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Pre-admission and surgical risk assessment

Clinical Discipline(s)/Organ System(s)
Anaesthesiology, Digestive System, General Surgery
Progress Test Topic(s)
General duties, Homeostasis
Description
A 69 year old Māori woman attends her appointment at the Surgical Pre-admission Clinic. She is due to have her gallbladder removed. She has had a lot of health problems in the past, including heart and lung disease. However, she has had recurrent bouts of biliary colic and is keen to have the operation.
Applied Science for Medicine 
   - Anatomy and physiology of the heart and lungs
   - Physiology of body fluid compartments
   - Microbiology of methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), extended-spectrum beta-lactamases (ESBLs)
   - Pharmacology of low molecular weight heparin, clopidogrel, aspirin
Clinical and Communication Skills 
   - History from a patient in a surgical pre-admission clinic; take a medication history
   - Perform a full systems examination
   - Recognise adverse factors that increase the risk of perioperative complications
   - Classify patients using American Society of Anaesthesiologists (ASA) criteria and undertake a risk vs benefit assessment
   - Perform venepuncture, arterial blood gas
   - Indications for echocardiogram
   - Interpret full blood count, renal function, liver function tests, coagulation screen, ECG, chest X-ray, pulmonary function tests/spirometry, HbA1c, blood group and antibody screen
   - Management in the perioperative period of thromboembolic disease, anticoagulation and antiplatelet agents, fluid and electrolyte balance, glucose control, antibiotics, decolonisation of resistant organisms
   - Outline management of perioperative checklist (eg. marking surgical site, consent form), high-risk surgical patient
   - Provide instructions for pre operative medication regimen and prescribe on in-patient prescription chart
   - Role of anaesthetist, cardiologist, surgeon, transfusion medicine specialist
   - Anaesthetic and common post-surgical complications
Personal and Professional Skills 
   - Empathise with the patient who has experienced pain for a long period of time
   - Undertake full informed consent process, allowing the patient to fully voice concerns and ask questions
   - Discuss prescribing decisions with colleagues
Hauora Māori 
   - Appropriate engagement and consultation with whānau
   - Ability to cater for differential health literacy needs of Māori patients and whānau
   - Awareness of differing risk profiles for Māori (and other disadvantaged populations) requiring surgery compared with non-Māori in NZ
   - Inequities in medical/surgical error/adverse events between Māori and non-Māori
   - Consideration of access to cultural/spiritual support for patient and whānau
Population Health 
   - Epidemiology in New Zealand of MRSA, VRE, ESBL
   - Standardised pre-admission forms and protocols
Conditions to be considered relating to this scenario
Common
gallstones, ischaemic heart disease, valvular heart disease, atelectasis, pneumonia, asthma, COPD, peripheral vascular disease, cardiac arrhythmias, pulmonary embolism, deep vein thrombosis, malnutrition, diabetes mellitus, obesity
Less common but 'important not to miss'
pulmonary fibrosis, pulmonary hypertension