Published: 09/08/2019

Perioperative Medicine

Preoperative assessment

Learning outcomes

  • To perform a structured preoperative anaesthetic assessment of a patient prior to surgery and recognise when further assessment/optimisation is required
  • To explain options and risks of routine anaesthesia to patients, in a way they understand, and obtain their consent for anaesthesia
  • To formulate a plan for the management of common co-existing diseases, in particular the perioperative plan for the patient with diabetes

NB: All competencies annotated with the letter ‘E’ can be examined in any of the components of the Primary examination identified in the FRCA examination blueprint on page B-99 or in the Final examination identified in the Final FRCA blueprint on page C72 of Annex C.

A) History Taking

Objectives:

  • To elicit a relevant structured history
  • To record the history accurately
  • To synthesise the history with the relevant clinical examination

Knowledge
Competence Description Assessment Methods GMP
HT_BK_01 Lists the important elements of anaesthetic history taking A,C,E 1
HT_BK_02 Recognises that patients do not always present history in a structured fashion A,C,E 1
HT_BK_03 Lists the likely causes and risk factors for conditions relevant to mode of presentation A,C,E 1
HT_BK_04 Uses the patient’s agenda and history to inform examination, investigation and management A,C,E 1

 

Skills
Competence Description Assessment Methods GMP
HT_BS_01 Identifies and overcomes barriers to effective communication A,D 3,4
HT_BS_02 Manages time and draws consultations to a close appropriately A,D 1,3
HT_BS_03 Recognises that effective history taking in non-urgent cases may require several discussions with the patient and other parties over time A,C 1
HT_BS_04 Supplements history with standardised instruments or questionnaires when relevant A,C 3
HT_BS_05 Identifies alternative and conflicting views from family, carers, friends and members of the multi-professional team C,M 3,4
HT_BS_06 Assimilates history from the available information from the patient and other sources A,C,M 1,3
HT_BS_07 Interprets and uses non-verbal communication to and from patients and carers A,D 3,4
HT_BS_08 Focuses on relevant aspects of history A,D 1

 

B) Clinical Examination

Objectives:

  • To perform focused, relevant and accurate clinical examination
  • To develop the ability to relate physical findings to history in order to establish a diagnosis and formulate a management plan

Knowledge
Competence Description Assessment Methods GMP
CE_BK_01 Describes the need for a targeted and relevant clinical examination A,C,E 1
CE_BK_02 Describes the basis for clinical signs and the relevance of positive and negative physical signs A,C,E 1
CE_BK_03 Recognises constraints to performing physical examination and uses strategies to overcome them A,C 1
CE_BK_04 Recognises the limitations of physical examination and the need for adjunctive forms of assessment to confirm diagnoses A,C 1
CE_BK_05 Offers or uses a chaperone when appropriate A,C 3,4

 

Skills
Competence Description Assessment Methods GMP
CE_BS_01 Performs an examination relevant to the presentation and risk factors that is valid, targeted and time efficient A,D 1
CE_BS_02 Reports the possibility of deliberate harm [both self-harm and harm by others] in vulnerable patients to appropriate agencies A,C,D 2,4
CE_BS_03 Actively elicits important clinical findings D 1
CE_BS_04 Performs relevant additional examinations A,D 1

 

C) Investigations

Objectives:

  • To describe the indications for basic preoperative investigations
  • To interpret and act upon basic investigations with relevance to anaesthesia and surgery
Knowledge
Competence Description Assessment Methods GMP
IN_BK_01 (formerly OA_BS_03)

Interprets clinical data including, but not exclusively:

  • Patient clinical case notes and associated records
  • Clinical parameters such as:
    • BP, Pulse, CVP
    • BMI
  • Fluid balance
  • Physiological investigations such as:
    • ECGs
    • Echocardiography and stress testing
    • Pulmonary function tests
 A,C,E 1
Skills
Competence Description Assessment Methods GMP
IN_BS_01 (formerly OA_BS_04)

Interprets clinical laboratory data including:

  • Haematology such as
    • Routine report of Hb, WBC, haematocrit etc.
  • Biochemistry such as
    • Arterial blood gases/acid-base balance
    • Urea and electrolytes
    • Liver function
    • Endocrine biochemistry such as blood glucose and thyroid function
 A,C,E 1
IN_BS_02 (formerly OA_BS_05)

