which patient would you send for cardiac workup

[militarymd]

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Patient A:

a 30 something single mom and nurse who works out on a regular basis and is otherwise healthy but complains of intermittent chest "burning" not associated with her workouts.

or

Patient B:

a 60 something retired Navy Captain...long history of smoking, drinking, and other bad habits...long history of htn, dm, copd....and has a non healing foot ulcer related to peripheral vascular disease.

These are real patients....I attached a photo of patient A

 

[Eta Carinae]

this seems too easy.

Is there more to these histories?

 

[oudoc08]

this seems too easy.

Is there more to these histories?

Of course, or he wouldn't bother to post. But you wouldn't ship somebody off to cards with only the scant history above either. However,given ONLY the brief points above, if you had to choose, (and he asked you to choose) you choose patient B.

Maybe A has undiagnosed aortic coarct, MVP, etc. etc. and maybe B has a clean cath, who knows.

But given the risk profile, A prob has GERD, B prob has multi-vessel CAD if you're taking vegas odds.

 

[militarymd]

this seems too easy.

Is there more to these histories?

at the time what I saw these patients...that's all the history I had....

 

[militarymd]

Of course, or he wouldn't bother to post. But you wouldn't ship somebody off to cards with only the scant history above either. However,given ONLY the brief points above, if you had to choose, (and he asked you to choose) you choose patient B.

Maybe A has undiagnosed aortic coarct, MVP, etc. etc. and maybe B has a clean cath, who knows.

But given the risk profile, A prob has GERD, B prob has multi-vessel CAD if you're taking vegas odds.

have I become so transparent?

 

[Narcotized]

Of course, or he wouldn't bother to post. But you wouldn't ship somebody off to cards with only the scant history above either. However,given ONLY the brief points above, if you had to choose, (and he asked you to choose) you choose patient B.

Maybe A has undiagnosed aortic coarct, MVP, etc. etc. and maybe B has a clean cath, who knows.

But given the risk profile, A prob has GERD, B prob has multi-vessel CAD if you're taking vegas odds.

Exactly. Of the 2 you send B for the workup. You might send A if there was a little more detail to the brief history (I would certainly get more history than what is given). But what happened? Patient B skipped all the way home and patient A died. But you still made the right call working up B, and you would still work up B over A 100 times out of the next 100 times and be correct in your judgement.

 

[pd4emergence]

There would have to be a much higher index of suspicion for pt A, ie very strong family history like "my mom had her first MI at 31", or "when I get the chest pain, I break out into a cold sweat, nearly pass out, it feels like an elephant sitting on my chest and only eases off when I take my mom's nitro" in other words I would have to look for reasons to work her up further. As for B, it would depend on what kind of procedure, and if he was having any symptoms that could not be reasonably attributed to something else. So my vote is with the histories above..neither.

 

[Planktonmd]

Based on the information provided (partial and meaningless info as usual) I would not send either patients for a cardiac workup.
I would be interested though in finding out what surgery each one is getting because then (and only then) I might consider more diagnostic workup (not likely though).
Also I wonder how many laws it violates when you post a patient's picture on the internet?

 

[militarymd]

There would have to be a much higher index of suspicion for pt A, ie very strong family history like "my mom had her first MI at 31", or "when I get the chest pain, I break out into a cold sweat, nearly pass out, it feels like an elephant sitting on my chest and only eases off when I take my mom's nitro" in other words I would have to look for reasons to work her up further. As for B, it would depend on what kind of procedure, and if he was having any symptoms that could not be reasonably attributed to something else. So my vote is with the histories above..neither.

A - no family history....and her complaints are just that...she gets buring in her chest when she gets up in the morning...and it resolves as she gets ready for the day.
I kind of have a doc-in-the-box practice for people I work with...I have charts on all of them....I make referrals for them to specialists...I refill meds. etc....and A came to me with her complaint...she is not scheduled for surgery.

B- is scheduled for a fem-pop to fix his non-healing ulcer...he is sedentary.

 

[Eta Carinae]

I still say B.

I like how the story is slowly unfolding

 

[coprolalia]

Based on the information provided (partial and meaningless info as usual) I would not send either patients for a cardiac workup.
I would be interested though in finding out what surgery each one is getting because then (and only then) I might consider more diagnostic workup (not likely though).
Also I wonder how many laws it violates when you post a patient's picture on the internet?

