Presenting a case to a consultant pre-op as a medical student or junior doctor can be a difficult and nerve-racking task, especially if you don’t have a good structure. The most important aspect is to be able to first convey the dominant patient issues succinctly whilst the extended details can be provided afterwards if necessary. Hopefully by the end of this article, you will have a better understanding of this.
The pertinent Information
- Age, Gender, BMI, ASA, Type of Surgery
- Risk Level – High, moderate or Low risk
- Elective or Emergency/Urgent
- The main issues – some examples are:
- Hemodynamically unstable (Emergency surgery?)
- Is there a difficult airway? (Small mouth opening, poor neck extension, difficult BVM)
- Is there an anaesthetic risk (Family history, bad experience with anaesthesia in the past
- High BMI, poor exercise tolerance?
- Significant cardiac or respiratory problems?
- How you would solve these main issues
- Location of hospital/Theatre
- Who do you need. Some Examples
- Second Anaesthetist?
- ICU involvement post operation?
- Blood bank?
- Tertiary Obstetric Centre?
Once you have summarised the pertinent information, you may continue to provide more specific details if necessary. This would include discussing –
- Previous problems with Anaesthesia – Post-op pain, PONV issues
- Family issues with anaesthesia – Anaphylaxis, malignant hyperthermia, sux apnoea, congenital cardiac issues/arrythmias
- Other issues found in each system – cardiovascular, respiratory, liver, kidney
- Medications (Cardiovascular, Respiratory, Corticosteroids, Diabetic, Anticoagulants)
- Fasting Status
- Examination findings
- Airway Exam: Mallampati Score, Mouth Opening, Jaw protrusion, Thyromental distance, Neck Extension
- Heart and Lung auscultation
- Dental Examination
- Investigation Findings (ECG, CXR, Echo, Coags etc)
Many of these details can be found in the pre-admission clinic note if they have already been seen before the surgery. Otherwise, you may find this in their past medical notes. However it is always important to take another history of the patient in the anaesthetic bay prior to the surgery to ensure that all the information you have is correct.
Here is an example below of how one may be presented
Our next case is a 45 year old male with a BMI 28 who is going for a laparoscopic cholecystectomy. This is a low risk elective procedure. The main issue is that he has aortic stenosis, however we can manage this by monitoring him with an arterial line, and giving him 3mg of Midazolam, 300mg of Fentanyl and 25mg of Propofol on induction. We can also have some metaraminol on hand as well. The surgery will be happening in Theatre 10 at The Royal Melbourne Hospital. There would be no other special staff needed.
In more specific detail,
- GA/PONV/Post-op Pain/Fhx
- CVS/Lungs/Liver/Kidney issues
- Medications and Allergies
Here are some other examples that you may practice on
- 40yo F, BMI 35 for large incisional hernia repair. She has had previous issues with PONV, and no family history of anaesthesia problems. She suffers from congestive heart failure and is on an ACE inhibitor, Beta blocker and Furosemide. No allergies. She is fasted however suffers from reflux. An airway examination demonstrates MP 2, MO 5cm, Neck circumference is large, Neck extension is appropriate, TMD is 7cm and Jaw protrusion is A.
- 78yo M, BMI 30, with a ruptured AAA who is going for a laparotomy who is rushed into ED. He has a past medical history of PVD, MI, stents, HTN and currently has a BP of 85/40. Past medical records notes he is on aspirin and clopidogrel, no allergies and suffers from reflux. An airway examination demonstrates MP 4, MO 4cm, Neck circumference is Normal, Neck extension is unable to be ascertained, TMD is 6cm and Jaw protrusion is A.
As you continue to use a structured format, the presentation of each case will become easier and almost monotonous. However, by having a systematic way to present the case not only allows the other person easily to digest the information but also allows you to sound more expertise about what you are doing. If your anaesthetist only has time to listen to the initial pertinent patient problems, having the rest of the history on hand on a piece of paper to show them later is not a bad idea either. An important point to note is that an excellent presentation can only come after an excellent history. It is a good idea to have the anaesthetic proforma (Link) to develop your skills in history taking when starting out.
Our first patient is [Insert Name] who is a 40 year old female with a BMI of 35 who is undergoing an incisional hernia repair. This would be a moderate risk elective surgery. The main issues with this case would be that
- she suffers from congestive heart failure for which from her notes she seems compliant on her medications of [Insert medications names].
- She suffers from reflux for which is not well controlled
- Large neck circumference.
My plan would be to use a rapid sequence induction to minimise the time needed to bag the patient due to potential difficulty from her large neck and to also protect the airway as soon as possible. For her heart failure, I would use 1mg/kg of Propofol for induction and 5mg of Midazolam as well as 50mcg of fentanyl. I would insert an arterial line and have metaraminol and ephedrine on hand as well.
In further detail.. [Anaesthetic History]
Our next patient is [Insert Name], who is a 78yo M with a BMI of 30 undergoing a laparotomy for a AAA repair. This is an urgent high risk procedure. The main issues regarding this case would be
- Currently Hemodynamically unstable with a BP of 85/40 and currently haemorrhaging
- Currently on Aspirin and Clopidogrel, thus exacerbating his AAA
- Potentially difficult airway
My anaesthetic plan would be to do a rapid sequence induction with ketamine and to tube him with a video laryngoscope and a bougie. I would activate the rapid transfusion protocol and call the blood bank, notify ICU and the haematologist as well.
In further detail… [Anaesthetic History]
Dr Dan Tran