I/NF Case #8

[sozme]

I/NF CASE #8
(Internal medicine, family medicine)
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Links to previous cases:
Case 1 Case 2 Case 3
Case 4 Case 5 Case 6
Case 7
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66-year old Hispanic female with a history of type II diabetes presents to outpatient clinic for preoperative clearance for right total knee arthroplasty.

History:
She denies any recent fever, cough, chest pain, dizziness, syncopal episodes.
Sleep breathing disorder screening is negative.
Bleeding disorder screening is negative.
Drinks 1-2 glasses of wine per week on the weekends
Has never used tobacco
Does not take any illegal or non-prescription drugs/supplements
Has no history of opioid addiction/dependence
No personal or family history of adverse reaction to local or general anesthesia

Functional capacity:
Can walk >2 blocks without chest pain or SOB (ambulates with cane)
Can walk up a flight of stairs, but knee pain causes her to avoid this

Exam:
BMI is 36.2 kg/m2. BP 132/79. HR 78. Temp 98.6F. RR 14. Exam unremarkable save for predictable findings consistent with osteoarthritis of right knee.

Medications:
Metformin HCL extended release (Glucophage XL®) 2,000mg PO QAM
Rosuvastatin 10mg PO QHS (taken for primary prevention)
Aspirin 81mg PO QD (taken for primary prevention)
Multivitamin

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Because patient is diabetic and obese, you want to order a resting 12-lead EKG, CBC, BMP, and urinalysis.

CBC shows a platelet count of 134 (ref range lower limit for your lab is 140)
BMP shows a non-fasting glucose of 143 and a calcium of 8.1 (lower limit of normal for your lab is 8.4)
Urinalysis shows "moderate" bacteria and trace protein, otherwise within normal limits. You ask patient about urinary symptoms - she denies any dysuria, frequency, urgency, hematuria.

EKG:

• Today's (2017) EKG: ONE and TWO
  
• Comparison EKG (from 2005): ONE

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Questions

1. Which of the ordered tests are appropriate given the history and exam?
   
2. Is diabetes or obesity an indication for pre-operative EKG?
   
3. What is your interpretation of the lab abnormalities?
   
4. What is your interpretation of this EKG?
   
5. What is the next most appropriate step in management?

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RESOLUTION

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[quickfeet]

1. Which of the ordered tests are appropriate given the history and exam?
   
2. Is diabetes or obesity an indication for pre-operative EKG?
   
3. What is your interpretation of the lab abnormalities?
   
4. What is your interpretation of this EKG?
   
5. What is the next most appropriate step in management?

I will take a swing at question #1.

None of those tests seem appropriate, save for BMP and urinalysis in diabetic patient if it hasn't been done within the past year. This is assuming that I am this persons primary physician. If I am a rando just doing a pre-op physical then its probably not necessary.

For question #2.

As far as I can remember, EKG is only necessary in patients with known CAD, previous MI, dysrhythmia, or hyperlipidemia or peripheral arterial disease.

For the other questions i will leave to others. My EKG reading skills are quite bad. The comparison one does not seem abnormal to me. There is obviously some **** going on in the new ones though.

BTW this pts RCRI score is 0 (0.4%) - though I suppose that couldn't be known without the Cr (though probably reasonably implied if you have old lab tests, I think using one within the past few months is acceptable).

 

[whoknows2012]

That looks like an epsilon wave on the EKG (ARVD??)! RBBB as well?

 

[GadRads]

1. Which of the ordered tests are appropriate given the history and exam?--arthroplasty does not seem like a high risk procedure and not for this patient. With age >65, hemoglobin (CBC) and checking creatinine appear reasonable. UA for protein is not necessary unless it's for yearly tests in a patient with diabetes mellitus.
2. Is diabetes or obesity an indication for pre-operative EKG?--No, except the patient gives recent hx of symptoms (chest pain, SOB, recent MI), for cardiac surgery, high risk procedures or intermediate procedures with one or more cardiovascular risk factors or for morbidly obese patients (BMI > 40 or BMI >35 with obesity-related complications).
3. What is your interpretation of the lab abnormalities?--Labs are ok. Asymptomatic bacteriuria doesn't require treatment except in pregnant women and those with symptoms. Platelets are >50K. I won't worry about the calcium, but feel free to give Os-Cal.
4. What is your interpretation of this EKG?--Looks like RBBB with left axis deviation? Small qrs complexes in several leads which may be due to obesity. Otherwise sinus rhythm, regular rate.
5. What is the next most appropriate step in management?--nothing. schedule for surgery.

