Pre Anesthesia Checkup (PAC) Record, MPMMCC and HBCH Varanasi, IN-221005, v 3.0 (released 25 Dec 2025, Author: Prof. Jyotirmay Kirtania, Licence: GNU GPL v3)

Airway Assessment (check all that apply)

Difficult airway is not anticipated

History of previous airway difficulty is present

Includes, Documented difficult mask ventilation; difficult laryngoscopy; failed intubation; emergency surgical airway.

Anticipated difficult mask ventilation or oxygenation

Includes, Age > 55 years; BMI ≥ 30 kg/m²; Beard / facial hair; Edentulous or poor dentition; History of snoring or obstructive sleep apnea; Reduced lung compliance (stiff lungs); Reduced chest wall or abdominal compliance; Central airway obstruction.

Anticipated difficult supraglottic airway device (SGA) insertion or ventilation

Includes, Reduced mouth opening (< 2.5 cm); Upper airway obstruction; Distorted upper airway anatomy; Reduced cervical spine mobility; Reduced lung compliance (stiff lungs); Reduced chest wall or abdominal compliance; Central airway obstruction.

Anticipated difficult laryngoscopy and tracheal intubation

Includes, Distorted airway anatomy; Upper airway obstruction; Mouth opening < 3 cm; Thyromental distance < 6 cm; Mallampati class III or IV; Anterior sliding of mandible absent on upper lip bite test (ULBT); Reduced neck mobility; Prior neck surgery or irradiation; "Woody" or indurated or edematous submental space; Tongue edema or macroglossia.

Anticipated difficult infraglottic airway (tracheostomy / cricothyrotomy)

Includes, Previous neck surgery; Neck edema or hematoma or infection; Obesity; Neck irradiation or fibrosis; Pre-tracheal or neck tumor.

Anticipated shared airway

Includes, Endo laryngeal procedures; Endo tracheal and endo bronchial interventions; Tracheal resection; Carinal resection; Foreign body airway removal; Tracheoesophageal fistula stenting or repair; Bronchopleural fistula repair.

Anticipated difficult extubation

Includes, Known difficult airway; Airway bleeding; Airway edema; Airway trauma; Obesity or obstructive sleep apnea; Restricted postoperative access to airway; High aspiration risk; Significant cardiovascular, respiratory, neurological, or metabolic risk.

Elevated cardiovascular or hypoxia risk during induction and intubation

Includes, Reduced FRC, Acute or Chronic Hypoxia; Shock; Heart failure; Severe metabolic acidosis; Pulmonary hypertension or right ventricular dysfunction.

Increased risk of pulmonary aspiration

Includes, Inadequate fasting; Intestinal obstruction; Gastric outlet obstruction; Recent trauma; Pregnancy; Obesity; Hiatus hernia; Symptomatic GERD; Conditions associated with delayed gastric emptying (e.g., diabetic gastroparesis, uremia)

Loose teeth

Artificial dentures

Chest Auscultation

No lab file imported.

Clinical Laboratory Reports

Lab Reports

Hb (g/dL): TLC (×10^9/L): ANC (×10^9/L): Platelets (×10^9/L): FBS (mg/dL): RBS (mg/dL): 2hPPBS (mg/dL): HbA1c (g/dL): S. Creatinine (mg/dL): INR: PT (s): APTT (s): S. Bilirubin (T) (mg/dL): S. Bilirubin (C) (mg/dL): S. Albumin (g/dL): S. ALT (U/L): S. AST (U/L): S. NT-proBNP (pg/mL): S.TSH (mIU/L): S.FT4 (ng/dL): ECG: Resting Echocardiography: Stress ECG: Pulmonary Function Tests: Chest X Ray or CT Thorax:

Urgency of Surgery

Select the urgency of surgery:

ASA Physical Status*

Select ASA Physical Status: ASA Information Pop-Up

ASA Physical Status Classification

ASA PS I: No other illness except the indication for surgery, non-pregnant, non-tobacco user.

1. Adult examples include healthy, non-smoking, no or minimal alcohol use.

2. Pediatric examples include healthy (no acute or chronic disease), normal BMI percentile for age.

3. Obstetric example is nil.

ASA PS II: Patient with mild systemic disease.

