Pre-Anaesthetic Assessment · Complete PAC Record

§ 1

Patient Identification

Full Name

Age / Sex

IP / OP / MRD No.

Ward / Bed No.

Surgeon

Surgery Date / Time

Planned Surgery

Blood Group

Weight (kg)

Height (cm)

BMI (kg/m²)

Ideal Body Weight — IBW (kg) ? Devine Formula (1974)
Male: IBW = 50 + 2.3 × (height in cm / 2.54 − 60)
Female: IBW = 45.5 + 2.3 × (height in cm / 2.54 − 60)

Valid for heights > 152 cm (5 ft).
For heights ≤ 152 cm: IBW ≈ actual body weight.

Used for: tidal volume targets (6–8 mL/kg IBW), drug dosing (suxamethonium, rocuronium), ventilator settings.

—

Enter height & sex to calculate

§ 2

Diagnosis & Surgical Details

Presenting Complaint / Diagnosis

Planned Procedure (Surgical Details)

Surgical Urgency

Elective Urgent Emergency

Surgical Risk Category

Select Risk Level

↑ Risk Reference Image
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Expected Duration of Surgery

§ 3

History

3A · Chief Complaints

Chief Complaints

3B · History of Present Illness

History of Present Illness

3C · Past Medical & Surgical History

Comorbidities — Tick all that apply

Hypertension Diabetes Mellitus (Type 1 / 2) Coronary Artery Disease / IHD Congestive Heart Failure Valvular Heart Disease Arrhythmia / AF Prior PTCA / CABG Pacemaker / ICD Cerebrovascular Disease / Stroke / TIA Chronic Kidney Disease Liver Disease / Cirrhosis COPD / Asthma / ILD Obstructive Sleep Apnoea Epilepsy / Seizure Disorder Thyroid Disorder Malignancy (active / prior) Haematological Disorder Coagulation Disorder / DVT / PE Rheumatoid / Connective Tissue GERD / Hiatus Hernia Obesity (BMI >30) Psychiatric Disorder Other:

Prior Surgeries (Procedure / Year / Anaesthesia Type)

Complications from Prior Anaesthesia

None Difficult Intubation PONV Delayed Recovery Awareness

Details

Family History of Anaesthetic Problems (Malignant Hyperthermia, Pseudocholinesterase Deficiency, Others)

3D · Current Medications

Antihypertensives (ACEi / ARB / BB / CCB / diuretics) Antidiabetics (OHA / Insulin — last dose: ) Antiplatelet (aspirin / clopidogrel / ticagrelor) Anticoagulant (warfarin / LMWH / DOAC) Steroids (chronic — stress dosing required) Antiepileptics Antithyroid / Thyroid replacement Statins Bronchodilators / Inhalers Psychiatric meds (MAOI / SSRI / lithium) Herbal / OTC / Supplements Other:

Drug List (Name · Dose · Frequency · Last Taken)

3E · Allergy History

⚠ Allergies — Document Carefully

Drug Allergies

Latex / Environmental

Food Allergies

Nature of Reaction (Rash / Anaphylaxis / Intolerance / GI)

3F · Personal & Social History

Smoking

Never Ex-Smoker Current

Pack-Years / Quit Date

Alcohol

None Occasional Regular

Units / Week

Substance Use

None Cannabis Other:

Occupation / Activity Level

3G · Obstetric / Gynaecological History (if applicable)

G / P / L / A

LMP

Pregnancy Status

N/A Pregnant (wks: ) Post-partum

Relevant Gynaec History

§ 4

Physical Examination

4A · Vitals at PAC

bpm

mmHg

SpO₂ (RA)

/min

Temp

°C

GCS

/15

General Appearance

Built / Nourishment

Pallor

Absent Mild Moderate Severe

Icterus

Absent Present

Cyanosis / Clubbing / Oedema

Lymphadenopathy

JVP

Capillary Refill Time / IV Access

4B · Airway Assessment (LEMON + Scoring)

