Navigating The Preop Visit In Primary Care
Listen
Watch
Show notes:
The preop exam. Every patient having surgery needs to have a visit with a healthcare provider before their surgery in order to assess their health and verify that it is relatively safe to proceed with surgery. When they end up on your schedule, it’s up to you whether or not they will get the go ahead - no pressure. If you are wondering how, as someone who has not been trained to perform surgeries, you are supposed to understand a patient’s ability to tolerate a surgery or procedure, this video should help.
What Does It Mean To “Clear” A Patient For Surgery?
Every surgery comes with a certain amount of risk, and no patient or surgery is ever going to be considered zero risk. Both patients and surgeries have varying levels of risk (low, medium, high), and the preop visit is the place to get an understanding of how the pairing of the patient and the surgery is most likely to pan out. Many times, your judgment will be adequate and you can determine whether or not the patient should proceed with surgery; other times, more information will be needed, and it may be wise to send them to a specialist for the final word.
In this week’s video, we will talk about the particulars of the preop patient and the preop exam.
The elements of a preop exam in primary care
Relative risk levels of surgeries, and how to understand them for the purpose of a preop exam
How to factor in the comorbidities when considering the patient’s safety for surgery
The role of preop testing and imaging
How to get feedback from a collaborating physician for tricky cases
Not all preop examinations are created equal, and so much of it depends on the surgery the patient is planning. Try not to get overwhelmed by the prospect; improving your understanding of the patient and assessing them for surgery, and when you should send them somewhere else, gets better with time and practice.
Resources mentioned in this episode:
If you liked this post, also check out:
-
WEBVTT
1
00:00:08.580 --> 00:00:12.760
Hey there, welcome to the Real World NP podcast.
2
00:00:13.120 --> 00:00:20.400
I'm Liz Rohr, family nurse practitioner, educator, and founder of Real World NP, an educational
3
00:00:20.400 --> 00:00:23.160
company for nurse practitioners in primary care.
4
00:00:24.480 --> 00:00:29.400
I'm on a mission to equip and guide new nurse practitioners so that they can feel
5
00:00:29.400 --> 00:00:33.020
confident, capable, and take the best care of their patients.
6
00:00:33.500 --> 00:00:38.260
If you're looking for clinical pearls and practice tips without the fluff, you're in
7
00:00:38.260 --> 00:00:39.040
the right place.
8
00:00:39.260 --> 00:00:42.980
Make sure you subscribe and leave a review so you won't miss an episode.
9
00:00:43.320 --> 00:00:49.260
Plus, you'll find links to all the episodes with extra goodies over at realworldnp.com
10
00:00:49.260 --> 00:00:50.420
slash podcast.
11
00:00:54.090 --> 00:00:57.870
Well, hey there, it's Liz Rohr from Real World NP, and you're watching NP Practice
12
00:00:57.870 --> 00:01:01.570
Made Simple, the weekly videos to help save you time, frustration, and help you
13
00:01:01.570 --> 00:01:03.970
learn faster so you can take the best care of your patients.
14
00:01:04.290 --> 00:01:06.750
So today I'm going to be talking about preoperative exams.
15
00:01:07.050 --> 00:01:10.830
It's kind of a big topic, but I'm going to do my very best to kind of give you
16
00:01:10.830 --> 00:01:15.970
an overview of guidance of how I conduct my exams and how I recommend you do based
17
00:01:15.970 --> 00:01:17.210
on the available guidelines.
18
00:01:17.470 --> 00:01:23.110
A couple of disclaimers I want to make from the beginning is that if you are
19
00:01:23.110 --> 00:01:29.370
an algorithm-loving, tool-loving kind of girl like I am, or boy, that you
20
00:01:29.370 --> 00:01:32.630
might be a little bit disappointed for pre-op exams because they're a little
21
00:01:32.630 --> 00:01:33.270
bit complicated.
22
00:01:33.870 --> 00:01:37.610
So really, one of the take-homes I want you to take away from this is that
23
00:01:39.530 --> 00:01:43.690
each pre-op exam is for that patient at that time with those chronic
24
00:01:43.690 --> 00:01:46.190
conditions for that type of surgery, unfortunately.
25
00:01:46.370 --> 00:01:49.270
So it's really hyper-individualized, and that's a very good reason is
26
00:01:49.270 --> 00:01:51.570
because there's a lot to think about.
27
00:01:51.970 --> 00:01:55.750
So with that in mind, I think it's really important that you, I really want
28
00:01:55.750 --> 00:01:59.350
to stress that you ask questions whenever you're not sure, right?
29
00:01:59.350 --> 00:02:02.650
So there's a spectrum of the different types of pre-ops we're seeing, right?
30
00:02:02.650 --> 00:02:06.650
There's healthy patients undergoing low-risk surgeries all the way through
31
00:02:06.650 --> 00:02:10.289
very complicated, multiple chronic comorbidities, very ill patients
32
00:02:10.289 --> 00:02:13.530
trying to undergo high-risk surgeries or asking for your clearance.
33
00:02:14.430 --> 00:02:17.830
And so I'm going to be talking a little bit more towards the kind of
34
00:02:17.830 --> 00:02:20.230
second one I mentioned just because that's kind of come up as a lot,
35
00:02:20.770 --> 00:02:21.770
as a question a lot.
36
00:02:22.590 --> 00:02:25.410
But one other kind of like disclaimer I want to add is that I'm
37
00:02:25.410 --> 00:02:27.830
a family nurse practitioner and I've been doing this for four years.
