During the history-taking procedure, in addition to the standard medical enquiries (see Ch. 2) it is important to explore the patient’s attitude to previous treatment, and their probable responses to planned treatment. It is also advisable to assess whether the patient is unusually anxious or shows evidence of any other departures from normal behaviour. Discussions regarding the patient’s social background should identify, particularly for older patients, whether they live alone or have family support.

GENERAL ASSESSMENT

When surgery is contemplated, it is in response to a patient’s clinical complaint. However, it is important to ensure that the problem is given appropriate priority within the patient’s general, social and health care, so that the treatment recommended is relevant and is seen by the patient to be acceptable and desirable.

For the compromised patient the likely outcome must be considered against the risks and consequences of the surgery’a treatment plan which may be routine and sensible for a healthy patient may need to be modified considerably when dealing with an elderly or sick patient.

In the general practice environment, short episodes of treatment are usually tolerated well but extensive, prolonged surgical procedures are not recommended.

Patients who are psychologically vulnerable and who may become confused when treatment is described to them should be encouraged to discuss the proposals with a family member or friend whilst in the surgery. It is often beneficial to arrange a second appointment specifically for this purpose. It is also important not to increase anxiety by emphasizing unlikely risks, particularly if the treatment proposed is essential. If the surgery is part of a longer-term treatment plan, then the patient’s ability to complete the whole course (physically and financially) must be confirmed.

A patient’s aftercare must also be taken into account. The recovery period will require an adjustment for the patient in terms of daily activities and diet, and support at home (from partner, relatives or friends) is an important factor. For patients who are unwell, the effects of their illness, including their medications, on wound healing and the prescription of drugs required to aid recovery are additional important factors to take into account.

Before finalizing a surgical treatment plan which is appropriate and specific for the patient, they will have been assessed:

• socially (support, financial)

• psychologically

• medically.

ASSESSMENT OF MEDICAL STATUS

When the history is documented, a detailed medical enquiry (often obtained initially from a questionnaire completed by the patient) will have identified whether the patient has had, or is suffering from, any significant disease. It is important to remember that even if the patient has been seen at the practice for many years, the history must be checked before arranging any surgery.

Patients may be suffering from diseases of which they are unaware and the surgeon must take into account the patient’s social status when interpreting the medical history; for example, an overweight, middle-aged man who consumes alcohol should be considered a possible risk for a degree of liver dysfunction. Also, with increasing age, patients may suffer from undiagnosed cardiovascular (cardiores-piratory) disorders such as hypertension and ischaemic heart disease.

Once a disease state has been identified, there must be some attempt to categorize the illness, so that planned surgery is based on a systematic approach rather than a ‘one-off’ judgement.

As well as identifying the disease some attempt should be made to assess its severity. For example, the length of time the patient has suffered from the problem and the effect it has on their life and mobility are helpful measures. Direct enquiries about whether the patient has been hospitalized (and when and how often) and how the patient is managed (whether by their practitioner or with regular outpatient visits to a hospital specialist unit) will also assist.

The assessment scale first introduced by the American Society of Anesthesiologists (see Ch. 3) has provided a basis for similar classifications, such as scales for the severity of congestive heart failure or for severity of cardiopulmonary disease. This type of grading may be helpful in the assessment of a patient’s general medical status. A suggested system is given below.

Grade 1:

• Fit young patient—no known disease

• Fit elderly patient—assume undiagnosed mild cardiorespiratory disease

• Psychologically vulnerable patient who has adequate family or social support

• Patient apparently well, but whose social history suggests risk factors.

Grade 2:

• Patient with mild controlled disease—little or no interference with daily activities

• Disorder which may require modification of management because of the condition or drug therapy

• Patient who denies illness, but who appears to be unwell (e.g. short of breath).

Grade 3:

• Patients with more than one disease

• Complex drug regimens that will affect management