You have been asked by an orthopedic surgeon to perform preoperative consultation and clearance on a 76-year-old woman who fell and broke her left hip. She has a past medical history of hypertension, diabetes controlled with oral medications, hypothyroidism, and coronary artery disease for which she underwent bypass surgery 2 years ago. Until the fall she was able to do her own housework and to climb one flight of stairs slowly without any chest discomfort. She is on appropriate medical therapy for each of her conditions. On physical examination she is awake and alert but in some pain, afebrile, BP 150/90, HR 95, RR 18, O2 saturation 93% on room air. Other than her externally rotated left hip with local swelling and pain, her examination is unremarkable. Her ECG shows no evidence of acute ischemia. Her chest x-ray shows a normal heart and clear lungs. CBC reveals a hemoglobin of 10.1 with an MCV of 90 fL. Chemistry panel and urinalysis are normal.
Which of the following is the most appropriate next step in this case?
Preoperative assessment of patients with multiple medical problems is an important step that must be taken with great care. While several risk stratification algorithms and methods are available, the most commonly used is that published by the American College of Cardiology/American Heart Association (ACC/AHA) of 2007 and updated in 2009. Key components are to (1) determine if the patient has an immediate cardiac problem such as active angina symptoms, severe (Class IV) heart failure, tachy or brady arrhythmias, or severe valvular heart disease—none of which are present in this patient; (2) determine the functional status of the patient—in this case the patient can climb a flight of stairs without angina symptoms; hence she can perform 4 metabolic equivalents of work (4 METS) which is considered acceptable and makes her lower risk; (3) assess resting ECG—hers does not show any significant ST elevation or depression or Q waves which is reassuring; and finally (4) evaluate the risk of the particular surgery—major orthopedic surgery is of “intermediate” risk. Overall she has a baseline risk of between 1% and 5% of a perioperative cardiovascular event. Apart from the ACC/AHA guidelines, the patient has a significant anemia. Transfusion criteria continue to be revised with most studies showing it is best to reserve transfusion for patients with a hemoglobin below 7. In patients with known cardiac or respiratory disease (as in this patient—the coronary artery disease history), it is acceptable to transfuse patients when their hemoglobin falls below 8. This patient’s hemoglobin of 10 does not qualify her for preoperative transfusion. If the patient had a poor functional status and had not had a cardiac evaluation recently, then the ACC/AHA guidelines would recommend a nuclear medicine stress test and, if this is abnormal, a left heart catheterization (LHC). Cardiology consultation for immediate LHC is not indicated on the basis of her risk assessment.
A 42-year-old man is persuaded by his wife to come to you for general checkup. She hints of concern about alcohol use. After asking the CAGE questions and finding that he has tried unsuccessfully to Cut back, has become Angry with family urging him to quit drinking, has felt Guilty about his drinking, and has even had an Eye-opener drink in the morning from time to time, you advise the patient that he is an “at-risk drinker.” He admits to drinking on average three to four beers per night with more on the weekends. He has never had a problem going a few days without drinking.
What would be a practical next step to take that might help you further evaluate the physical consequences of this patient’s drinking?
This patient’s liver enzymes including AST, ALT, and GGT are likely to be at least mildly elevated. On his CBC, the mean corpuscular volume (MCV) may be elevated due to his chronic alcohol intake. Using these lab abnormalities one can explain to the patient that he has a high likelihood of serious physical consequences if he continues drinking. At-risk drinking is considered more than 14 drinks per week or more than 4 drinks at one setting by a male (7 and 3respectively for a woman). An ultrasound or CT scan might show signs of cirrhosis in a seriously affected patient, but they are unlikely to be positive at this stage of the man’s drinking. EGD would be recommended if cirrhosis is documented but would be premature at this point. α-Fetoprotein is useful in evaluating a liver mass in a patient with cirrhosis as it is usually elevated in the setting of a hepatocellular carcinoma. A CA-19-9 test is used to follow patients with pancreatic cancer.
A 55-year-old woman comes to the clinic with insomnia, fatigue, a 10-lb weight loss over the past month, loss of interest in most activities, and diminished ability to concentrate. She lost her husband 6 months ago to an MI and now lives alone. She denies suicidal or homicidal ideation. Physical examination is normal and basic laboratory workup is negative, including a normal TSH and CBC. You diagnose her with depression and prescribe fluoxetine 20 mg daily. One month later she is no better.
What is the best next step in her management?
This patient has not responded to a month of antidepressant therapy. It would be appropriate at this time to increase the dose of fluoxetine. Unless the patient has intolerable side effects, you should advance to the full dose of the initial SSRI before changing to another SSRI or switching to an SNRI (such as bupropion). Although full response to an antidepressant may take 6 to 8 weeks, you would like to see some improvement after 1 month. Referral to a psychiatrist would be unnecessary unless she is refractory to first- and second-line therapy or unless she develops an indication for hospitalization. Admission to a psychiatric facility is reserved for patients who are considered a risk to themselves or to others (suicidal or homicidal ideation), or those with psychotic features. Tricyclic antidepressants are effective but carry more side effects as well as more serious risk of fatal overdose.
A 65-year-old woman was hospitalized for pulmonary embolus and eventually discharged on warfarin (Coumadin) with a therapeutic INR. During the next 2 weeks as an outpatient, she was started back on her previous ACE inhibitor antihypertensive, given temazepam for insomnia, treated with ciprofloxacin for a urinary tract infection, started on over-the-counter famotidine (Pepcid) for GI symptoms, and told to stop the OTC naproxen she was taking. Follow-up INR is 5.0.
Which of the following drugs most likely potentiated the effects of warfarin and led to the high INR?
Many medications can potentiate warfarin (Coumadin), including the fluoroquinolones and various other broad-spectrum antibiotics. ACE inhibitors, benzodiazepines, and famotidine have no effect on the metabolism of warfarin. Nonsteroidal anti-inflammatory drugs may occasionally enhance warfarin’s effect, so discontinuing naproxen, if anything, should lower the INR. If the H2 blocker cimetidine or the proton pump inhibitor omeprazole had been used for gastric acid reduction in this case, either of these can potentiate warfarin and increase the INR. Of interest, the over-the-counter herbal product ginkgo biloba can also potentiate the anticoagulant effect of warfarin.
A 20-year-old college basketball player is brought to the university urgent care clinic after developing chest pain and palpitations during practice. There is no dyspnea or tachypnea. He denies family history of cardiac disease, and social history is negative for alcohol or drug use. Cardiac auscultation is unremarkable, and ECG shows only occasional PVCs.
Which of the following is the most appropriate next step in evaluation and/or management?
The question of cocaine use must be raised in virtually all young adults with cardiovascular symptoms, despite a professed negative history. Therefore, a urine drug screen should be obtained early on. If this is negative, the patient may need further cardiac evaluation, such as echocardiogram, ambulatory cardiac monitoring, and/or stress test. In the absence of dyspnea, recent immobilization, or physical examination evidence of venous thrombosis, workup for asthma or DVT would not be warranted. Beta-blockers can be used for symptomatic treatment of PVCs but not until the more serious issue of substance abuse has been addressed. Cardiovascular complications from cocaine abuse include hypertension (which may be severe), arrhythmias, myocardial infarction, and stroke.
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