38
00:02:27.830 --> 00:02:30.910
However, the patients that I'm seeing are generally on the healthier side
39
00:02:32.590 --> 00:02:37.210
or are having lower-risk surgeries if they have some chronic comorbidities.
40
00:02:37.750 --> 00:02:40.370
So I'm actually, I think that's actually a benefit for making this video,
41
00:02:40.450 --> 00:02:43.630
though, because if I were to switch over to that type of practice
42
00:02:43.630 --> 00:02:46.210
in internal medicine, doing those kind of higher-risk patients,
43
00:02:46.670 --> 00:02:47.690
this is what I would do.
44
00:02:47.970 --> 00:02:51.850
So just one other thing to say before we start is that you kind of
45
00:02:51.850 --> 00:02:53.250
want to have a discussion with your supervisor.
46
00:02:53.470 --> 00:02:55.850
I'm going to be going over kind of like the steps that I recommend
47
00:02:55.850 --> 00:02:58.370
that I would take if I was kind of transitioning into that practice
48
00:02:58.370 --> 00:03:02.510
of a more intense internal medicine position in terms of doing,
49
00:03:02.710 --> 00:03:06.190
I mean, my job is intense, but it's just not doing that intense skill.
50
00:03:06.550 --> 00:03:08.250
This is kind of like the approach that I would take,
51
00:03:08.250 --> 00:03:11.590
but I would also present this to my collaborating physician
52
00:03:11.590 --> 00:03:14.470
and my supervisor and talk about, here's my approach.
53
00:03:14.490 --> 00:03:16.250
And is this something that you recommend?
54
00:03:16.630 --> 00:03:18.070
Do you have other protocols in the clinic?
55
00:03:18.110 --> 00:03:20.170
Do you have other forms of patients fill out like things like that?
56
00:03:20.170 --> 00:03:21.710
Just having that kind of discussion first.
57
00:03:21.890 --> 00:03:23.970
Now that those disclaimers are all out of the way,
58
00:03:23.970 --> 00:03:25.730
actually, this is one more kind of disclaimer,
59
00:03:26.070 --> 00:03:28.890
is that people talk about pre-op clearance.
60
00:03:28.990 --> 00:03:30.870
It's not clearance. Don't say clearance.
61
00:03:30.990 --> 00:03:31.910
I don't say clearance anymore.
62
00:03:32.330 --> 00:03:35.270
It's really like you can never erase the risk somebody has
63
00:03:35.270 --> 00:03:38.310
of having a surgery, but what you're doing is you're optimizing the surgery
64
00:03:38.310 --> 00:03:42.870
so that optimizing their health so that the surgery is as low risk as possible.
65
00:03:42.890 --> 00:03:46.010
And you're talking about the risks and benefits and alternatives
66
00:03:46.010 --> 00:03:48.350
and deciding if the risks outweigh the benefits, right?
67
00:03:48.350 --> 00:03:51.290
Because there is always the option of not clearing somebody, right?
68
00:03:51.290 --> 00:03:54.870
They're not recommending them to have surgery,
69
00:03:55.090 --> 00:03:58.870
but optimizing is the kind of buzzword to use in perioperative medicine, it sounds like.
70
00:03:58.890 --> 00:04:02.010
So I first kind of start my assessment with this,
71
00:04:02.370 --> 00:04:04.990
is it a low-risk surgery, moderate or high-risk surgery?
72
00:04:05.010 --> 00:04:07.330
And that kind of frames the workup and the history questions
73
00:04:07.330 --> 00:04:08.570
and all the stuff that I'm doing, right?
74
00:04:08.670 --> 00:04:11.530
So a low-risk surgery, for example, is like a cataract surgery.
75
00:04:12.730 --> 00:04:15.670
Not a whole lot that you have to do to kind of clear them for surgery, right?
76
00:04:15.670 --> 00:04:18.990
To optimize them for surgery because the biggest risk for complication
77
00:04:18.990 --> 00:04:20.930
is for having an uncontrolled high blood pressure.
78
00:04:22.130 --> 00:04:26.210
Whereas, you know, if you have some sort of GI surgery or brain surgery,
79
00:04:26.390 --> 00:04:29.070
things like that, those have different risks, right?
80
00:04:29.090 --> 00:04:32.410
And so the risk is based on how long the surgery is,
81
00:04:32.770 --> 00:04:35.230
how much blood loss there is and the fluid shifts.
82
00:04:35.670 --> 00:04:37.890
And unfortunately, there's no comprehensive list that I've found.
83
00:04:37.950 --> 00:04:39.490
I found a pretty solid one.
84
00:04:39.610 --> 00:04:42.910
And actually, I should have mentioned that I have a handout down below this video
85
00:04:42.910 --> 00:04:46.130
kind of with a cheat sheet of the information I'm going to be giving you in this video.
86
00:04:46.130 --> 00:04:50.210
So talking about the risks and the risks of the different types of surgeries is on there.
87
00:04:50.330 --> 00:04:54.030
If you find that there's a surgery that's not listed, this is again,
88
00:04:54.210 --> 00:04:58.930
if I was in your shoes, I would discuss with one of my collaborating providers
89
00:04:58.930 --> 00:05:01.350
and I would say, you know, are you familiar with the surgery,
90
00:05:01.510 --> 00:05:03.370
how long it is, how involved it is,
91
00:05:03.370 --> 00:05:05.410
and would you assess it to be a low, moderate or high risk?
92
00:05:05.810 --> 00:05:10.770
And again, I kind of also like as another kind of direction pointer,
93
00:05:11.210 --> 00:05:14.190
you can kind of search and see if there's specific information
94
00:05:14.190 --> 00:05:17.550
for the evaluation, pre-op evaluation for cataract surgery, for example,
95
00:05:17.610 --> 00:05:21.850
or pre-op evaluation for cholecystectomy or something like that.
