A 53-year-old man, 5-foot-6-inches and 306 pounds, arrives in the hospital outpatient unit for arthroscopic repair of a torn rotator cuff of his shoulder. A three-packs-a-day smoker, he's recently had a cardiac workup for a syncopal episode that occurred during a prolonged coughing spell. That workup revealed concentric left ventricular hypertrophy, normal cardiac function and significant supra ventricular extrasystoles, which were treated with a beta-blocker. A pre-op note from his internist "cleared" him for surgery and listed no allergies.