Mallampati Class

Soft palate, fauces, uvula, tonsillar pillars visible

Soft palate, fauces, uvula (partially) visible

III

Soft palate & base of uvula only

Hard palate only — no soft palate

Anticipated Cormack-Lehane Grade

Full cords

IIa

Partial cords

IIb

Arytenoids only

III

Epiglottis only

Upper Lip Bite Test

Lower incisors bite above upper lip mucosa

Lower incisors bite upper lip — skin visible

III

Cannot bite upper lip at all

Predicted Airway Difficulty

Easy Possibly Difficult Difficult Airway

Interincisor Gap (cm)

Neck Circumference (cm)

LEMON Checklist

Mouth opening <3 cm (2-finger test) Thyromental distance <6 cm (3 fingers) Hyomental distance <4 cm — 3-3-2 rule Short / thick neck Limited neck extension (<35°) Prognathism / retrognathia Large tongue / macroglossia Beard / facial hair Obesity (BMI >35) Prior documented difficult intubation Obstruction / mass / foreign body Trismus / limited TMJ movement

Dentition (Loose / Caps / Prosthesis)

Previous Intubation Grade (if known)

El-Ganzouri Airway Risk Index (EARI) Multivariate Difficult Airway Predictor

Mouth Opening ? Measure interincisor gap (IIG) with mouth fully open. <4cm predicts difficulty.

Thyromental Distance (TMD)

Mallampati Class (oropharyngeal view)

Neck Mobility

Ability to Prognath (advance mandible)

Body Weight (BMI correlation)

History of Difficult Intubation

El-Ganzouri Total Score 0

0–3 → Standard airway management · 4–6 → Prepare difficult airway cart · ≥7 → Awake intubation / surgical airway backup

Wilson Risk Sum Score Intubation Difficulty Predictor · 5 Parameters

Weight ? Higher weight correlates with difficult laryngoscopy due to limited mobility and increased tongue size.

Head and Neck Movement

Jaw Movement / Mandibular Protrusion

Receding Mandible

Buck Teeth (Prominent Upper Incisors)

Wilson Total Score 0

≤2 → Low risk · 3–4 → Moderate risk (prepare) · ≥5 → High risk — anticipate difficult intubation

4C · Systemic Examination

Cardiovascular System

Heart Sounds / Murmurs

Added Sounds (S3 / S4 / Rub)

Peripheral Pulses / Perfusion

Features of CCF / HF

Respiratory System

Breath Sounds (Bilateral)

Wheeze / Crepitations / Rhonchi

Chest Expansion / Tracheal Position

Respiratory Pattern

Abdomen

Tenderness / Organomegaly

Distension / Ascites

Bowel Sounds

Surgical Scar / Stoma

Neurological

Conscious Level / Orientation

Focal Neurological Deficits

Pre-existing Neuropathy

Pupillary Response

Spine / Regional Anatomy

Lumbar / Thoracic Spine

Deformity / Scoliosis / Fusion

Skin over Proposed Site

Intervertebral Space Palpable

Yes No

Musculoskeletal — Joint Mobility / Neck Mobility

Other Significant Findings

§ 5

Investigations

Laboratory Results

Parameter	Parameter	Parameter	Parameter
Hb (g/dL)	PCV / Hct (%)	WBC (×10³/µL)	Platelets (×10³/µL)
Na⁺ (mEq/L)	K⁺ (mEq/L)	Cl⁻ / HCO₃⁻	Urea / BUN
Creatinine (mg/dL)	eGFR (mL/min)	Blood Sugar (Random)	HbA1c (%)
Bilirubin (T/D)	ALT / AST / ALP	Total Protein / Albumin	PT / INR
APTT	Type & Screen / Crossmatch	Urine R/E	TSH / Thyroid Profile

Viral Markers

HBsAg (Hepatitis B Surface Antigen)

Result

Date / Remarks

HIV I & II (Anti-HIV)

Result

Date / Remarks

HCV (Anti-HCV / Hepatitis C)

Result

Date / Remarks

Viral Marker Precautions / Universal Precautions Applied

ECG

Rate / Rhythm

Axis / PR / QRS / QTc

Ischaemic Changes / LBBB / Other

Interpretation / Action

Chest X-Ray

Cardiothoracic Ratio

Lung Fields

Mediastinum / Trachea

Interpretation / Action

Echocardiography (if done)