96
00:05:22.190 --> 00:05:25.490
They may or may not exist, but that's like another kind of path to go down.
97
00:05:25.750 --> 00:05:27.950
So once I've kind of determined if it's low, moderate or high,
98
00:05:28.050 --> 00:05:30.210
kind of like if it's a low-risk cataract surgery,
99
00:05:30.270 --> 00:05:33.550
I'm not necessarily going to get into the full thing necessarily, right?
100
00:05:34.070 --> 00:05:36.530
But if I've determined it's kind of like a moderate to high risk,
101
00:05:36.790 --> 00:05:39.610
I'm going to kind of go down this, this is the typical path that I would go down.
102
00:05:39.690 --> 00:05:42.990
And so I'm going to kind of, the framework is that I'm assessing their chronic conditions,
103
00:05:42.990 --> 00:05:50.410
I'm assessing their cardiac and pulmonary risk scores, risk factors,
104
00:05:51.690 --> 00:05:54.890
and kind of taking it from there as well as like recapping their medications,
105
00:05:55.050 --> 00:05:58.090
getting an accurate social history during the full physical exam
106
00:05:58.090 --> 00:05:59.530
and then deciding what testing to do.
107
00:05:59.630 --> 00:06:02.650
So the main risks of having a surgery are death,
108
00:06:03.870 --> 00:06:05.550
cardiac complications and pulmonary complications.
109
00:06:05.670 --> 00:06:08.170
There's others, of course, but those are kind of like the main ones
110
00:06:08.170 --> 00:06:10.470
you want to think about in terms of framing your pre-op exam.
111
00:06:10.470 --> 00:06:16.190
So for assessing the cardiac risk, I'm just going to kind of go through that.
112
00:06:16.250 --> 00:06:17.710
There's the most to talk about with that one.
113
00:06:18.630 --> 00:06:21.410
So the kind of two scenarios that we're talking about are
114
00:06:21.410 --> 00:06:24.770
somebody who has established cardiovascular disease,
115
00:06:24.950 --> 00:06:28.310
aortic stenosis, AFib, history of an MI.
116
00:06:28.670 --> 00:06:31.370
Those patients, me personally, this is a recommendation that I'm going to make
117
00:06:31.370 --> 00:06:33.070
is that they go see their cardiologist
118
00:06:33.070 --> 00:06:36.210
to have their input on the preoperative optimization.
119
00:06:36.590 --> 00:06:38.410
Are they optimized from their cardiologist perspective
120
00:06:38.410 --> 00:06:40.310
or at the very least get them on the phone, right?
121
00:06:40.310 --> 00:06:43.050
And say like, what are your kind of thoughts about this?
122
00:06:43.070 --> 00:06:44.910
Once I've kind of gathered all of my information,
123
00:06:45.130 --> 00:06:47.250
so I can present the case, right?
124
00:06:47.250 --> 00:06:49.970
Which I talk about in how to ask questions the right way
125
00:06:49.970 --> 00:06:51.510
if you haven't seen that video yet.
126
00:06:51.850 --> 00:06:54.390
Kind of getting all your stuff together before you're asking all the questions
127
00:06:54.390 --> 00:06:56.850
and asking very specific questions, especially of a specialist.
128
00:06:58.010 --> 00:07:00.170
And then you have the other patient who's coming in
129
00:07:00.170 --> 00:07:02.270
that you're kind of the detective and you're deciding,
130
00:07:03.530 --> 00:07:07.230
is there an underlying cardiovascular disease that we haven't discovered yet
131
00:07:07.230 --> 00:07:09.470
and that if we don't discover it is going to put them at risk
132
00:07:09.470 --> 00:07:12.630
for cardiovascular complications around their surgery or risk for death, right?
133
00:07:12.630 --> 00:07:13.290
Which is like, ooh.
134
00:07:13.750 --> 00:07:15.350
So here's the advice that I recommend.
135
00:07:15.650 --> 00:07:17.710
So you're kind of asking a history, right?
136
00:07:17.710 --> 00:07:20.510
So you're talking about, do you have any obvious signs, right?
137
00:07:20.530 --> 00:07:24.310
Of angina, shortness of breath, dyspnea and exertion, edema, things like that.
138
00:07:24.510 --> 00:07:26.550
Do they have a story of something that's coming
139
00:07:26.550 --> 00:07:27.930
that we haven't really assessed yet?
140
00:07:29.090 --> 00:07:31.150
And also, we're going to look at functional capacity.
141
00:07:31.330 --> 00:07:33.550
So that's talking about like, what are they capable of doing
142
00:07:33.550 --> 00:07:34.350
in their day-to-day lives?
143
00:07:34.430 --> 00:07:36.830
Are they able to go grocery shopping, go up the stairs,
144
00:07:36.830 --> 00:07:39.710
walk around the block without any of those symptoms, right?
145
00:07:39.710 --> 00:07:40.230
Or are they not?
146
00:07:40.550 --> 00:07:41.810
And there's a couple of tools you can use.
147
00:07:41.850 --> 00:07:43.550
One is called the MET score, M-E-T-S.
148
00:07:43.630 --> 00:07:45.330
So these are where the scoring tools come in,
149
00:07:45.390 --> 00:07:46.730
make your job a little bit easier.
150
00:07:47.110 --> 00:07:48.610
The MET score and that kind of,
151
00:07:48.710 --> 00:07:50.930
you can just ask them the questions and then fill that out
152
00:07:50.930 --> 00:07:51.950
and that gives them a score.
