? Perioperative cardiac Ix

45-year-old lady for hysterectomy 

Background

  • Menorrhagia
  • Smoker – cigarettes and marijuana
  • Laparoscopic salpingectomy recently, no issues
  • Ex-IVDU
  • Ex heavy ETOH
  • Very difficult social situation

Issues:

  • Intermittent chest pain
    • Challenging history
    • Atypical and self-limiting
    • Weekly, Exacerbated by stress
    • DASI > 4 METs
    • Normal ECG, no other cardiac investigations
  • Asthma
    • NYHA class 3 dyspnoea
    • Regular Ventolin use
    • No admissions or steroids
    • Unable to afford preventer
    • Normal spirometry
  • Epilepsy
    • weekly seizures, improved from previous
    • GP managing as currently awaiting neurologist appt. 
  • Menorrhagia
    • Letter from gynaecologist – try progesterone therapy first
    • Uncertain as to why has been listed for surgery
    • Hb 120, ferritin 36

Discussion

Optimisation

  • Cardiac Stress Test indicated?
    • Difficult decision, low-risk surgery. 
    • Patient not keen for further investigations despite risks and benefits being outlined in clinic
    • GP has written medical certificate at patients request stating that chest pain is stress-induced and not angina-related.
  • Respiratory consult
    • Stable asthma
    • Not compliant with preventer therapy – encouraged to do same

Plan:

  • Discussion with GP regarding need for cardiac investigations
  • Discuss with gynae surgeon – elucidate reason for procedure. 
  • Smoking cessation
  • Recommence asthma preventer
  • Social work support