You know, who the f*** is ignoring who? I mean, seriously. Can we all just agree to not make this little play like we are ignoring each other? I'm not. It's especially childish. It's getting hard to keep track.

Read the person's post. Show the self-restraint not to respond. Don't openly state you are ignoring the person, especially when it's completely clear that you're not whether or not you're reading their content.

Seriously, it's like I'm twelve-years-old sitting at the f***ing dinner table fighting with my older brother who's ignoring me and all our conversation is going through one of our parents. You're not ignoring each other if you're responding indirectly, by definition, through other people's posts!

Plankton, I'm talking to you. You're acting like a f**king 10-year-old girl.

ALL PEOPLE CLAIMING TO IGNORE OTHER PEOPLE, STOP BEING A BUNCH OF *******! PLEASE!

-copro

 

[Arch Guillotti]

Patient A:

a 30 something single mom and nurse who works out on a regular basis and is otherwise healthy but complains of intermittent chest "burning" not associated with her workouts.

or

Patient B:

a 60 something retired Navy Captain...long history of smoking, drinking, and other bad habits...long history of htn, dm, copd....and has a non healing foot ulcer related to peripheral vascular disease.

These are real patients....I attached a photo of patient A

neither one

 

[Planktonmd]

neither one

Exactly!
If you are an anesthesiologist then you will only encounter B and she resembles most of the patients who we meet everyday, she has multiple vascular pathology(most likely CAD as well), and needs her blood flow to her leg corrected so she doesn't lose her leg, she goes to the OR.
Patient A is usually not seen by Anesthesiologists (since she is not having surgery!).
But If I was still doing internal medicine, I would get this patient to have a stress test and if it was negative then GI workup, but we are not internists on this forum are we?

 

[militarymd]

neither one

so that it is clear in my mind...

you wouldn't work up a solid intermediate risk patient who is sedentary about to undergo a high risk procedure

 

[Eta Carinae]

Exactly!
If you are an anesthesiologist then you will only encounter B and she resembles most of the patients who we meet everyday, she has multiple vascular pathology(most likely CAD as well), and needs her blood flow to her leg corrected so she doesn't lose her leg, she goes to the OR.
Patient A is usually not seen by Anesthesiologists (since she is not having surgery!).
But If I was still doing internal medicine, I would get this patient to have a stress test and if it was negative then GI workup, but we are not internists on this forum are we?

great points, but I wonder if since her chest pain is described as "burning" and occurs on awakening,

I might do a GI history first before a stress test

AND

At this point, I'm going with an IM mindset as well with A

 

[Planktonmd]

why would you want more diagnostic workup on this patient?
What do you want to know?
I can tell you right now that she has CAD and PVD.
If she does not have unstable angina, significant arrhythmia or decompensated CHF there is nothing else you need.
Go to the OR and fix her leg circulation.

so that it is clear in my mind...

you wouldn't work up a solid intermediate risk patient who is sedentary about to undergo a high risk procedure

 

[Arch Guillotti]

why would you want more diagnostic workup on this patient?
What do you want to know?
I can tell you right now that she has CAD and PVD.
If she does not have unstable angina, significant arrhythmia or decompensated CHF there is nothing else you need.
Go to the OR and fix her leg circulation.

what he said.

this is a routine case.

 

[militarymd]

what he said.

this is a routine case.

Yup....it IS routine...diabetics have non healing ulcers for weeks at a time for a variety of causes...and it's PVD in this case....but...still...no emergency here....

What about what the ACC says? You think nothing of what they say?

 

[Planktonmd]

The ACC recommendations are just guidelines that need to be interpreted with caution.
And before you send a patient for cardiac workup you have to ask yourself what are you going to do with the results?
The current approach is that revascularization before surgery is rarely needed and most of the times it carries more risk than the surgery itself.
If you are going to apply the ACC/AHA protocol using concrete thinking and little flexibility then you will end up canceling about 50% of your daily routine cases.

Yup....it IS routine...diabetics have non healing ulcers for weeks at a time for a variety of causes...and it's PVD in this case....but...still...no emergency here....

What about what the ACC says? You think nothing of what they say?

 

[EternalMD]

What the F*k is up with the profiling here? you people sicken me 😀😀

 

[Noyac]

Plank, do you care to know at what BP and HR Pt B gets symptomatic?

 

[Planktonmd]

For patients with PVD with multiple risk factors like this one I would assume that they all have CAD and take all the precautions to minimize intraoperative and post operative stress.
I don't really need a stress test to know that.
If they have unstable angina or are "symptomatic" at rest then that's different story.