153
00:07:52.030 --> 00:07:53.170
And so if it's four or more,
154
00:07:53.350 --> 00:07:55.630
they're less likely to have cardiovascular complications.
155
00:07:55.910 --> 00:07:57.910
And so for those patients, you know,
156
00:07:57.950 --> 00:08:00.190
depending on the history and what your assessment is,
157
00:08:00.210 --> 00:08:01.950
plus the functional capacity of that MET score,
158
00:08:01.970 --> 00:08:05.850
you can decide, are they at risk for cardiovascular complications or not?
159
00:08:05.850 --> 00:08:09.670
Are they at risk for an underlying CAD or something like that?
160
00:08:09.670 --> 00:08:10.970
That's kind of what we're getting at here.
161
00:08:10.990 --> 00:08:12.130
But that's kind of like what I would do.
162
00:08:12.430 --> 00:08:13.530
There's another one called the,
163
00:08:14.270 --> 00:08:16.630
the next thing is aside from assessing the functional capacity
164
00:08:16.630 --> 00:08:18.970
of the cardiovascular risk specifically in a surgery.
165
00:08:19.430 --> 00:08:21.030
And there's a couple of tools for that.
166
00:08:21.490 --> 00:08:24.050
The NESQIP is one of them, N-S-Q-I-P.
167
00:08:24.270 --> 00:08:26.530
And then the revised cardiac risk index,
168
00:08:26.530 --> 00:08:27.510
I believe is the other one.
169
00:08:28.050 --> 00:08:29.590
And so that kind of, they don't overlap.
170
00:08:29.710 --> 00:08:30.830
So it's kind of you pick one or the other,
171
00:08:30.850 --> 00:08:32.470
they don't really compare to each other.
172
00:08:32.970 --> 00:08:34.490
And again, just depends on your conversation
173
00:08:34.490 --> 00:08:36.429
you've had with your supervisor of like,
174
00:08:36.450 --> 00:08:37.370
should we be using the NESQIP?
175
00:08:37.470 --> 00:08:39.210
Do you use this, et cetera, et cetera?
176
00:08:39.809 --> 00:08:41.850
And using that kind of with a grain of salt, right?
177
00:08:41.850 --> 00:08:43.390
Because that's not perfect.
178
00:08:43.650 --> 00:08:45.090
I mean, the METS isn't perfect either,
179
00:08:45.130 --> 00:08:47.450
but the NESQIP, again, which is like a tool
180
00:08:47.450 --> 00:08:49.030
where you input the type of surgery they have,
181
00:08:49.090 --> 00:08:50.550
their age, their risk factors,
182
00:08:50.690 --> 00:08:52.270
the medications, like things like that.
183
00:08:52.590 --> 00:08:53.810
It's a whole online thing.
184
00:08:53.850 --> 00:08:54.750
Again, it's in that handout.
185
00:08:54.950 --> 00:08:57.750
And you can kind of use that to inform your clinical judgment.
186
00:08:57.870 --> 00:08:59.450
And I think the main drawback for that
187
00:08:59.450 --> 00:09:02.450
is they don't have every surgery and it's not perfect, right?
188
00:09:02.890 --> 00:09:04.050
You can't just look at that and be like,
189
00:09:04.050 --> 00:09:04.870
okay, you're done.
190
00:09:05.170 --> 00:09:07.130
It's really like more complex than that.
191
00:09:07.310 --> 00:09:09.350
But it's helpful in terms of gathering a tool
192
00:09:09.350 --> 00:09:11.310
if that's something that your supervisor recommends.
193
00:09:12.790 --> 00:09:14.470
So that's like the main thing for cardiovascular.
194
00:09:14.590 --> 00:09:16.470
And what your kind of conclusion about that is,
195
00:09:16.630 --> 00:09:18.930
is do they have a less than 1% risk of death
196
00:09:18.930 --> 00:09:21.310
or complications or greater than 1%.
197
00:09:21.310 --> 00:09:22.290
And if it's greater than 1%,
198
00:09:22.290 --> 00:09:23.830
then they need cardiovascular evaluation.
199
00:09:23.970 --> 00:09:25.070
And so what does that look like?
200
00:09:25.390 --> 00:09:27.550
Personally, I really recommend you send them to cardiology
201
00:09:28.310 --> 00:09:31.230
because it's one thing to know to order a stress test,
202
00:09:31.230 --> 00:09:33.550
but it's another thing to be able to order the correct one
203
00:09:33.550 --> 00:09:34.610
and interpret it correctly.
204
00:09:34.710 --> 00:09:37.410
And then to follow up and decide whether you need more testing
205
00:09:37.410 --> 00:09:39.270
because it's a false negative or something like that.
206
00:09:41.190 --> 00:09:43.070
You can do it if you want to,
207
00:09:43.170 --> 00:09:45.910
but never feel yourself pressured to do so.
208
00:09:46.130 --> 00:09:47.550
Because I feel like I just hear that,
209
00:09:47.550 --> 00:09:48.830
and this is maybe a soapbox moment,
210
00:09:48.850 --> 00:09:50.930
but I just feel like I hear from so many new grads
211
00:09:50.930 --> 00:09:52.130
who put that pressure on themselves.
212
00:09:52.390 --> 00:09:53.370
I'm like, I have to know it.
213
00:09:53.830 --> 00:09:55.530
I know to order stress tests, I'm going to do it.
214
00:09:55.530 --> 00:09:57.610
But then again, you have to just be really careful
215
00:09:57.610 --> 00:09:59.230
with the things that you get back.
