Pertinent Insights For Preoperative H&Ps

   It is important to appreciate where the preoperative history and physical examination fits into the overall patient history and physical (H&P) hierarchy. As noted in the previous article (see “Why Complete H&Ps Should Be More Common In Podiatry,” page 56, September issue), the preoperative history and physical examination are essential for screening patients and assessing possible surgical risks.    After evaluating these findings, podiatric physicians can make decisions regarding their patients’ suitability and stability to undergo a planned foot or ankle procedure.    While the roots of the preoperative H&P belong in the traditional medical H&P, it is really a more succinct type of examination. One must gear the preoperative history toward the reason(s) that led to the planned surgical event. The reasons might include any relevant past medical and surgical history, social history, systems review and family history, particularly with regard to both surgical as well as anesthetic management.    Knowing the patient’s current medications, allergies and prior anesthetic history is very important with this type of work up. Physicians will cover most of these types of questions during a typical initial patient encounter so there is no need to dwell on these here.    In general, podiatric physicians are well acquainted with the physical examination but the emphasis in day-to-day podiatric practice usually centers upon the organ systems present in the lower extremities. In general, there are 13 organ systems one must review and examine as part of the general physical examination. These systems typically include general appearance (including abdominal, head, ears, nose, throat and neck); rectal and genitourinary; cardiovascular (including peripheral vascular); neurologic/psychiatric; respiratory; musculoskeletal; hematopoetic/ lymphatic; and dermatologic.    For the purposes of the preoperative physical examination, the breast and rectal examinations are not essential although they may yield vital information for other types of examination.

Monitoring Vital Signs

   As with most patient encounters, the preoperative H&P assessment begins with careful notation of the vital signs, taking care to note any irregularities and their relationship to the patient’s general medical history and proposed surgery.    Recording the blood pressure is particularly important as it may reveal important information you need to know before subjecting a patient to sedation or other types of anesthesia that may adversely affect the patient.    One may record blood pressure with either a mercury or aneroid manometer. According to the American Heart Association, there is some evidence that using mercury devices may obtain more accurate readings. However, one may obtain an accurate blood pressure measurement with either type and that ultimately it is up to the doctor. Although a nurse or medical assistant often records this measurement, the examining surgeon should also record it. When considering surgery and anesthesia, one should also be cognizant of other important “vital signs” such as the patient’s height and weight. Unfortunately, these may be overlooked. Various formulas exist for calculating the body mass index and this is a more helpful measurement than simply recording the gross body weight.    After performing an examination of the vital signs, it makes sense for the remainder of the examination to follow in a straightforward head to toe type of sequence. This eliminates the risk of missing a body part or organ system. This is particularly important for podiatric physicians who may spend the majority of their physical examinations assessing the lower extremity.

What To Assess In The Patient’s General Appearance

   After assessing the aforementioned vital signs, clinicians should note the general appearance of the patient. Since the advent of the Evaluation and Management Guidelines, this physical examination finding has been a required element for certain levels of examination.    A comment on the general appearance may involve nothing more that stating the obvious (e.g. “Pleasant patient is in no obvious mental or physical distress”). However, it may also reveal signs of an underlying disorder that would then prompt further examination of those organ systems during the examination. For example a “moon face” may indicate exogenous steroid use. There are, of course, literally dozens of examples. What this basic observation tells us in the education of residents and students is that they have actually looked beyond the immediate problem (the foot or ankle) and that they are at least aware of the fact that there is a patient attached to that appendage.    General appearance should not simply include the assessment for obvious signs of acute or chronic illness. It should also include notations for apparent age, personal hygiene, overall body type and the presence of any obvious odors, all of which can contribute to the overall physical makeup of the patient.

How To Get Started With The HEENT Examination

   The next portion of the examination should cover the head, eyes, ears, nose and throat (HEENT examination). This is probably one of the more time-consuming portions of preoperative history and physical examination since it involves looking at several organ systems within a small area.    The first portion of the HEENT examination involves looking at the patient’s head. A general comment regarding the appearance and structure of the head is appropriate. Make a note of size, shape, symmetry and any evidence of trauma. Again, it may be nothing more than the obvious norm (e.g. “normocephalic and atraumatic”) but abnormal findings should be related to other medical problems and any potential impact upon surgery. If a patient wears a hairpiece, he or she should remove it first.    One important aspect of facial symmetry is to assess for facial nerve (cranial nerve (CN) VII) function. One can do this quite easily by assessing for gross symmetry before asking the patient to perform basic facial expressions such as smiling, frowning, pursing of the lips and blowing out of the cheeks. Any facial weakness may result from either a central lesion involving the upper motor neurons between the cortex and the pons. This may involve a cerebrovascular accident or a peripheral lesion of the nerve itself.