Plank, do you care to know at what BP and HR Pt B gets symptomatic?

 

[EvoX]

Not that this changes anything but the flowchart is from the old guidelines. The new chart is

 

[pd4emergence]

I know he doesn't do much, but the question is why and how much can he do, does he get chest pain, does he get short of breath, has this gotten worse or changed lately, has he seen a cardiologist lately, does he have any new EKG findings? I know the ACC guidelines point us toward a workup in this guy for an elective case, but this is not a totally elective case. If he does not have any major symptoms (unstable angina, arrythmias, uncompensated CHF), I would proceed without any further workup as long as he knows the risks involved. If he doesn't get fixed he will lose his foot sooner rather than later. Does he have time to wait 4-6 weeks for a dual antiplatelet therapy for a bare metal stent, would he have been better off not being revascularized for this surgery?

 

[militarymd]

So, patient A actually goes and gets an EKG on herself when she had this "burning".....and it showed diffuse st segment elevation in the anterior leads.

I looked at it...and thought it looked kind of scary....but then it also could have been caused by hyperventilation.....the cardiologist who I showed it to...thought the same thing....

But because patient A was a medical professional and was a coworker of both myself and the cardiologist...non-invasive testing was arranged for her....

It turned out...after it was all said and done.....she had a VERY proximal LAD lesion that was stented

 

[militarymd]

Patient B is my father-in-law.....The reason he is sedentary is because of his overall poor health.

He kept putting off the need to address his foot until he got admitted with pneumonia...and was intubated...and during the hospital course...because of hypoxia and hypotension he suffered from an MI diagnosed by enzymes.

He had a subsequent cardiac cath before his surgery.......NO coronary artery disease.

 

[militarymd]

so I guess my question in the initial post was not asked properly...rather than asking which one would you send to have a workup...it should have been which one do you think would be more LIKELY to have coronary artery disease based on their profile.

Despite the polling results.....I would have put money on patient B.....

and despite the likelihood of being correct.....I was wrong.

The cute blond got a stent...and my father-in-law got his fem-pop.

 

[militarymd]

Why did I post this thread?

Because Cop's profiling thread made me think about these 2 cases in my life separated by years of practice experience.

And it surprises me that SOOOO many medical professionals TRAINED in PROFILING patients are NOT willing to Profile middle eastern muslim terrorists....

because of some strange need to be Politically Correct.


and instead FOCUS on the EXCEPTIONS...the john walker lynns...or in my case ...my cute blond.


If all the 9/11 bombers...were middled aged successful anesthesiologists born in the 60's in Hong Kong....I would have no problem if they simply said that I'm NOT allowed to fly at ALL.


I guess all you folks who don't believe in profiling have forgotten about Bayes Theorem.

 

[militarymd]

What the F*k is up with the profiling here? you people sicken me 😀😀

because that's what works.

 

[EternalMD]

Why did I post this thread?

only took 28 or so posts before you revealed the true motive behind your transparent thread - i'm impressed. Personally, i thought you would have let this linger for about 40 or so (past 60 i think people would have stopped caring).

 

[Planktonmd]

What a joke!
Hitler also thought that medicine and racial profiling were the same thing, actually the Nazis had very well known studies on the subject.
http://en.wikipedia.org/wiki/Eugenics
I know some one is probably going to cry Godwin's law but I can't ignore the similarity between the pathological thinking of some ******s on this forum and the Nazi ideology!
It is a very scary thought but these racists do represent a certain percentage of the population and they are multiplying now because they are benefiting from the ignorance fueled xenophobia that we are witnessing.

 

[militarymd]

only took 28 or so posts before you revealed the true motive behind your transparent thread - i'm impressed. Personally, i thought you would have let this linger for about 40 or so (past 60 i think people would have stopped caring).

self awareness and education....it's never too late....

ask yourself...why are you so against profiling in one part of your life...while that is what you are taught to do in another part.

ask yourself...why do you have such a need to be "politically correct"?

 

[militarymd]

Very funny MMD. The odds of patient B needing a stent was more than 1/30000...the rough odds of a Muslim being a terrorist. It's all about not needing to spend more money to profile by race or religion. The current system is fine, despite their recent f*ck up. Why do idiots at TSA screen randomly? Because they can't be trusted to tell the difference between a Buddhist monk, a Creole from Louisiana, and an Islamic Jihadist.

perhaps those numbers are correct....but does it apply when you change the denominator to "Muslims who are flying by themselves on one way tickets from Yemen".....