216
00:09:59.350 --> 00:10:00.510
And maybe there's another test
217
00:10:00.510 --> 00:10:01.730
that they would recommend instead.
218
00:10:02.350 --> 00:10:03.850
Again, that's my own personal opinion
219
00:10:03.850 --> 00:10:05.250
just to save yourself a little bit of sanity.
220
00:10:05.510 --> 00:10:07.650
And it's a right thing to do.
221
00:10:07.830 --> 00:10:08.750
Both of them are right,
222
00:10:08.790 --> 00:10:11.970
but it's okay to send them to cardiology,
223
00:10:11.990 --> 00:10:12.730
and that's what I recommend.
224
00:10:13.290 --> 00:10:14.810
And then pulmonology, pulmonary,
225
00:10:15.190 --> 00:10:16.950
that's kind of the cardiac risk assessment.
226
00:10:17.210 --> 00:10:18.510
So the pulmonology risk assessment
227
00:10:18.510 --> 00:10:21.830
is a little bit less algorithmic.
228
00:10:22.290 --> 00:10:24.050
I don't like it as much, less guideline-based,
229
00:10:25.210 --> 00:10:26.990
but same moral of the story here goes
230
00:10:26.990 --> 00:10:28.930
is that do they have an established COPD,
231
00:10:29.590 --> 00:10:30.850
asthma, et cetera, et cetera,
232
00:10:30.850 --> 00:10:33.030
I keep forgetting about sleep apnea.
233
00:10:33.290 --> 00:10:35.030
But do they have those established already?
234
00:10:35.690 --> 00:10:36.930
Do they see a pulmonologist already?
235
00:10:37.110 --> 00:10:37.910
I'm going to have a conversation
236
00:10:37.910 --> 00:10:38.610
with a pulmonologist
237
00:10:38.610 --> 00:10:39.770
or have them see the pulmonologist
238
00:10:39.770 --> 00:10:40.910
to get their opinion about
239
00:10:40.910 --> 00:10:43.490
if this is a high-risk surgery
240
00:10:43.490 --> 00:10:45.270
or is it appropriate risk for them.
241
00:10:46.590 --> 00:10:48.050
Otherwise, are you assessing somebody
242
00:10:48.050 --> 00:10:49.130
who has an underlying lung disease
243
00:10:49.130 --> 00:10:50.110
that hasn't been uncovered yet?
244
00:10:50.450 --> 00:10:52.230
So do they have some risk factors for sleep apnea?
245
00:10:52.290 --> 00:10:54.350
There's that stopping scoring,
246
00:10:54.370 --> 00:10:55.930
which again, I'll put in the handout,
247
00:10:56.470 --> 00:10:58.110
which you can kind of guide
248
00:10:58.110 --> 00:10:59.150
and see if you have sleep apnea.
249
00:10:59.170 --> 00:11:00.470
None necessarily that's going to bar you
250
00:11:00.470 --> 00:11:01.350
from having surgery,
251
00:11:01.410 --> 00:11:03.270
but it's just another factor to think about.
252
00:11:03.610 --> 00:11:05.330
Again, when you get all this data
253
00:11:05.330 --> 00:11:05.990
and this information,
254
00:11:06.110 --> 00:11:07.290
what I personally would do
255
00:11:07.290 --> 00:11:08.710
if I was in that situation
256
00:11:08.710 --> 00:11:10.110
was that I would get all the information,
257
00:11:10.370 --> 00:11:11.830
do all the physical exam,
258
00:11:11.850 --> 00:11:13.110
the history, all that stuff,
259
00:11:13.430 --> 00:11:15.830
present it to my supervising physician
260
00:11:15.830 --> 00:11:17.050
or collaborator,
261
00:11:17.470 --> 00:11:18.870
and then ask what they think.
262
00:11:20.030 --> 00:11:22.390
So again, do they have a long-term smoking history?
263
00:11:22.490 --> 00:11:24.590
Do they have dyspnea that hasn't been diagnosed yet?
264
00:11:24.610 --> 00:11:25.910
Do they have a cough that's not diagnosed yet?
265
00:11:25.990 --> 00:11:26.730
Things like that.
266
00:11:26.790 --> 00:11:28.790
Let's just make sure that that's optimized first.
267
00:11:28.790 --> 00:11:30.370
So maybe you need to delay the surgery
268
00:11:30.370 --> 00:11:31.390
until they see pulmonology.
269
00:11:31.450 --> 00:11:33.390
Again, you could consider doing a chest x-ray
270
00:11:33.390 --> 00:11:35.510
versus pulmonary function tests,
271
00:11:37.450 --> 00:11:39.090
but again, do you feel confident
272
00:11:39.090 --> 00:11:40.570
with your PFT interpretation?
273
00:11:40.630 --> 00:11:41.570
I'm just going to be real right now
274
00:11:41.570 --> 00:11:44.310
that I don't feel that confident with PFTs.
275
00:11:44.470 --> 00:11:45.590
It's something that I'm working on,
276
00:11:45.690 --> 00:11:46.770
but again, I'm not a pulmonologist
277
00:11:46.770 --> 00:11:48.750
in terms of there are certain things
278
00:11:48.750 --> 00:11:49.750
that I understand about it,
279
00:11:49.790 --> 00:11:51.630
but do I feel confident differentiating
280
00:11:51.630 --> 00:11:53.570
between COPD versus interstitial lung disease
281
00:11:53.570 --> 00:11:55.630
versus other things that are going on?
282
00:11:56.390 --> 00:11:58.310
It's not just as simple as asthma and COPD.
