors. This may be due to increased of operating (e.g. bleeding risk) or from anaesthesia (e.g. hypotension from ACEi).

  4. Screening for key co-morbidities that may impact anaesthetic or surgical survival e.g. anaemia, poor renal function, diabetes (healing and peri-op BM management), hormonal issues (e.g. Addisons who will require additional steroids), and smoking history.

  5. As always a history of any past anaesthetic or operation is useful to predict how the patient might react to further intervention. For example, in clinical practice patients will often remember if they had violent post op nausea and it might help you to prescribe a more comprehensive anti-emetic plan. Or they might recall dihydrocodeine made them very constipated and you can then prescribe additional laxatives or use a less constipating opioid.

Submit for Scoring

Tags | General Surgery | Pre-op assessment

Station Written by: Mr Mark Plews

Peer Reviewed by: Dr Benjamin Armstrong

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