 

[coprolalia]

and instead FOCUS on the EXCEPTIONS...the john walker lynns...or in my case ...my cute blond.

But, this wasn't really an exception... your young blond nurse... she was acting suspiciously... based on her repeated unusual chest pain. That is also part of creating the profile. And, you got the EKG, which was appropriate when your suspicion started to grow. That is part of the "art" in what we do.

The same would hold true in the airport. If a white, well-dressed businessman was acting suspiciously then your suspicion would grow and you'd more heavily screen him.

This is the point of profiling, medical or otherwise, when your suspicion level is raised, you do more testing. In her case, she got an EKG. And, you appropriately escalated your intervention based on growing suspicion.. and that was appropriate there.... just like it's appropriate for ALL of us to have to walk through a metal detector.

What you don't do is pull a patient - any random patient - out of the waiting room, do a chest x-ray, a set of cardiac enzymes, EKG, cardiac cath, and a nuclear scan on them. And, I think that was your point Mil, right? That's tantamount to what the government is proposing. And, we need to grow the eff up.

And, Planktonmd, you're just clueless. Completely clueless. And, for some strange reason, really fascinated by Nazis. If you don't think profiling is already going on, what can I say? The land of gumdrops and candy canes and fairy tales and butterflies is I believe you think where we all live... in which case you're sorely mistaken. I live in the real world (and not the MTV version either).

-copro

 

[coprolalia]

I agree with you there...when you start adding risk factors, they need to be profiled.

Bingo! And, that's the point. We don't need more security techniques and to spend more money (like the Plankton's of the world who think it grows on trees), but better application of the technology we already have.

-copro

 

[DScully]

Interesting post as well as interesting conclusions.

This reminds me of the class during med school about stereotype. We initially thought we, as physicians, do not stereotype people, and we shouldn't to a certain extent, but the truth is - we DO. Stereotype is just another word for pattern recognition, which we all use in order to make sense of the world and therefore to survive in the unknown.

We just have to be careful when we stereotype people. You should acknowledge when this occurs and keep remembering that it is just an assumption, which needs to be supplemented by evidence.

 

[Eta Carinae]

As an aside, I just saw "Body of Lies"...if you guys are itching to see a good movie (out on video), check this one out.

 

[militarymd]

But, this wasn't really an exception... your young blond nurse... she was acting suspiciously... based on her repeated unusual chest pain. That is also part of creating the profile. And, you got the EKG, which was appropriate when your suspicion started to grow. That is part of the "art" in what we do.

The same would hold true in the airport. If a white, well-dressed businessman was acting suspiciously then your suspicion would grow and you'd more heavily screen him.

This is the point of profiling, medical or otherwise, when your suspicion level is raised, you do more testing. In her case, she got an EKG. And, you appropriately escalated your intervention based on growing suspicion.. and that was appropriate there.... just like it's appropriate for ALL of us to have to walk through a metal detector.

What you don't do is pull a patient - any random patient - out of the waiting room, do a chest x-ray, a set of cardiac enzymes, EKG, cardiac cath, and a nuclear scan on them. And, I think that was your point Mil, right? That's tantamount to what the government is proposing. And, we need to grow the eff up.

And, Planktonmd, you're just clueless. Completely clueless. And, for some strange reason, really fascinated by Nazis. If you don't think profiling is already going on, what can I say? The land of gumdrops and candy canes and fairy tales and butterflies is I believe you think where we all live... in which case you're sorely mistaken. I live in the real world (and not the MTV version either).

-copro

you're right....patterns...profiles....stereotypes.....whatever we want to call it.....

except for some reason.....it's ok when it comes to practicing medicine...but when you apply the same thought processes to something else....like catching extremist terrorists.....

it's "ignorant", "racist", "unintellectual"...or whatever other terms everyone who is PC wants to call it.

 

[Narcotized]

.

 

[coprolalia]

As I said earlier, profiling/stereotyping/pattern recognition, whatever you want to call it, is a basic survival instinct. If you say you don't, you are probably lying just to be PC, and if you truly don't evolution will weed you out over time.

I gotta say this again... just so my bigger point isn't missed...

We all recognize (at least I hope we do), in some form, that profiling is going on.

I have a problem with people being singled-out who don't fit the profile just to be subjected to "fairness" searches in the name of political correctness.