A Guide To Examining The Patient’s Eyes

   One should also examine the patient’s eyes. Before performing any specific tests, conduct a basic appraisal of the anatomy and structure of the eye. This includes looking at the conjunctiva and sclera, cornea, lens and iris. Note the sclera and conjunctiva for color, and note the vascular pattern against the white scleral background. Position, alignment and eyelid and eyebrow characteristics are also important.    After inspecting these and noting any abnormalities, proceed to assess visual fields, visual acuity, light and near reaction, corneal reflex and extraocular movements.    When examining visual fields, one would test for the function of cranial nerve (CN II). Visual fields represent the area seen by the eye when looking at a central point. They are normally limited by the eyebrows, the cheeks and the nose. The visual fields extend farthest temporally and one should conduct initial testing of the fields by testing in the temporal fields.    If one suspects a defect in one eye, cover the good eye and test the suspect eye more carefully. Sometimes, using a small red object may help. An eraser at the end of a pencil is good for this purpose.

Pertinent Keys To Vision Testing

   Visual acuity tests central vision, which one can do with the aid of a Snellen chart or a Rosenbaum pocket chart. If the patient is unable to understand letters, use a picture chart. Assess for both near and far vision. The advantage of testing for both near and far vision is that it helps the examiner to distinguish between a refractive problem versus a specific lesion (e.g. cataract of optic nerve injury). In a normal examination, there should be good near and far vision and, in the perfect situation, the patient should possess 20/20 vision. This corresponds with the line on the Snellen chart that the patient should be able to read from 20 feet away.    Note the size and symmetry of the pupils. The normal pupil size is about 4 mm but up to a 20 percent difference in size is acceptable. Proceed to assess light and near reaction. Testing these reactions assesses the CN III (oculomotor) function. For light reaction, shine a penlight into the eye. In the normal case, the ipsilateral will constrict and one will also observe the cosensual response (i.e. the contralateral pupil will constrict as well).    For accommodation, use a pencil or finger and starting from approximately 14 inches in front of the patient, bring the object slowly into contact with the tip of the patient’s nose. The examiner should observe these findings in the normal situation: convergence of the eyes, medial rectus (CN III) and accommodation of the eyes by cilliary muscle contraction.    Note the finding as “pupils equally round, reactive to light and accommodation” (or PERRLA). Since accommodation is often not specifically tested, using the PERRL shorthand will suffice.    Corneal reflex testing partially tests the trigeminal nerve (CN V). This test involves using a moistened cotton wisp to touch the cornea of one eye gently. In the normal situation, both eyes should blink. One can then proceed to test the remainder of the trigeminal nerve. The remainder of the sensory distribution is divided into three broad divisions of the face: ophthalmic (V1), maxillary (V2) and mandibular (V3).    Test this by stroking a wisp of cotton gently over each of these three areas and ask the patient if he or she can feel anything. Test the motor division by placing fingers on the temporal or masseter muscles and asking the patient to clench his or her jaw. One should feel the masseter muscle contract. Also assess the other three muscles of mastication: temporalis, buccinator and pterygoids.    When testing extraocular movements, stand approximately 12 inches in front of the patient. Then ask the patient to follow the direction of the extended forefinger. Move the finger laterally, medially and obliquely outward and obliquely downward. For a normal exam, one must note duplication of the movement of the finger in both eyes.    Then proceed to test the following muscles: lateral rectus (CN VI), superior oblique (CN IV) and medial rectus, inferior oblique, superior rectus and inferior rectus (CN III). Also test their associated innervating cranial nerves as well. One can abbreviate intact extraocular movements as “EOMI” during the physical examination.    Conduct the ophthalmoscopic examination in a darkened room. There should be no need to dilate the pupils for a general screening examination. Accordingly, one will mainly see the posterior retinal structures. Both the examiner and patient should remove their glasses but may leave contact lenses in place.    Begin the examination by asking the patient to fix upon a distant point. Then starting with the largest, round bright light at 0 diopters (“neutral” lens) on the instrument, commence the examination. Stand approximately 1 foot away from the patient and approximately 15 degrees to the side. Use your right eye to examine the patient’s ipsilateral eye. Shine the beam of light into the patient’s eye. It should pass through the transparent media of the eye and reflect off the retina with a clear, orange-red glow, the “red reflex,” which should shine back through the pupil.    The absence of this reflex may indicate a lens opacity (cataract) or another lesion such as a false eye or detached retina. Locate the optic disc and follow the course of the vessels. The disc serves as a reference point for measuring the vessels and lesions on the retina. Be sure to note the color and clarity of the disc, the disc:cup ratio (2:1 is normal) and artery:vein ratio (normal is 2:3).