1. Adult examples include mild diseases only without substantive functional limitations. Current smoker, social alcohol drinker, pregnancy, obesity (30 < BMI < 40), well-controlled diabetes mellitus or hypertension, mild lung disease.

2. Pediatric examples include asymptomatic congenital cardiac disease, well controlled dysrhythmias, asthma without exacerbation, well controlled epilepsy, non-insulin dependent diabetes mellitus, abnormal BMI percentile for age, mild/moderate OSA, oncologic state in remission, autism with mild limitations.

3. Obstetric examples include normal pregnancy, well controlled gestational hypertension, controlled preeclampsia without severe features, diet-controlled gestational diabetes mellitus.

ASA PS III: Patient with severe systemic disease.

1. Adult examples include substantive functional limitations; one or more moderate to severe diseases. Poorly controlled diabetes mellitus or hypertension, COPD, morbid obesity (BMI ≥40), active hepatitis, alcohol dependence or abuse, implanted pacemaker, moderate reduction of ejection fraction, ESRD undergoing regularly scheduled dialysis, history (more than 3 months) of myocardial infarction, stroke, TIA, or coronary artery disease or coronary stents.

2. Pediatric examples include uncorrected stable congenital cardiac abnormality, asthma with exacerbation, poorly controlled epilepsy, insulin dependent diabetes mellitus, morbid obesity, malnutrition, severe OSA, oncologic state, renal failure, muscular dystrophy, cystic fibrosis, history of organ transplantation, brain or spinal cord malformation, symptomatic hydrocephalus, premature infant PCA less than 60 weeks, autism with severe limitations, metabolic disease, difficult airway, long term parenteral nutrition. Full term infants less than 6 weeks of age.

3. Obstetric examples include preeclampsia with severe features, gestational DM with complications or high insulin requirements, a thrombophilic disease requiring anticoagulation.

ASA PS IV: Patient with severe systemic disease that is a constant threat to life.

1. Adult examples include recent (within 3 months) myocardial infarction, stroke, TIA or coronary artery disease or coronary stents, ongoing cardiac ischemia or severe valve dysfunction, severe reduction of ejection fraction, shock, sepsis, DIC, AKI or ESRD not undergoing regularly scheduled dialysis.

2. Pediatric examples include symptomatic congenital cardiac abnormality, congestive heart failure, active sequelae of prematurity, acute hypoxic-ischemic encephalopathy, shock, sepsis, disseminated intravascular coagulation, automatic implantable cardioverter-defibrillator, ventilator dependence, endocrinopathy, severe trauma, severe respiratory distress, advanced oncologic state.

3. Obstetric examples include preeclampsia with severe features complicated by HELLP or other adverse event, peripartum cardiomyopathy with LVEF less than 40 percent, uncorrected or decompensated heart disease, acquired or congenital.

ASA PS V: Moribund patient who is not expected to survive without the operation.

1. Adult examples include ruptured abdominal or thoracic aneurysm, massive trauma, intracranial bleed with mass effect, ischemic bowel in the face of significant cardiac pathology or multiple organ or system dysfunction.

2. Pediatric examples include massive trauma, intracranial hemorrhage with mass effect, patient requiring ECMO, respiratory failure or arrest, malignant hypertension, decompensated congestive heart failure, hepatic encephalopathy, ischemic bowel or multiple organ or system dysfunction.

3. Obstetric examples include uterine rupture.

ASA PS VI: Brain-dead patient whose organs are being removed for donor purposes.

