Pertinent Insights For Preoperative H&Ps
It is important to appreciate where the preoperative history and physical examination fits into the overall patient history and physical (H&P) hierarchy. As noted in the previous article (see “Why Complete H&Ps Should Be More Common In Podiatry,” page 56, September issue), the preoperative history and physical examination are essential for screening patients and assessing possible surgical risks.
After evaluating these findings, podiatric physicians can make decisions regarding their patients’ suitability and stability to undergo a planned foot or ankle procedure.
While the roots of the preoperative H&P belong in the traditional medical H&P, it is really a more succinct type of examination. One must gear the preoperative history toward the reason(s) that led to the planned surgical event. The reasons might include any relevant past medical and surgical history, social history, systems review and family history, particularly with regard to both surgical as well as anesthetic management.
Knowing the patient’s current medications, allergies and prior anesthetic history is very important with this type of work up. Physicians will cover most of these types of questions during a typical initial patient encounter so there is no need to dwell on these here.
In general, podiatric physicians are well acquainted with the physical examination but the emphasis in day-to-day podiatric practice usually centers upon the organ systems present in the lower extremities. In general, there are 13 organ systems one must review and examine as part of the general physical examination. These systems typically include general appearance (including abdominal, head, ears, nose, throat and neck); rectal and genitourinary; cardiovascular (including peripheral vascular); neurologic/psychiatric; respiratory; musculoskeletal; hematopoetic/ lymphatic; and dermatologic.
For the purposes of the preoperative physical examination, the breast and rectal examinations are not essential although they may yield vital information for other types of examination.
Monitoring Vital Signs
As with most patient encounters, the preoperative H&P assessment begins with careful notation of the vital signs, taking care to note any irregularities and their relationship to the patient’s general medical history and proposed surgery.
Recording the blood pressure is particularly important as it may reveal important information you need to know before subjecting a patient to sedation or other types of anesthesia that may adversely affect the patient.
One may record blood pressure with either a mercury or aneroid manometer. According to the American Heart Association, there is some evidence that using mercury devices may obtain more accurate readings. However, one may obtain an accurate blood pressure measurement with either type and that ultimately it is up to the doctor. Although a nurse or medical assistant often records this measurement, the examining surgeon should also record it. When considering surgery and anesthesia, one should also be cognizant of other important “vital signs” such as the patient’s height and weight. Unfortunately, these may be overlooked. Various formulas exist for calculating the body mass index and this is a more helpful measurement than simply recording the gross body weight.
After performing an examination of the vital signs, it makes sense for the remainder of the examination to follow in a straightforward head to toe type of sequence. This eliminates the risk of missing a body part or organ system. This is particularly important for podiatric physicians who may spend the majority of their physical examinations assessing the lower extremity.
What To Assess In The Patient’s General Appearance
After assessing the aforementioned vital signs, clinicians should note the general appearance of the patient. Since the advent of the Evaluation and Management Guidelines, this physical examination finding has been a required element for certain levels of examination.