 

[deleted763299]

Which of the ordered tests are appropriate given the history and exam?
One important piece of information from the history is missing: the patient's exercise tolerance. Can she do 4 MET's? Assuming she can, if these are being ordered solely for the purpose of pre-op testing, none are indicated. However, BMP and UA may be indicated for screening purposes since the pt is diabetic. On the morning of surgery, I'll draw an H&H and type and crossmatch since TKA's can be bloody.

Is diabetes or obesity an indication for pre-operative EKG?
No!

What is your interpretation of the lab abnormalities?
PLT >100, they're fine. BG is non-fasting, so not very useful. Calcium of 8.1 won't stop her from going to the OR. Asymptomatic bacteruria should be ignored in the non-pregnant. The new RBBB is interesting, but again, won't stop her from going to the OR.

What is your interpretation of this EKG?
New RBBB

What is the next most appropriate step in management?
Schedule for surgery. Instruct the patient to stop ASA 7 days pre-op, and skip her metformin on the morning of surgery.

 

[GadRads]

What is the next most appropriate step in management?
Schedule for surgery. Instruct the patient to stop ASA 7 days pre-op, and skip her metformin on the morning of surgery.

Good point on the meds.

 

[sozme]

Which of the ordered tests are appropriate given the history and exam?
One important piece of information from the history is missing: the patient's exercise tolerance. Can she do 4 MET's?

Added to the original post.

Functional capacity:
Can walk >2 blocks without chest pain or SOB (ambulates with cane)
Can walk up a flight of stairs, but knee pain causes her to avoid this

 

[cbrons]

Which of the ordered tests are appropriate given the history and exam?
One important piece of information from the history is missing: the patient's exercise tolerance. Can she do 4 MET's? Assuming she can, if these are being ordered solely for the purpose of pre-op testing, none are indicated. However, BMP and UA may be indicated for screening purposes since the pt is diabetic. On the morning of surgery, I'll draw an H&H and type and crossmatch since TKA's can be bloody.

Is diabetes or obesity an indication for pre-operative EKG?
No!

What is your interpretation of the lab abnormalities?
PLT >100, they're fine. BG is non-fasting, so not very useful. Calcium of 8.1 won't stop her from going to the OR. Asymptomatic bacteruria should be ignored in the non-pregnant. The new RBBB is interesting, but again, won't stop her from going to the OR.

What is your interpretation of this EKG?
New RBBB

What is the next most appropriate step in management?
Schedule for surgery. Instruct the patient to stop ASA 7 days pre-op, and skip her metformin on the morning of surgery.

Are you obligated to do something about that EKG? I mean, its not on her old one.

 

[deleted763299]

Are you obligated to do something about that EKG? I mean, its not on her old one.

Disclaimer: I'm but a lowly anesthesia intern.

So, RBBB can definitely be a bad thing. You can see it with a PE, cor pulmonale, or ischemic heart disease to name a few. All of these things I absolutely care about for someone I'm evaluating preoperatively. However, the patient's history does not support these scary things. I'm doubtful that an asymptomatic, ambulatory patient has a PE or cor pulmonale. The other piece of history we have is that she can do 4 MET's of activity without CP/SOB. Does this mean that she doesn't have any CAD whatsoever... certainly not. However, she doesn't have symptomatic CAD.

Also, we shouldn't have gotten the EKG anyway even the ACC/AHA preop guideline flowchart says so.

 

[sozme]

RESOLUTION

Good replies, thanks for the participation.

In this patient, an EKG was not necessarily indicated on the basis of the diabetes alone, but it was not unreasonable to obtain one to establish a baseline. There is wide-variation in terms of who needs a preop EKG. The UA was unnecessary, as were the other labs if they had already been taken within the past 3-4 months.

The only acceptable reason for a preop UA is for procedures in which GU instrumentation is planned (in other words, when there is a high risk for mucosal bleeding).

BTW - This is based on a real-life patient. Her RBBB prompted the primary physician to order a pharmacologic stress test (which was negative). She was cleared for surgery.

Here are my notes on various test preoperative test indications. Please feel free to let me know if there are any errors here.

 

[sozme]