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