283
00:11:58.850 --> 00:12:01.030
That's why there's pulmonary as a specialist.
284
00:12:01.630 --> 00:12:02.650
So anyway, I'm being on a soapbox,
285
00:12:02.710 --> 00:12:03.810
but it's for your benefit
286
00:12:03.810 --> 00:12:05.430
because I don't want you to feel that pressure
287
00:12:05.430 --> 00:12:06.810
of having to do all the things
288
00:12:06.810 --> 00:12:08.090
and be all the things at all at once
289
00:12:08.090 --> 00:12:10.030
because I hear that over and over again,
290
00:12:10.030 --> 00:12:11.170
and I felt that myself too.
291
00:12:13.190 --> 00:12:15.750
So cardiac risk, so low, medium, or high risk,
292
00:12:15.830 --> 00:12:18.650
cardiac risk assessment, pulmonology risk assessment.
293
00:12:18.650 --> 00:12:20.070
There's no tools that I'm aware of,
294
00:12:20.170 --> 00:12:22.090
deciding what testing they need to do,
295
00:12:22.170 --> 00:12:23.350
if they need to do anything.
296
00:12:23.530 --> 00:12:24.730
And then the next thing is like,
297
00:12:24.730 --> 00:12:26.210
once you kind of like met those things
298
00:12:26.210 --> 00:12:27.490
is thinking about like,
299
00:12:27.490 --> 00:12:28.610
what are their chronic conditions, right?
300
00:12:28.610 --> 00:12:29.870
So you're kind of optimizing those, right?
301
00:12:29.870 --> 00:12:30.570
So they have diabetes.
302
00:12:30.690 --> 00:12:33.170
I'm just doing a recap in the history of like,
303
00:12:33.170 --> 00:12:37.350
diabetes A1C in October 2019 was 6.8.
304
00:12:37.430 --> 00:12:39.390
They take myformin twice a day.
305
00:12:39.810 --> 00:12:41.150
Blood sugars have been this and this,
306
00:12:41.490 --> 00:12:43.750
nothing less than 70, greater than 300.
307
00:12:44.190 --> 00:12:46.190
Here are the symptoms, they are asymptomatic.
308
00:12:47.050 --> 00:12:47.770
Same thing for hypertension,
309
00:12:47.870 --> 00:12:49.610
just like a recap of like their chronic conditions.
310
00:12:49.650 --> 00:12:50.690
And you don't necessarily have to do
311
00:12:50.690 --> 00:12:51.910
like the full laundry list.
312
00:12:52.010 --> 00:12:53.250
I mean, it really depends, again,
313
00:12:53.450 --> 00:12:54.410
conversation with your supervisor,
314
00:12:54.450 --> 00:12:56.330
but if they've got like seven chronic conditions,
315
00:12:56.330 --> 00:12:59.310
if you can do your best to do a very quick recap
316
00:12:59.310 --> 00:13:00.150
of all that stuff,
317
00:13:00.230 --> 00:13:01.790
like that can be really helpful for the surgeon
318
00:13:02.430 --> 00:13:04.010
and the medical team that's taking care of it
319
00:13:04.010 --> 00:13:05.670
because they don't know the baseline like you do, right?
320
00:13:06.770 --> 00:13:08.530
And then in terms of the R.O.S.
321
00:13:08.550 --> 00:13:09.910
and the physical exam, those are really,
322
00:13:09.990 --> 00:13:12.210
the main thing is like respiratory and cardiovascular.
323
00:13:12.970 --> 00:13:14.470
So like cough, shortness of breath,
324
00:13:14.630 --> 00:13:16.890
dyspnea exertion, chest pain,
325
00:13:17.170 --> 00:13:18.730
syncope, near syncope, edema,
326
00:13:19.130 --> 00:13:21.070
but then also relevant to the type of surgery
327
00:13:21.070 --> 00:13:21.690
they're having, right?
328
00:13:21.690 --> 00:13:22.490
Are they having eye surgery?
329
00:13:22.570 --> 00:13:23.970
Maybe do an eye R.O.S., right?
330
00:13:25.730 --> 00:13:27.750
But like the full physical exam,
331
00:13:28.050 --> 00:13:30.830
I just, that's my default because, you know,
332
00:13:31.010 --> 00:13:34.090
again, there's a lot of complex moving parts
333
00:13:34.090 --> 00:13:35.790
and if they've got something cardiac or respiratory,
334
00:13:35.790 --> 00:13:37.190
they could have something, you know,
335
00:13:37.350 --> 00:13:39.190
in their abdomen like they could have distended at,
336
00:13:39.470 --> 00:13:41.410
like just, I just do the full thing.
337
00:13:41.450 --> 00:13:42.490
And maybe you do something different
338
00:13:42.490 --> 00:13:43.530
and maybe your supervisor tells you
339
00:13:43.530 --> 00:13:44.110
to do something different,
340
00:13:44.110 --> 00:13:45.550
in which case do that, right?
341
00:13:45.550 --> 00:13:47.110
But that's what I'm gonna start with.
342
00:13:47.370 --> 00:13:48.530
I'm gonna get all that information,
343
00:13:48.750 --> 00:13:50.730
do my exam, present it.
344
00:13:50.930 --> 00:13:52.470
The other history questions you wanna think about
345
00:13:52.470 --> 00:13:53.850
are really good social history.
346
00:13:53.850 --> 00:13:55.510
Are they drinking alcohol?
347
00:13:56.150 --> 00:13:56.910
How much?
348
00:13:56.950 --> 00:13:57.690
How often?