LVEF (%)

LV Function / Regional WMA

Valvular Lesions

Diastolic Dysfunction Grade

PASP / RV Function

PFT / Spirometry (FEV1, FVC, FEV1/FVC, DLCO)

Other Investigations (ABG / Special Tests / Imaging)

Specialist Opinions / Clearance Letters Received

§ 6

Risk Stratification Scores

RCRI — Revised Cardiac Risk Index Cardiac MACE risk in non-cardiac surgery · Use for all patients undergoing intermediate/high-risk surgery

High-risk surgery (intrathoracic / intraperitoneal / suprainguinal vascular)+1

History of ischaemic heart disease+1

History of congestive heart failure+1

History of cerebrovascular disease (TIA / stroke)+1

Diabetes mellitus on insulin+1

Pre-op serum creatinine >2.0 mg/dL+1

Score 0 → <1% MACE · 1–2 → 1–7% · ≥3 → >11%
≥3: Consider cardiology referral before elective surgery per ACC/AHA 2014 guidelines

Functional Capacity (METs) Exercise tolerance assessment · Use alongside RCRI; <4 METs + RCRI ≥1 triggers further workup

Self-care only (eat, dress, toilet)1 MET Walk indoors / light housework2–3 METs Walk on level ground ~4 km/h~3–4 METs Climb a flight of stairs / walk uphill≥4 METs Run short distance / heavy housework~5–8 METs Strenuous sports (swimming / singles tennis)>10 METs

<4 METs → Poor functional capacity · ≥4 METs → Adequate
<4 METs + RCRI ≥1: further workup per ACC/AHA algorithm. Offer cardiopulmonary exercise testing if available.

ASA Physical Status Classification Overall systemic disease severity · Mandatory for all patients undergoing anaesthesia

Normal healthy patient

Mild systemic disease

III

Severe systemic disease — not incapacitating

Severe systemic disease — constant threat to life

Moribund — not expected to survive without surgery

Brain-dead — organ donor

Add "E" suffix for emergency surgery (e.g., ASA III E)
ASA III–IV: increased peri-operative morbidity; informed consent must document risk stratification

STOP-BANG Questionnaire Obstructive Sleep Apnoea (OSA) screening · Use for all obese, snoring, or hypertensive patients

Snoring — loud enough to be heard through closed doors+1

Tired — often fatigued / sleepy during daytime+1

Observed — apnoeas witnessed by partner+1

Pressure — hypertension (treated or untreated)+1

BMI >35 kg/m²+1

Age >50 years+1

Neck circumference >40 cm (both sexes)+1

Gender — Male+1

0–2 → Low OSA risk · 3–4 → Moderate · ≥5 → High
High: post-op continuous monitoring; anticipate difficult mask ventilation; CPAP counselling

Apfel Score PONV (Post-Operative Nausea & Vomiting) risk · Use for all patients receiving GA

Female sex+1

Non-smoker+1

History of PONV or motion sickness+1

Postoperative opioid use expected+1

0–1 → 10–20% risk · 2 → ~40% · 3–4 → 60–80%
≥2: dual prophylaxis (ondansetron + dexamethasone ± scopolamine patch)

ARISCAT Score Post-operative Pulmonary Complication (PPC) risk · Use for thoracic, upper abdominal, prolonged surgeries

Age 51–80 years+3

Age >80 years+16

SpO₂ 91–95% on room air+8

SpO₂ ≤90% on room air+24

Respiratory infection in past month+17

Pre-op anaemia (Hb ≤10 g/dL)+11

Upper abdominal / intrathoracic surgery+15

Duration of surgery >2 hours+16

Emergency procedure+8

<26 → Low (1.6%) · 26–44 → Moderate (13%) · ≥45 → High (42%)
High: lung-protective ventilation, chest physio, early mobilisation

Caprini Score VTE / DVT thromboprophylaxis risk stratification · Use for all surgical patients