Identifies normal appearances and significant abnormalities in radiographs including:

  • Chest X-rays
  • Trauma films – cervical spine, chest, pelvis, long bones
  • Head CT and MRI showing clear abnormalities
 A,C,E 1

 

D) Specific Anaesthetic Evaluation

Objectives:

  • To establish a problem list
  • To determine whether the patient is risk assessed and optimally prepared
  • To plan anaesthesia and postoperative care for common surgical procedures
  • To recognise own limitations and reliably determine the level of supervision required
  • To explain options and risks of routine anaesthesia to patients, in a way they understand, and obtain their consent for anaesthesia
Knowledge
Competence Description Assessment Methods GMP
OA_BK_01 Gives examples of methods of anaesthesia that are suitable for common operations. A,C,E 1,2
OA_BK_02 Describes the ASA and NCEPOD classifications and their implications in preparing for and planning anaesthesia and postoperative care A,C,E 1
OA_BK_03 Explains the indications for and interpretation of preoperative investigations A,C,E 1
OA_BK_04 Lists the indications for preoperative fasting and appropriate regimens A,C,E 1
OA_BK_05 Explains the methods commonly used for assessing the airway to predict difficulty with tracheal intubation A,C,E 1,2
OA_BK_06 Lists the indications for Rapid Sequence Induction A,C,D,E 1,2
OA_BK_07 Gives examples of the effect of common co-existing diseases on anaesthesia and surgery including but not exclusively: obesity; diabetes; asthma; ischaemic heart disease; hypertension; rheumatoid disease; epilepsy A,C,E 1
OA_BK_08 Discusses how to manage drug therapy for co-existing disease in the perioperative period including, but not exclusively: diabetic treatment; steroids; anti-coagulants; cardiovascular and respiratory medication; anticonvulsants A,C,E 1
OA_BK_09 Explains the available methods to minimise the risk of thromboembolic disease following surgery A,C,E 1,2
OA_BK_10 Describes the complications of anaesthetic drugs [including anaphylaxis, suxamethonium apnoea and malignant hyperpyrexia] and how to predict patients who are at increased risk of these complications A,C,E 1,2
OA_BK_11 Identifies the principles of consent for surgery and anaesthesia, including the issue of capacity A,C,E 3,4
OA_BK_12

Explains the guidance given by the GMC on consent, in particular:

  • Understands that consent is a process that may culminate in, but is not limited to, the completion of a consent form
  • Understands the particular importance of considering the patient's level of understanding and mental state [and also that of the parents, relatives or carers when appropriate] and how this may impair their capacity for consent
 A,C,E 3,4
OA_BK_13 Summarises the factors determining a patient’s suitability for treatment as an ambulant or day-stay patient A,C,E 1
OA_BK_14 Recalls the factors that affect the risk of a patient suffering post-operative nausea & vomiting A,C,E 1
Skills
Competence Description Assessment Methods GMP
OA_BS_01

Obtains a history specifically relevant to the planned anaesthesia and surgery including:

  • A history of the presenting complaint for surgery
  • A systematic comprehensive relevant medical history
  • Information about current and past medication
  • Drug allergy and intolerance
  • Information about previous anaesthetics and relevant family history
 A,D,E 1
OA_BS_02

Performs a relevant clinical examination including when appropriate:

  • Cardiovascular system
  • Respiratory system
  • Central and peripheral nervous system: GCS, peripheral deficit
  • Musculoskeletal system: patient positioning, neck stability/movement, anatomy for regional blockade
  • Other: nutrition, anaemia, jaundice
  • Airway assessment/dentition
 A,D,E 1
OA_BS_06

Makes appropriate plans for anaesthesia:

  • Reviews current medication and seeks advice where appropriate
  • Plans appropriate anaesthetic technique[s]
  • Secures consent for anaesthesia
  • Recognises the need for additional investigation and acts accordingly
  • Discusses issues of concern with relevant members of the team
  • Reliably predicts the level of supervision they will require
 A,C,E 1
OA_BS_07 Presents information to patients [and carers] in a format they understand, checking understanding and allowing time for reflection on the decision to give consent A,M 3,4
OA_BS_08 Provides a balanced view of care options A,C,E,M 2,3