Thread by @aoglasser

THREAD Friday mini #tweetorial! Despite having a learner w me in #periopmedicine clinic the last two days, I neglected to tweet any #postitpearls (though lots of great learning + pt care!). BUT had 2 back-to-back cases raising questions of weight we place on self-reported pt info

2/ will be intentionally vague to protect PHI without diluting learning value...for all the talk re #EHR clutter, EHRs helping propagate accurate info but also "chart lore" false info, #backtobedside, #patientsbeforepaperwork...when can you "take a pt's word for it" in preop?

3/ pt A-early 50s, elective ortho surgery (though pain affecting QOL & activity levels), VERY vague "MI" and "CAD" history in chart from decade ago, no immediately available records, some risk factors for premature CAD (tobacco) but no interval events...

4/ learner gets great, juicy, narrative history from pt--sounds much more like troponin elevation from some systemic illness than AMI, pt reports still had cath done, "no blockages", "didn't need any cardiology fu"

5/ EKG is NSR, exam unremarkable, ? doing > 4 METS until recently, quit tobacco, meds including ACE-I, no statin or aspirin

6/ to pause for a second (and before I share what we did), what would you do next:

7/ pt B-in mid 70s, big/invasive malignancy related surgery. Essentially blank chart, no meds...no clear cardiac disease risk factors

8/ on history, previously very healthy. no HTN (a little white coat...), no tobacco, no HLD. EKG is "schmutzy"--RBB and LAFB, sinus 70s

9/ learner continues to get great narrative history--clearly capable > 4 METS at 10K feet (I love preop functional status assessment in Oregon) without angina/dyspnea

10/ I "casually" ask in wrapping the assessment of "it sounds like you have no heart disease" with "have you ever had a stress test for any reason"?

11/ the answer is YES! stress test ~10 years ago before cataract surgery...HUH???
pt gives great narrative --> an abnormal EKG but no symptoms prompting stress...stress self-reportedly normal...cardiologist said "was something electrical misfiring", ? current bundle branch blocks

12/ to pause again, what would you do in this case?

13/ what we did-
pt A--luck out and GET old records. pt had STEMI (!!), heparin/integrillin, 40% proximal LAD lesion, ECHO w low normal EF w mid anterior and apical hypokinesis to akinesis
pt B--quick attempt (ie Epic link to out-of-state) finds no leads on tracking down records

14/ what would you do know?

15/ what if I added that on ROS (EHR checkboxes, UGH), pt A endorses recently worsened "heartburn", seems nocturnal and non-exertional, but his STEMI presentation was "really bad heartburn that wouldn't go away"??

16/ decision
pt A-elective surgery, refer to cardiology 4 testing (v order stress myself) & to reestablish for CAD (40% prox LAD lesion) that has been lost to fu (no statin/aspirin)
pt B-time-sensitive surgery, no testing/referral. Non-spec EKG changes, long-standing, >> 4 METS

17/ in conclusion, HISTORY (and exam) are critical pre-op. I love getting that juicy, narrative, patient-focused history, which I aim to balance with available records (EHR or not), pre-test probability of Dz, & risk of "progression" of disease from ? 10 years ago

18/ I also try to stress for learners that often gleaning insight into the rational behind past testing fills in important details, esp with someone is told "no followup needed"
"I've had 5 prior stress tests for annual screening until my new PCP stopped" diff from MI/cath ~40yo!