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 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!

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More from @aoglasser

Aug 30, 2018
Thank you so much to @PlenarySessShow @Plenary_Session for having me on episode 4 to talk about the benefits of #medtwitter! It was great to find another venue (ie not typing in < 280 characters) to discuss its role in learning, patient care, advocacy, & professional development
shout out to @ReneeDversdal (about a minute after my segment starts ~24:30) and another podcast (wink, wink, nudge, nudge @thecurbsiders)
HT also to my closest #medtwitter network, who I've gotten to collaborate with after meeting on twitter, one of the benefits discussed, with subtle nods to past and current projects!
@RJmdphilly @gretchendiemer @MargMChapman @michellebr00ks @WrayCharles @tony_breu
Read 4 tweets
Aug 24, 2018
from the 2014 ACC/AHA guidelines on pre-op EKG
this is reference 140:
Conclusions: Bundle branch blocks identified on the preoperative
ECG were related to POMI and death but did not improve prediction
beyond risk factors identified on patient history.…
Read 4 tweets
Aug 14, 2018
1/n #Tweetorial: As an Assistant PD for @OHSUIMRes focused on scholarship, #medtwitter, & #hcsm (health care social media), I’m often guide residents and colleagues on how to best use Twitter for academics, networking, learning, etc...
2/n recently, while welcoming newbies (esp students) and “onboarding” them to #medtwitter & #hcsm, I was asked to put together advice for IM applicants on how to best use social media during application/interview season. I think this advice is applicable beyond IM, too.
3/n First, tell me about yourself:
Read 28 tweets
Aug 7, 2018
1/ Thread: This morning I gave Dept of Medicine #GrandRounds @OHSUSOM @OHSUNews. In #medtwitter’s spirit of sharing & learning, here is my first #Tweetorial summarizing highlights & crediting #hcsm’s incredible contributors & source material
2/ 4 months ago EBM & cardiology expert Dr. Milton Packer published a blog post detailing how he found Twitter uninformative and emotion/opinion driven
Is this the reality of #medtwitter??…
3/ #SoMe is digitally based mediums that helps us
60% of physicians say their most popular activity on #hcsm = Following what colleagues are sharing and discussing
Channel the “look at me” negative stereotype of #SoMe into “look at THIS” learning etc...
Read 28 tweets

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