How To Assess The Patient’s Ears And Hearing

   Proceed to assess the patient’s ears. Note the gross structure and anatomy. Pay particular attention to the ear lobe, which may be a useful site for a surgeon to look for potential signs of reaction to skin trauma. For example, ear piercings may result in keloid formation.    Otoscopic examination can follow the gross inspection of the external ear. Upon introducing the otoscope, one should note the presence of any cerumen (wax) and proceed to inspect the eardrum. Make a note of the ear drum color and the other structures. Inflammatory processes such as the otitis media may impact upon the decision to proceed with elective foot and ankle surgery. This is particularly the case if one is using implants, which produce more swelling and redness of the tympanic membrane.    After completing the otoscopic examination, assess the patient’s hearing. Using a 512 Hz tuning fork can assist with these assessments. Normally, one should hear the sensation from the tuning fork in both ears simultaneously.    Then assess for conduction through the ear. One may use the Rinne test for this assessment. In this assessment, the patient should appreciate the vibration from the tuning fork for a longer time through the air than through bone. Air conduction is greater than bone conduction.    Hearing loss can essentially result from two processes, either conductive or sensorineural. Conductive losses tend to affect the middle and external ear while the sensorineural losses tend to affect the inner ear, which is innervated by the vestibulocochlear nerve (CN VIII). Accordingly, assessing hearing function is important for assessing cranial nerve function.    Granted, the aforementioned hearing tests can be time consuming. One can make a simpler and cruder assessment of the patient’s hearing just by whispering behind the patient’s ear or placing a ticking watch behind the ear and asking patients what they hear.

What The Nose And Throat Exams Can Reveal

   The final portions of the HEENT examination involve the nose and throat. Nasal examination again initially focuses on the gross structures. One may make a crude assessment of the olfactory nerve (CN I) by placing a mild smelling substance, such as soap, in the immediate vicinity of the nose. Cover the patient’s eyes for this portion of the examination and test each nasal orifice separately. During the nasal examination, examine the sinuses (frontal, maxillary and sphenoid). Tenderness of these could suggest inflammatory or infectious processes that may serve as a contraindication to elective foot or ankle surgery.    Proceed to inspect the gross structure of the mouth and throat. Direct particular attention toward the lips, dentition and gingiva. Dental health can give a fair indication of how well patients may be caring for themselves. Also keep in mind that there are also several diseases and medications that leave their effects within the oral cavity. These include dilantin therapy that produces gingival hyperplasia.    Note the presence of a cold sore on the left lower lip of a patient. Examination of the teeth in this patient may reveal multiple fillings. This may be indicative of poor dental hygiene, which may be a precursor to distant foci of infection.    Then proceed to examine the posterior oropharynx. Note the movement of the soft palate and uvula, and also listen to the voice. These simple observations give insight into glossopharyngeal (CN IX) and the vagus (CN X) function. These two cranial nerves can be harder to assess than some of the others. However, hoarseness of the voice may indicate pathology of CN IX while no uvula/soft palate movement or an abnormal (ipsilateral) movement may indicate CN X pathology. Normally, the uvula and soft palate should move symmetrically and in the mid-line.    While examining the posterior oropharynx, one should assess the potential ease of intubation. This may have an impact upon anesthesia selection. One would typically use the Mallampati Airway Classification for this purpose. The classifications are as follows:    Class I: Visualization of soft palate, fauces, uvula, anterior and posterior pillars    Class II: Visualization of soft palate, fauces and uvula    Class III: Visualization of soft palate and base of uvula    Class IV: Soft palate not visible    Lastly, in this portion of preoperative examination, note the function of the hypoglossal nerve (CN XII). One can easily assess this by asking the patient to protrude the tongue. In the normal case, it should protrude midline. Deviations suggest a lesion on the same side as the drift.

Keys To Assessing The Neck

   Clinicians should proceed to check the patient’s neck. Initially, they should appreciate the gross structures, including the tracheal position, which should be in a midline position. Note any obvious masses such as a thyroid goiter. One may detect carotid or jugular distention or pulsation but typically, one can more closely examine these during the cardiac examination.    Assess the spinal accessory nerve (CN XI), either by the shoulder shrug or head turning movement, both to resistance.    Finally, palpate the lymph nodes of the head and neck region, the main ones being pre and post-auricular, occipital, submandibular, submental, superficial and posterior cervical, the deep cervical chain and the supraclavicular.

Final Notes

   This article emphasizes the initial steps of performing a thorough preoperative H&P. Other aspects of the preoperative H&P will be addressed in an upcoming article. However, checking the patient’s vital signs and performing a thorough HEENT exam can reveal significant findings that may affect one’s decision to perform foot and ankle surgery. Dr. Yorath is the Chairman of the Department of Surgery of the Dr. William A. Scholl College of Podiatric Medicine at the Rosalind Franklin University of Medicine and Science in Chicago. He is the Director of the Podiatric Medicine and Surgery-36 Residency Program at the Advocate Illinois Masonic Medical Center in Chicago. Dr. Yorath is a Fellow of the American College of Foot and Ankle Surgery, and the American College of Foot and Ankle Orthopedics and Medicine.
 

References:

1. Bates. Guide to Physical Examination, 7th Edition, Lippincott.
2. Mosby. Expert 10-Minute Physical Examination, 2nd Edition, Elsevier Mosby.
3. Novey DW. Rapid Access Guide to the Physical Examination, Year Book Medical Publishers
4. Goldberg S. The Four Minute Neurological Exam, MedMaster, Inc.