1 pt each: Age 41–60 · Minor surgery · BMI >25 · Swollen legs · Varicose veins · Pregnancy/postpartum · OCP/HRT · Sepsis <1 month · Lung disease · Bed rest · IBD1×

2 pts each: Age 61–74 · Major surgery · Malignancy · Laparoscopy >45min · Central venous access · Immobilising cast · Bed rest >72h2×

3 pts each: Age ≥75 · Prior DVT/PE · Family h/o thrombosis · Thrombophilia · Lupus anticoag / anticardiolipin Ab3×

5 pts each: Stroke <1m · Elective arthroplasty · Hip/pelvis/leg fracture · Spinal cord injury <1m · Multiple trauma <1m5×

0–1 → Very Low · 2 → Low (TEDS) · 3–4 → Moderate (LMWH or IPC) · ≥5 → High (LMWH + IPC)
≥5: mechanical + pharmacological prophylaxis required

CHA₂DS₂-VASc Stroke risk in patients with AF · Guides peri-operative anticoagulation decisions

Congestive heart failure / LV dysfunction+1

Hypertension (treated or untreated)+1

Age ≥75 years+2

Diabetes mellitus+1

Stroke / TIA / thromboembolism (prior)+2

Vascular disease (prior MI / PAD / aortic plaque)+1

Age 65–74 years+1

Sex category — Female+1

0(M) / 1(F) → Low risk (no anticoag) · 1(M) → Moderate · ≥2 → Anticoagulate
High score: bridging anticoagulation decision critical peri-operatively

HAS-BLED Score Bleeding risk on anticoagulation · Use in patients on warfarin / DOAC peri-operatively

Hypertension — SBP >160 mmHg uncontrolled+1

Abnormal renal function (dialysis / creatinine >2.26 / transplant)+1

Abnormal liver function (cirrhosis / bilirubin >2×ULN / ALT/ALP >3×ULN)+1

Stroke history+1

Bleeding history or predisposition (anaemia, thrombocytopenia)+1

Labile INR (TTR <60%)+1

Elderly — age >65 years+1

Drugs (antiplatelets / NSAIDs)+1

Alcohol use (≥8 drinks/week)+1

0–1 → Low bleeding risk · 2 → Moderate · ≥3 → High
High HAS-BLED ≠ withhold anticoag; address modifiable factors (BP control, stop NSAIDs, correct anaemia)

§ 7

Assessment Summary

Score	Score	Risk Category / Interpretation
RCRI	Apfel
METs	STOP-BANG
ASA PS	Caprini
ARISCAT	CHA₂DS₂-VASc
El-Ganzouri	HAS-BLED
Wilson Score	IBW (kg)	Devine Formula · Male: 50+2.3×(in−60) / Female: 45.5+2.3×(in−60)
Mallampati	Overall Surgical Risk

§ 8

Anaesthesia Plan & Disposition

Additional Investigations Required

Specialist Referrals Initiated

Proposed Anaesthesia Technique

General Anaesthesia Spinal Epidural CSE Regional Block MAC / Sedation Combined GA + Regional Other:

Airway Management Plan

Direct Laryngoscopy Video Laryngoscopy Awake Fibreoptic Intubation LMA / Supraglottic RSI Surgical Airway Backup

Medications — Continue / Stop / Bridge

Instructions

Fasting Instructions (Solid / Clear Fluids)

Pre-Medication Plan

Monitoring Plan

Standard ASA Invasive Arterial Line Central Venous Access TOF / NMB Monitoring Temperature Monitoring BIS / Depth of Anaesthesia PA Catheter / TOE Neuromonitoring

Post-Operative Destination

Ward General ward HDU High dependency ICU Intensive care PACU Monitored recovery

Special Instructions / Concerns / Risk Communication to Patient & Surgeon

✦

Anaesthetic Fitness Assessment

Fit for Anaesthesia & Surgery

No significant concerns identified

Fit — with precautions noted above

Proceed with documented precautions

Conditionally Fit

Pending:

NOT Fit

Reason:

Resident Anaesthesiologist — Name & Designation

Consultant Reviewed — Name & Designation