349
00:13:57.770 --> 00:13:58.310
Things like that,
350
00:13:58.310 --> 00:13:59.410
because they could go into alcohol withdrawal,
351
00:13:59.450 --> 00:14:00.250
like that's pretty serious.
352
00:14:00.310 --> 00:14:01.290
How much do they smoke?
353
00:14:02.190 --> 00:14:04.310
Again, like nicotine withdrawal, things like that.
354
00:14:04.890 --> 00:14:06.690
And then, do they have any history
355
00:14:06.690 --> 00:14:08.490
of like malignant hyperthermia?
356
00:14:08.850 --> 00:14:10.250
Having had surgery before?
357
00:14:10.390 --> 00:14:11.710
Have they ever had surgery before?
358
00:14:11.990 --> 00:14:12.690
And then the medications,
359
00:14:12.830 --> 00:14:13.710
like what are they taking for meds?
360
00:14:14.370 --> 00:14:16.290
That's actually like a whole discussion in and of itself.
361
00:14:16.570 --> 00:14:18.190
So I don't really have like good rules for that,
362
00:14:18.190 --> 00:14:20.110
but that really is case by case dependent
363
00:14:20.110 --> 00:14:21.030
and surgery dependent,
364
00:14:21.110 --> 00:14:22.550
whether or not they continue aspirin
365
00:14:22.550 --> 00:14:23.350
or stop aspirin,
366
00:14:24.870 --> 00:14:26.630
continue autoblockers, et cetera, et cetera.
367
00:14:27.070 --> 00:14:29.690
So again, I'd either talk with a surgeon
368
00:14:29.690 --> 00:14:30.910
or collaborate with my physician,
369
00:14:31.070 --> 00:14:32.150
depending on the case, right?
370
00:14:32.510 --> 00:14:34.350
So I think that's it.
371
00:14:34.750 --> 00:14:36.170
And you know, I didn't really touch a ton
372
00:14:36.170 --> 00:14:38.110
on like the healthy patient
373
00:14:38.110 --> 00:14:39.630
with a low-risk surgery very much,
374
00:14:39.650 --> 00:14:42.010
but I wanna keep this short and sweet if I can.
375
00:14:42.250 --> 00:14:43.570
There's a list of history questions
376
00:14:43.570 --> 00:14:45.210
that are included in the handout down below
377
00:14:45.210 --> 00:14:47.610
that I kind of have my students,
378
00:14:47.630 --> 00:14:48.510
I kind of give to my students
379
00:14:48.510 --> 00:14:51.450
to do a pre-op exam on somebody that's on a healthier.
380
00:14:52.010 --> 00:14:53.710
Again, just like elicits any history
381
00:14:53.710 --> 00:14:55.770
of cardiovascular disease or liver disease
382
00:14:55.770 --> 00:14:57.050
or stuff like that.
383
00:14:57.290 --> 00:14:58.450
You're just trying to uncover
384
00:14:58.450 --> 00:15:00.610
what else is going on under there, right?
385
00:15:00.610 --> 00:15:01.750
So you don't have any surprises
386
00:15:01.750 --> 00:15:03.690
around the time of having that surgery.
387
00:15:04.070 --> 00:15:05.710
You know, one other thing actually I wanna add
388
00:15:05.710 --> 00:15:06.950
is about the testing.
389
00:15:07.930 --> 00:15:11.890
So one quick thing before I wrap up
390
00:15:11.890 --> 00:15:15.090
is that for testing what we over test
391
00:15:15.090 --> 00:15:18.070
in the United States for preoperative exams,
392
00:15:18.510 --> 00:15:20.450
there aren't for the healthy adult
393
00:15:20.450 --> 00:15:21.410
with a low-risk surgery,
394
00:15:21.750 --> 00:15:23.950
there really isn't very much that's recommended at all.
395
00:15:24.110 --> 00:15:26.270
Again, please look at your case-by-case situation,
396
00:15:26.690 --> 00:15:29.410
but the main testing I want you to think about
397
00:15:29.410 --> 00:15:30.850
is if they have any cardiac risk factor,
398
00:15:30.990 --> 00:15:32.530
hypertension, high cholesterol,
399
00:15:32.850 --> 00:15:34.230
other cardiac abnormalities,
400
00:15:34.490 --> 00:15:36.530
consider doing an EKG,
401
00:15:36.610 --> 00:15:39.030
also considering that in diabetes and CKD.
402
00:15:39.350 --> 00:15:40.710
The rationale for that being like
403
00:15:40.710 --> 00:15:41.390
you're getting a baseline
404
00:15:41.390 --> 00:15:44.430
because they're at higher risk for complications,
405
00:15:44.690 --> 00:15:47.310
but also you can help detect anything that's abnormal
406
00:15:47.310 --> 00:15:48.410
that they need to have investigated
407
00:15:48.410 --> 00:15:49.690
before their surgery, right?
408
00:15:49.690 --> 00:15:52.330
Chest X-rays, one to consider maybe.
409
00:15:53.130 --> 00:15:53.950
Case-by-case dependent,
410
00:15:54.110 --> 00:15:55.190
if they're a long-term smoker,
411
00:15:55.310 --> 00:15:56.310
things like that.
412
00:15:56.450 --> 00:15:57.710
If they have an older age,
413
00:15:57.730 --> 00:15:59.670
things like that, higher-risk surgery.
414
00:16:01.030 --> 00:16:02.890
Hemoglobin is recommended for adults
415
00:16:02.890 --> 00:16:05.750
over the age of 65, like a CBC,
416
00:16:06.110 --> 00:16:07.670
or people who are under 65
417
00:16:07.670 --> 00:16:09.550
if they have a higher risk,
418
00:16:09.790 --> 00:16:11.090
higher blood loss surgery.