It wastes my time and money. It wastes your time and money. It doesn't make us any safer. That's the bottom line.

-copro

 

[Noyac]

If we can't profile people based on race then why can we have affirmative action?

 

[Planktonmd]

There is more than 50 million Muslims in china, they are CHINESE, they all look exactly like miltaryMD, and speak his language:

4 of the Guantanamo detainees were Muslim Chinese fighting in Afghanistan.
So, shall we say that we should also include Chinese people in the proposed racial profiling?

What about the Millions of eastern European Muslims? and Russian Muslims? they are basically WHITE:

many of them are blond with blue eyes! What shall we do about them?

 

[2win]

There is more than 50 million Muslims in china, they are CHINESE, they all look exactly like miltaryMD, and speak his language:

4 of the Guantanamo detainees were Muslim Chinese fighting in Afghanistan.
So, shall we say that we should also include Chinese people in the proposed racial profiling?

What about the Millions of eastern European Muslims? and Russian Muslims? they are basically WHITE:

many of them are blond with blue eyes! What shall we do about them?

http://en.wikipedia.org/wiki/File:Islam_in_Europe.png

<1% 1%-3% (Italy, Slovenia) 3%-4% (Greece, Norway, Serbia, Spain) 4%-5% (Belgium, Austria, UK) 5%-10% (Denmark, France, Germany, Netherlands, Sweden, Switzerland) 10%-20% (Russia, Bulgaria, Montenegro, Cyprus) 20-60% (Bosnia Herzegovina, Macedonia) 60%-80% (Albania) 80%-95% (Kosovo) >95% (Turkey) Eastern Europe - countries members of EU have LESS THAN 1% Muslims..

 

[siednarb]

"If we can't catch a Nigerian with a powerful explosive powder in his oddly feminine-looking underpants and a syringe full of acid, a man whose own father had alerted the U.S. Embassy in Nigeria, a traveler whose ticket was paid for in cash and who didn't check bags, whose visa renewal had been denied by the British, who had studied Arabic in Al Qaeda sanctuary Yemen, whose name was on a counterterrorism watch list, who can we catch?"

That quote is from M.Dowd in the NYT last week and I couldn't agree more.

There are numerous reasons that should have been "profiled" on this guy:
1) young (23) year old muslim - looks/last name
2) traveling alone
3) paid $2800 in CASH for his ticket
4) did not check any bags - just one small carry on to fly from Nigeria to Detroit!?!
5) his father (a wealthy, well-connected banker) turns in his son (which must have been hard to do) to the US Embassy of all places!
6) the UK has him on their radar and revokes his visa

I am not a muslim - but I have a very semetic, arab sounding last name due to my father's family having come from north africa. I would be happy, elated - if I was "profiled" and given extra screening or virtually stripped searched with fancy computers if it meant we did it to others who fit that criteria and if it meant the end of sending 80 year old grandmothers from Iowa to get wanded or 4 year olds from Iowa getting frisked - all other and complete nonsense!

The Israelis would have had their eyes on this loser the second he paid cash for his ticket and he would have had his pants around his ankles the second he stepped foot in an airport in which they were providing security. Why? Because they would have easily profiled the guy for the reasons I enumerated above.

Despite the millions invested, the creation of the TSA and the NSA and counter-terrorism task force and all the other alphabet organizations of this government - they still missed this! Our government dropped the ball big time and what is more scary to me is not the safety of airline flying...

...it's the fact that this same government that couldn't find this guy is the government that believes they are the answer to health care. Barry believes that our government would be better than the private sector at managing our access to health care.

The fact that the government missed this guy could have meant the death of 260 people. That number will be eclipsed when the government is the direct reason thousands of americans miss their cancer diagnoses or miss their life-saving procedures and diagnostic tests once the government starts rationing health care. The death toll from those government "misses" will be far, far higher.

 

[militarymd]

I am still waiting for a good reason to not "profile"....other than the it is not "politically correct" reason.

 

[Noyac]

I am still waiting for a good reason to not "profile"....other than the it is not "politically correct" reason.

Thats because there is no good reason. Ask any peace officer.

 

[hoyden]

because that's what works.

👍

 

[hoyden]

As I said earlier, profiling/stereotyping/pattern recognition, whatever you want to call it, is a basic survival instinct. If you say you don't, you are probably lying just to be PC, and if you truly don't evolution will weed you out over time.

Bingo!