THE EXAMINATION

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THE EXAMINATION

As with the history that is taken, this concentrates on the cardiovascular and respiratory systems. Attention must also be paid to the airway, in order to try and identify those patients in whom there may be potential problems. The remaining systems are examined if problems relevant to anesthesia are identified.

Cardiovascular system

Determine if there are any dysrhythmias, for example atrial fibrillation, and look for signs of heart failure. The presence of a heart murmur suggests valvular heart disease, which may require further investigation. The patient’s blood pressure is best measured at the end of the examination to try and eliminate the effect of anxiety. The peripheral veins should be inspected to identify any potential problems with I.V. access.

Respiratory system

Look for cyanosis, at the pattern of ventilation and count the respiratory rate. Dyspnoea may be present at rest. Wheeziness, signs of collapse, consolidation and effusion should be identified. The presence and degree of pulse paradoxes is a useful indication of the severity of airway obstruction.

Nervous system

Chronic disease of the peripheral and central nervous systems should be identified and any evidence of motor or sensory impairment recorded. It must be remembered that some disorders will affect the cardiovascular and respiratory systems, for example dystrophic myotonic and multiple sclerosis.

Musculoskeletal

Patients with connective tissue disorders should have any restriction of movement and deformities noted. Patients suffering from chronic rheumatoid disease frequently have a reduced muscle mass, peripheral neuropathies and pulmonary involvement. Particular attention should be paid to the patient’s cervical spine and temporomandibular joints (see below).

The airway

All patients must have an assessment made of their airway, the aim being to try and predict those patients who may be difficult to intubate. Assessment is often made in three stages.

Observation of the patient’s anatomy.

Look for limitation of mouth opening, a receding mandible, position, number and health of teeth, size of tongue.
Examine the front of the neck for soft tissue swellings, deviated larynx or trachea.
Check the mobility of the cervical spine in both flexion and extension.

If any of these are abnormal, it suggests that intubation may be mare difficult. However, it must be remembered that all of these are subjective.

Simple bedside tests.

Whison score. Increasing weight, a reduction in head and neck movement, mouth opening, and the presence of a receding mandible or buckteeth all predispose to increased difficulty with intubation.

Mallampati criteria. The patient sitting upright is asked to open their mouth and maximally protrude their tongue. The view of the pharyngeal structures is noted and graded HV (Fig. 1.1). Grades III and IV suggest difficult intubation.

Thyromental distance. With the head fully extended on the neck, the distance between the bony point of the chin and the prominence of the thyroid cartilage id measured (Fig. 1.2). A distance of less than 7 cm suggests difficult intubation.

X-ray. On a lateral X-ray of the head and neck, a reduced distance between the occiput the spinous process of CI (<5 mm) and an increase in the posterior depth of the mandible (>2.5 cm) suggest an impaired view at laryngoscopy. The X-ray must make allowance for any magnification.

None of these tests, alone or in combination, predict all difficult intubations, bat if problems are anticipated, anesthesia should be planned accordingly. If intubation proves to be difficult, it must be recorded in a prominent place in the patient informed.

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