Evaluating the Patient Before Anesthesia - The Physical Examination

The physical examination should be thorough, but focused. Special attention is directed toward evaluation of the airway, heart, lungs, and neurologic status. Assessment of the block site is warranted before a regional anesthetic.

Vital signs

Vital signs.

  1. Blood pressure. If the patient has aortic arch disease, blood pressure measurement should be taken in both arms. Noninvasive blood pressure measurements should be avoided on an extremity with an arteriovenous fistula. While there is controversial evidence for causing lymphedema with a blood pressure cuff after axillary lymph node dissection or radiation, it is reasonable to avoid the limb for patient preference and assuaging anxiety. Arterial lines should, however, be avoided on the side of breast cancer surgery to reduce the risk of cellulitis causing lymphedema.
  2. Pulse. Resting heart rate should be noted for rhythm and rate.
  3. Respiratory rate. Respirations should be observed for rate, depth, effort, and pattern.
  4. Oxygen saturation. Etiology of a saturation less than 93% should be investigated.

Height and weight

Height and weight. Height and weight measurement are necessary for determining drug dosages, fluid requirements, adequate urine output, and ventilator settings. Ideal body weight (IBW) should be calculated using the formula:

  1. Males: IBW (kg) = 50 + 2.3 kg for each inch over 5 ft
  2. Females: IBW (kg) = 45.5 + 2.3 kg for each inch over 5 ft

Head and neck

Head and neck. During the basic preoperative examination, the anesthesiologist should evaluate the following:

  1. Maximal mouth opening.
  2. Ability to prognath. Upper lip bite test.
  3. Mallampati classification (see Chapter 13).
  4. Thyromental distance. Thyromental distance is the distance between the tip of the chin and the thyroid notch. Approximately three fingerbreadths distance is considered normal.
  5. Dentition. Evaluate teeth for those loose, chipped, or missing. Crowns, bridges, dentures, braces, retainers, and other dental appliances should be noted.
  6. Facial hair. A large beard or mustache may be taped with Tegaderm or shaved so as not to interfere with achieving a seal for bag-mask ventilation.
  7. Cervical spine. Evaluate range of motion in flexion, extension, and rotation of the cervical spine.
  8. Superficial neck. Check for tracheal deviation, cervical masses, and jugular venous distention. The presence of a carotid bruit is nonspecific but may suggest a need for evaluating carotid stenosis.
  9. Neck circumference. A neck circumference measurement of 17 inches for men and 16 inches for women are associated with OSA and obstruction during bag-mask ventilation.

Precordium

Precordium. Auscultation of the heart may reveal murmurs, S3, S4, or a pericardial rub.

Lungs

Lungs. Auscultate for wheezing, rhonchi, or rales, which should be correlated with observations regarding the ease of breathing and the use of accessory muscles of respiration.

Abdomen

Abdomen. Any evidence of abdominal distention, masses, or ascites should be noted as these may predispose the patient to regurgitation or ventilatory compromise.

Extremities

Extremities. Evaluate for muscle wasting and weakness, distal perfusion, clubbing, cyanosis, edema, and the presence of any cutaneous infections (especially over sites of planned vascular cannulation or regional nerve block). Ecchymosis or unexplained injury, especially in children, women, and elderly patients, can be an indication of an abusive relationship.

Back

Back. Note any deformity, scoliosis, bruising, rash, cellulitis, or skin condition that could lead to difficulty in patient positioning or performance of neuraxial analgesia.

Neurologic examination

Neurologic examination. Document mental status, cranial nerve function, cognition, and peripheral sensorimotor function.

Outline