Fitness of patient for the proposed procedure under anesthesia*

Patient is fit to undergo the proposed procedure under anesthesia with normal risk Patient is fit to undergo the proposed procedure under anesthesia with elevated risk Patient to be assessed again with reports of pending laboratory investigations, or review of prescriptions of current regular medications / medications taken within last one month Patient to be assessed again after acute medical illness subside Patient to be assessed again after improvement of chronic medical illness Patient to be assessed again after review by cardiologist / physician / nephrologist / pulmonologist Patient is provisionally fit to undergo the proposed procedure, subject to the compliance of pending lab. workup and / or preoperative advice Patient is unfit for elective major surgery under anesthesia because the risks of non-modifiable risk factors are greater than expected benefits of the treatment Other:

Patient should CONTINUE the following medications through the day of surgery

Patient should temporarily STOP the following medications before surgery, and RESTART after surgery

Preoperative Advice (check all that apply)

Do not smoke, not use smokeless tobacco, and not take alcohol No solid food, no semi solid food, no drinks (no tea, coffee, milk, carbonated drinks) for at least 6 hours before surgery No heavy meals for at least 8 hours before surgery Fasted patients should take sips (50 mL or 1/4th cup) of ORS or glucose water every hour, up to 2 hours before shifting to OT Tab. PANTOPRAZOLE 40 mg, 1 tab at 10 PM, night before surgery and 1 tab at 6 AM on the morning of surgery with 40 – 50 mL water Inj. FERRIC CARBOXYMALTOSE 500 mg/10 mL in 100 mL NS intravenous infusion over 30 minutes at daycare or ward. Repeat after 7 days Tab. MULTIVITAMIN, 1 tab once daily after food for 15 days

Medication Advice

Medication Name	Dose & Route	Frequency	Duration

Doctor’s Notes

CC Number* of Doctor attended the patient

Time and Date*

Automatically captured system date and time will be used during form submission.

License and Medical Disclaimer

Software License: GNU GPL v3. Copyright (C) [2025] [Prof. Jyotirmay Kirtania]. This program is free software: you can redistribute it and/or modify it under the terms of the GNU General Public License as published by the Free Software Foundation, either version 3 of the License, or (at your option) any later version. This program is distributed in the hope that it will be useful, but WITHOUT ANY WARRANTY; without even the implied warranty of MERCHANTABILITY or FITNESS FOR A PARTICULAR PURPOSE. See the GNU General Public License for more details. Medical Disclaimer (Cognitive Assist & Record Keeping). IMPORTANT: PLEASE READ CAREFULLY BEFORE USE. NOT A MEDICAL DEVICE: This tool is a Clinical Decision Support System (CDSS) intended for educational and cognitive assistance purposes only. It has not been cleared or approved by the FDA, EMA, or any other regulatory body for use as a primary medical device. NO SUBSTITUTE FOR CLINICAL JUDGMENT: This tool is designed to assist, not replace, the clinical judgment of qualified healthcare professionals. All calculations and logic must be independently verified against institutional standards before clinical application. DATA PRIVACY: This tool is designed to run locally on the user's device. No data is transmitted to external servers by the software. The user is solely responsible for ensuring that the use of this tool complies with local patient data privacy laws (e.g., HIPAA, GDPR) and institutional IT policies. LIMITATION OF LIABILITY: In no event shall the authors or copyright holders be liable for any claim, damages, or other liability, whether in an action of contract, tort, or otherwise, arising from, out of, or in connection with the software or the use or other dealings in the software.

Pre Anesthesia Checkup (PAC) Record

Primary Diagnosis and Proposed Procedure*

Clinical Details and Vitals

Allergies (check all options that apply)

Co-existing illness (check all options that apply)

List all medications taken in the last one month

Chemotherapy

Radiotherapy

Addictions (present and past) (Check all that apply)

Steroid or immunosuppressants use for chronic conditions

Recent fever or cough and cold within the last six weeks

Ascites

Sepsis

Ventilator dependent

Disseminated Cancer

Dyspnea

Chronic Heart Failure

Functional status

Current Smoker within 1 Year

History of Severe COPD

Dialysis

Acute Renal Failure

Airway Assessment (check all that apply)

Chest Auscultation

Clinical Laboratory Reports

Lab Reports

Urgency of Surgery

ASA Physical Status*

Fitness of patient for the proposed procedure under anesthesia*

Patient should CONTINUE the following medications through the day of surgery

Patient should temporarily STOP the following medications before surgery, and RESTART after surgery

Preoperative Advice (check all that apply)

Medication Advice

Doctor’s Notes

CC Number* of Doctor attended the patient

Time and Date*