SHM Converge Scientific Abstract ePoster Gallery-Maintaining the Differential Diagnoses: Cardiopulmonary Compromise in the Preoperative Assessment

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This case highlights the importance of keeping a broad differential during preoperative assessment, especially in older patients with multimorbidity. A 67-year-old man with tobacco use, obesity, untreated obstructive sleep apnea, and recurrent basal cell carcinoma was evaluated before major head and neck surgery. Although he previously tolerated surgery, he now reported 1 month of worsening dyspnea on exertion, reduced exercise tolerance, and fatigue. Initial vitals were relatively stable, but exam and ECG raised concern, including new T-wave inversions and an old infarct pattern. Standard perioperative risk tools suggested low-to-moderate risk, yet clinical concern persisted.<br /><br />Further evaluation with transthoracic echocardiography showed mild right ventricular enlargement with reduced function, prompting cancellation of surgery and cardiology assessment. When symptoms worsened, he presented to the ED with hypoxemia, elevated NT-proBNP, mild troponin elevation, and chest imaging showing multifocal ground-glass opacities. Differential diagnoses included acute heart failure, pneumonia, pulmonary embolism, COPD exacerbation, metastatic disease, deconditioning, and NSTEMI.<br /><br />Definitive testing revealed bilateral pulmonary emboli with right heart strain on CT angiography and extensive left-leg deep vein thrombosis on duplex ultrasound. He was started on heparin, reviewed by the Pulmonary Embolism Response Team, and then transitioned to apixaban; thrombolysis was not indicated because he remained stable.<br /><br />Key takeaways: risk calculators are useful, but they do not replace clinical judgment. Preoperative evaluation should consider the whole patient, not just surgical risk scores. In patients with unexplained dyspnea or ECG findings suggestive of PE, clinicians should consider PE-specific tools such as Wells and PERC and pursue additional testing when warranted.

Asset Subtitle

Avital Y. O'Glasser

Meta Tag

Author List Alexis Garcia, Avital Y. O'Glasser, Daniel Young, Elizabeth Hays, Howard Freeman, Mara Peterson, Ryan Kane

Category Clinical Vignettes

Concept Preoperative Assessment

Concept Pulmonary Embolism

Concept Clinical Context

Concept Right Heart Strain

Concept PE Risk Stratification

Distinguished Non-Finalist

Presenter Organization Oregon Health & Science University

Presenting Author Avital Y. O'Glasser

Track Adult

Keywords

preoperative assessment

pulmonary embolism

right heart strain

deep vein thrombosis

dyspnea on exertion

obstructive sleep apnea

ECG T-wave inversions

transthoracic echocardiography

perioperative risk

clinical judgment

Preoperative Assessment

Pulmonary Embolism

Clinical Context

Right Heart Strain

PE Risk Stratification