419
00:16:11.810 --> 00:16:13.630
And then again, like it depends on the surgery, right?
420
00:16:13.630 --> 00:16:14.710
Are they having a GU surgery?
421
00:16:14.750 --> 00:16:16.750
They should probably have a urinalysis, right?
422
00:16:16.770 --> 00:16:18.370
But like urinalysis for everybody,
423
00:16:18.370 --> 00:16:20.590
there isn't really enough evidence to recommend that.
424
00:16:21.470 --> 00:16:23.330
So again, always collaborate,
425
00:16:23.410 --> 00:16:24.310
always ask questions,
426
00:16:24.390 --> 00:16:25.390
case-by-case dependent,
427
00:16:25.710 --> 00:16:27.070
but those are kind of like
428
00:16:27.070 --> 00:16:28.030
the main ones to think about.
429
00:16:28.110 --> 00:16:29.730
I think the most important is the EKG
430
00:16:29.730 --> 00:16:31.190
for people who have cardiac risk factors
431
00:16:31.190 --> 00:16:32.610
because again, you're just digging to find
432
00:16:32.610 --> 00:16:34.130
if there are any cardiac abnormalities,
433
00:16:34.150 --> 00:16:35.130
and if you have any question
434
00:16:35.130 --> 00:16:36.430
about somebody with pulmonary abnormalities
435
00:16:36.430 --> 00:16:37.270
and you're not quite sure,
436
00:16:37.570 --> 00:16:38.330
do a chest X-ray,
437
00:16:38.370 --> 00:16:39.490
do they have any abnormalities,
438
00:16:41.250 --> 00:16:42.290
feel free to send them to PUM.
439
00:16:42.530 --> 00:16:43.130
So that's it.
440
00:16:43.130 --> 00:16:44.490
I'm sorry that was so much information.
441
00:16:44.490 --> 00:16:46.130
I tried to keep it as short and sweet as possible.
442
00:16:46.170 --> 00:16:47.470
Hopefully it was more helpful
443
00:16:47.470 --> 00:16:48.410
than it was confusing.
444
00:16:48.690 --> 00:16:50.010
And I hope that there were some helpful tips
445
00:16:50.010 --> 00:16:51.290
you can take away into your practice
446
00:16:51.290 --> 00:16:52.350
because again,
447
00:16:52.930 --> 00:16:54.310
it's such case-by-case dependent
448
00:16:54.310 --> 00:16:56.690
that you just have to be as careful as you can
449
00:16:56.690 --> 00:16:58.110
and then just ask for help when you need it.
450
00:16:58.110 --> 00:16:59.670
And just don't push yourself too hard
451
00:16:59.670 --> 00:17:02.150
because it's okay to ask for help
452
00:17:02.150 --> 00:17:03.770
and it's okay to refer out when you need to.
453
00:17:03.770 --> 00:17:04.650
And I say this a lot,
454
00:17:04.650 --> 00:17:05.750
but I just gotta keep saying it
455
00:17:05.750 --> 00:17:07.490
because I keep hearing it over and over again.
456
00:17:07.650 --> 00:17:10.109
So I hope that makes you feel a little bit better.
457
00:17:10.310 --> 00:17:11.470
Definitely leave a comment below.
458
00:17:11.690 --> 00:17:12.650
If this video was helpful,
459
00:17:12.670 --> 00:17:13.750
I'd love to hear from you.
460
00:17:13.930 --> 00:17:15.369
Also, if you have a difference of opinion
461
00:17:15.369 --> 00:17:16.930
about what testing we should be doing,
462
00:17:16.930 --> 00:17:18.089
definitely let me know.
463
00:17:18.089 --> 00:17:19.290
Maybe that's a little controversial.
464
00:17:19.510 --> 00:17:20.510
Hopefully it's not.
465
00:17:20.910 --> 00:17:22.270
Hopefully it's reassuring.
466
00:17:22.990 --> 00:17:25.569
And yeah, any other screening tools you use
467
00:17:25.569 --> 00:17:27.210
or other suggestions that you have
468
00:17:27.210 --> 00:17:28.470
or recommendations, things like that.
469
00:17:28.510 --> 00:17:29.670
And hopefully there's nothing I left out.
470
00:17:29.730 --> 00:17:31.490
Don't forget to grab your copy
471
00:17:31.490 --> 00:17:32.670
of the Ultimate Resource Guide
472
00:17:32.670 --> 00:17:35.070
from the new NP over at realworldnp.com
473
00:17:35.070 --> 00:17:36.350
if you haven't grabbed one already.
474
00:17:36.510 --> 00:17:38.590
And you'll get these videos
475
00:17:38.590 --> 00:17:40.410
that straight to your inbox with notes from me,
476
00:17:41.190 --> 00:17:43.170
bonus content that I just don't share anywhere else.
477
00:17:43.170 --> 00:17:44.790
So thank you so much for watching.
478
00:17:44.790 --> 00:17:46.890
Hang in there and I'll see you next time.
479
00:18:16.910 --> 00:18:19.250
With notes from me, patient stories,
480
00:18:19.530 --> 00:18:20.450
and extra bonuses,
481
00:18:20.690 --> 00:18:22.590
I really just don't share anywhere else.
482
00:18:23.030 --> 00:18:24.550
Thank you so much again for listening.
483
00:18:24.710 --> 00:18:25.950
Take care and talk soon.
© 2025 Real World NP. For educational and informational purposes only, see realworldnp.com/disclaimer for full details.
