Case Presentation: A 67-year-old man with tobacco use disorder, class I obesity, OSA, and recurrent basal cell carcinoma (BCC) of the external auditory canal presented to his preoperative appointment prior to planned surgical removal of his BCC with partial temporal bone resection, parotidectomy, and reconstruction. At the time, he endorsed subacute progressive dyspnea, dry cough, and intermittent chest discomfort. He demonstrated increased respiratory effort on exam. Labs were notable for WBC 15. ECG showed T-wave inversions in the anteroseptal leads. The decision was made to delay his surgery in order to conduct a more comprehensive cardiopulmonary evaluation before surgery. The initial differential diagnosis for his dyspnea included congestive heart failure (either left ventricular or right ventricular), atypical angina, community-acquired pneumonia, COVID-19, and pulmonary embolism (PE). An expedited outpatient echocardiogram demonstrated a mildly enlarged right ventricle with mildly reduced systolic function. Before additional outpatient work up or Cardiology consultation for right heart failure occurred, he was referred to the emergency department for worsening symptoms and was found to have bilateral submassive PE with significant clot burden.

Discussion: Perioperative care is moving towards a more collaborative approach, involving a general internist’s comprehensive assessment to stratify risk, coordinate preoperative patient optimization, and improve surgical outcomes. In order to provide an appropriate evaluation, the internist needs a clear preoperative framework utilizing historical information and clinical risk calculators to characterize a patient’s surgical risk, and the ability to engage interdisciplinary clinical providers to accomplish the shared goal of completing a safe, successful surgery and recovery. When proceeding with preoperative evaluation, providers may be confronted with acute or chronic medical symptoms that require more extensive workup prior to proceeding with surgery. This case outlines the preoperative evaluation of a patient with progressive dyspnea, underscoring the need to fully evaluate patients’ complaints in the context of their surgical risk. Additionally, this highlights that for all the emphasis on screening for ischemic heart disease in the perioperative guidelines, plus valvular disease or heart failure, other potentially life threatening etiologies for dyspnea must remain on the clinical radar.

Conclusions: Preoperative providers play a critical role in determining the need for further evaluation before a patient can safely proceed with surgery. This patient’s initial history supported the need for further evaluation of his shortness of breath with some preliminary clinical data concerning for PE. However, the diagnosis was confirmed with imaging based primarily on a high index of clinical suspicion. This highlights the importance of not only understanding the test characteristics for recognizing acute PE (e.g. ECG, Wells’ Score, and PERC Rule) but also counterbalancing one’s clinical judgement in diagnosis.