Profile picture
Avital O'Glasser @aoglasser
, 18 tweets, 4 min read Read on Twitter
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!
Missing some Tweet in this thread?
You can try to force a refresh.

Like this thread? Get email updates or save it to PDF!

Subscribe to Avital O'Glasser
Profile picture

Get real-time email alerts when new unrolls are available from this author!

This content may be removed anytime!

Twitter may remove this content at anytime, convert it as a PDF, save and print for later use!

Try unrolling a thread yourself!

how to unroll video

1) Follow Thread Reader App on Twitter so you can easily mention us!

2) Go to a Twitter thread (series of Tweets by the same owner) and mention us with a keyword "unroll" @threadreaderapp unroll

You can practice here first or read more on our help page!

Did Thread Reader help you today?

Support us! We are indie developers!

This site is made by just three indie developers on a laptop doing marketing, support and development! Read more about the story.

Become a Premium Member and get exclusive features!

Premium member ($3.00/month or $30.00/year)

Too expensive? Make a small donation by buying us coffee ($5) or help with server cost ($10)

Donate via Paypal Become our Patreon

Thank you for your support!