Ever seen complications hide silently while the internist spots cardiorespiratory fragility, anticoagulant mismanagement, delirium-triggers peri-incision? In pre-op clinics, the quietest risks often cause the loudest cancellations. The internist’s value is not extra testing, but better decisions. You translate comorbidities into a plan the OR team can trust. You also protect patients from medication chaos and rushed assumptions. Think of it as clearing fog, not adding paperwork. When the plan is clear, teams move faster and safer. And when the plan is wrong, the patient pays first.
Start with surgery stress and urgency
Every evaluation begins with the procedure, not the problem list. A cataract case and a bowel resection carry different physiologic stress. Urgency changes your threshold for optimization and delays. A true emergency shifts you toward rescue, not perfection. For elective cases, timing is a safety tool you can use. Ask what bleeding, fluid shift, and pain load the surgeon expects. Match that stress to the patient’s reserve and baseline function. This framing also guides which guidelines matter most, including ASA statements.
History that targets perioperative failure
A good pre-op history is not long, it is sharp. Focus on prior anesthesia issues, airway difficulties, and postoperative nausea patterns. Ask about recent infections, exertional symptoms, and new chest discomfort. Clarify baseline dyspnea using stairs, not vague “walking” descriptions. Explore syncope, palpitations, and heart failure signs without drama. Ask about reflux and aspiration risk when sedation is likely. Confirm allergies with reaction details, not just a listed label. These questions surface failure modes before monitors ever beep.
Functional capacity as a clinical shortcut
Functional capacity still predicts trouble better than many routine labs. Use simple MET-based questions about stairs, carrying groceries, and brisk walking. A patient who cannot climb one flight may have limited reserve. But also ask why, because pain can mimic breathlessness. If musculoskeletal limits dominate, look for other physiologic clues. Resting tachycardia, edema, and orthopnea often tell the real story. When uncertainty remains, consider objective testing per ACC or ESC frameworks. When function is strong, you can often avoid unnecessary cardiac testing.
Cardiac risk without reflexive overtesting
The internist helps the team avoid both overtesting and undertesting. Start with active cardiac conditions, not every remote history. Unstable angina, decompensated heart failure, and severe valvular symptoms change everything. Use a structured risk estimate, like RCRI, as a shared language. Then align that estimate with surgical risk and functional capacity. If testing will not change management, it rarely helps the patient. If testing will change timing or monitoring, it becomes meaningful. This is where collaboration with anesthesia pays off immediately.
Pulmonary risk and oxygen reserve
Pulmonary complications can ruin recovery even after “perfect” intubation. Identify COPD severity, recent exacerbations, and baseline oxygen use. Ask about cough, sputum, and wheeze changes over two weeks. Screen for sleep apnea risk with snoring and witnessed apneas. Consider STOP-Bang style cues without turning it into a questionnaire recital. Encourage bronchodilator optimization and inhaler technique checks before surgery. For smokers, even short abstinence can improve secretions and airway reactivity. NICE and many hospital policies emphasize targeted pulmonary preparation over blanket imaging.
Medication reconciliation that prevents harm
Medication lists often hide the real hazards of surgery week. Patients forget over-the-counter NSAIDs, herbals, and “natural” supplements. They also confuse brand names across countries and pharmacies. Confirm anticoagulants, antiplatelets, and the exact last dose timing. Clarify beta-blocker use, because withdrawal can provoke ischemia and tachycardia. Consider ACE inhibitors and diuretics with anesthesia, hypotension, and volume status in mind. Editörümüzün incelemeleri sonucu, missing anticoagulant details are a top cause of day-of holds. A clean medication story can prevent complications more reliably than many lab panels.
Diabetes and endocrine stability
Glucose management is about safety, not perfect numbers. Ask about hypoglycemia awareness and typical morning readings. Clarify insulin types and the patient’s real dosing habits. For oral agents, align perioperative holds with local protocol and anesthesia preference. Watch for steroid use, because adrenal suppression can be silent. Thyroid status matters when symptoms suggest instability, not for every remote history. Consider nutrition plans, because fasting affects insulin needs dramatically. A simple, written day-of plan reduces confusion at 5 a.m.
Anemia, bleeding, and clotting decisions
Anemia is not just a lab value, it is oxygen delivery. Investigate anemia causes early, especially before high-blood-loss surgery. Consider iron studies and treatment when time allows and benefit is likely. Clarify bleeding history using dental work, childbirth, or prior surgery clues. Review antiplatelet necessity with cardiology when stent history exists. Make sure the surgeon and anesthesia share the same stop and restart plan. Balance clot risk against bleeding risk with a documented rationale. Clear anticoagulation planning protects both the wound and the heart.
Kidney risk and perioperative physiology
Kidney protection starts with avoiding preventable hypotension and nephrotoxins. Identify baseline CKD stage, recent creatinine changes, and volume status. Review contrast exposure plans and hydration approach for imaging-heavy pathways. Adjust renally cleared medications and avoid duplicate NSAID use. Watch for obstructive symptoms and urinary retention risk in older patients. Discuss fluid strategy and blood pressure targets with anesthesia for fragile patients. Many institutions follow KDIGO-inspired principles for acute kidney injury prevention. This is less about heroics, more about steady physiologic respect.
Frailty and delirium prevention mindset
Frailty predicts complications even when organs look “fine” on paper. Ask about recent falls, weight loss, and difficulty with daily tasks. Screen cognition gently, because families often hide early decline. Evaluate sensory deficits, because hearing loss increases delirium risk. Review sedatives, anticholinergics, and alcohol use with a nonjudgmental tone. Plan postoperative orientation strategies with nursing, including sleep protection and early mobilization. Editörümüzün araştırmasına göre, delirium often follows poorly explained plans and noisy nights. When frailty is recognized early, teams can tailor anesthesia and postoperative support.
Communication that aligns the whole team
Your note should read like a map, not a diary. State the procedure, the key risks, and the mitigation plan clearly. Document functional capacity, risk estimate, and the reason for any testing. Write medication instructions in plain language with exact dates when possible. Flag allergies with reaction type and severity, not just a label. Include escalation triggers, like chest pain or worsening dyspnea before surgery. Refer to shared frameworks, such as ASA classification, when it helps clarity. Good documentation prevents late-night guesswork and fragmented decisions.
When should you pause and when should you proceed?
Not every abnormal result should delay surgery, but some must. Pause for unstable symptoms, decompensated heart failure, and untreated severe infection. Consider delaying when optimization is likely to change outcomes meaningfully. Proceed when the delay adds risk without improving physiologic readiness. Discuss uncertainties openly with anesthesia and the surgeon, not only in notes. Shared decision-making also includes the patient’s goals and risk tolerance. Be honest about what you can and cannot reduce. The internist’s best skill is choosing the safest next step, not the longest workup.