Long Cases

Again difficult to classify but useful to have as one document for printing:

A 75-year-old female presents for elective fixation of C3 and C5. She has a history of rheumatoid arthritis. Over the past 6 months she has complained of weakness in the right leg and both hands.

Drugs
Diclofenac and prednisolone.

Observations and examination
Blood pressure: 190/80 mmHg
Heart rate: 84/min
Lung function test: Reduced FRC and FEV1 to about 45% predicted. She also has a restrictive picture
Full blood count: Mild anaemia and elevated mean cell volume
Arterial blood gases: Mild respiratory alkalosis; nothing significant
Urea and electrolytes: Elevated urea; no other derangements
Chest X-ray: Hyperinflated, right basal consolidation, trachea deviated to the right side

Questions
1. Summarise the case.
2. What are the anaesthetic considerations in rheumatoid arthritis?
3. Give a detailed analysis of investigations, especially the chest X-ray.
4. What would be your anaesthetic management?
5. What drugs would you give the patient?
6. Discuss your airway management, giving detailed discussion of asleep fibreoptic intubation.
7. Discuss the positioning considerations.
8. What blood pressure would you be happy with intraoperatively?
9. Describe your fluid management for this patient.
10. How would you extubate this patient? What postoperative respiratory support should be given?
11. Discuss high-dependency unit/intensive care unit care.

A male in his 60s presents with a strangulated hernia for urgent surgery. He has known atrial fibrillation (AF) and hypertension. He has not been taking his medication. His ECG shows fast AF (150 bpm), with ischaemic changes. There are mild signs of heart failure on the chest X-ray. He is asymptomatic.

Questions
1. Discuss his preoperative optimisation.
2. Discuss his anaesthetic management.

You see a 70-year-old man 4 days after he has undergone abdominal aortic aneurysm repair. His past medical history includes a transient ischaemic attack, non-insulin-dependent diabetes mellitus, hypertension and shortness of breath on exertion. A chest X-ray shows pulmonary oedema, cardiomegaly and right lower lobe collapse with tracheal deviation. An ECG shows new atrial fibrillation (AF) with ischaemia.


1. Discuss AF management in the intensive care unit.
2. What are the possible causes of AF?
3. What other ways do you know to identify AF?
4. What drugs would you administer?

A 70-year-old male presents 4 days postoperatively, following elective abdominal aortic aneurysm repair, now in the intensive care unit with respiratory distress.

Past history:
Ischaemic heart disease
NIDDM
Osteoarthritis, with limited exercise tolerance
Hypertension
Peripheral vascular disease

Drugs:
NSAIDs
Amlodipine
prn glyceryl trinitrate

Examinations:
ECG: two ECGs presented; the first showed normal sinus rhythm, the second showed fast atrial fibrillation.
Chest X-ray: diffuse haziness, increased at right base.

Blood results:
Urea: 14 mmol/L
Creatinine: 170 µmol/L
Arterial blood gases:
PaO₂ 11 kPa
PaCO₂ 6.5 kPa
Bicarbonate: normal


Questions:
1. Why is this patient in respiratory distress?
2. What are the causes of raised hemidiaphragm?
3. What is your interpretation of the arterial blood gas results?
4. Discuss the ECG results, comparing the two ECGs.
5. What are the causes of atrial fibrillation?
6. How would you manage atrial fibrillation:
a) if blood pressure is stable?
b) if blood pressure is unstable?
7. How would you manage his respiratory distress?
8. What are the causes of renal dysfunction?
9. Discuss your perioperative management of the patient if he was on your list.
10. Would he benefit from preoptimisation?

You are presented with a 70-year-old man 4 days postoperatively after an abdominal aortic aneurysm repair. He has a complicated past medical history, which is as follows:

- Hypertension 1991
- Transient ischaemic attack (TIA) 1997
- Type 2 diabetes 1998
- Shortness of breath on exertion (SOBOE) 2000

He has presented to A+E with sudden onset shortness of breath. You, as the ITU registrar, are called down to assess him. His chest X-ray has shown pulmonary oedema, cardiomegaly and right lower lobe collapse with tracheal deviation. His ECG has shown atrial fibrillation (AF) with myocardial ischaemia.

QUESTIONS

1. Please talk in depth about the management of AF in intensive care.
2. Which drugs would you use to treat his AF?
3. What are the causes of AF?
4. How would you identify the causes in this situation?
5. How would you manage this case?

36y male with neurofibromatosis presents with convulsions he also had right sided homonymous hemianopia for last few weeks. He is a smoker and alcoholic. O/E consious, appropriate, no focal neurology other than the eye sight. PR 56/min BP 140/90mmHg.ECG- Right axis deviation, Up slurring of ST in V4&V5.CXR-RUL collapse consolidation and a well circumscribed mass in the midzone. FBC Unremarkable except MCV89 BioChem Unremarkable except high ALP. CT posterior cranial fossa tumour looks malignant. Neurosurgeons want to do a craniotomy

Questions

1.Summarise

2. Planned/ Emergency

3.Differential diagnosis Lung mets/ Nerofibromatosis

4.what is the % of Nerofibromatosis becoming malignant

5.What is R/homonymous hemianopia

6.Alcohol intake what is the recommendation

How much is a unit of alcohol

7.ECG description

8.CXR description

9.Why MCV high/ Causes of high MCV

10.Why ALP high in this Pt normal billirubin

11.What other investigation you need

12. Will you proceed with the case

13. Principal of neurosurgery

14.What is the position for this surgery

Middle aged Downs man for cataract, very anxious, has ASD, loud P2, XRC with prominent pulmonary veins, ECG with RAd and Rt sided strain, patient SOB.

1. summary

2.how would you proceed

3.how would cardiologist treat (diuretics)

4. how would you manage GA?

34 year old female presents for an elective thyroidectomy. 3 yrs ago she presented with palpitations, heat intolerance and anxiety. She was diagnosed as Graves disease and treated with radioiodine which was ineffective. She subsequently became pregnant and now has presented for surgery. She has a small goiter and a lid lag. She is on carbimazole, combined OCP. ECG – WPW syndrome . FBC – increased WCC and neutrophil. U+E – norma.l TFTs – raised T4 and low TSH. Thyroid scintigram – right lobe bigger than left. Some hypoechoic areas interspersed within normal areas. Post op inv – low Ca, low albumin

Summarise the case

What are the common indications for thyroidectomy? – hyperthyroid with failed medical management, goiter and malignancy

What are the features of Graves’s disease?

Why do they get eye signs? Will it get corrected after thyroidectomy?

Why do they get heat intolerance?

What is lid lag?

What do you think about blood results? What is the reason for raised WCC with neutrophilia? You have screened her for infection and the screen is negative. What else would you think of?

Tell about the ECG

Tell me about the thyroid function tests? What is TSH? Why is it raised? Where is secreted from? How is its secretion controlled?

What do you think about the thyroid scintigram? What do they use in this test? What are hot and cold spots? How do they appear in a normal person, in a person with hyperthyroidism and a person with malignancy?

What is radio iodine? How does it help in Graves disease? How is it different from lugol’s iodine? How does carbimazole work? What are you worried about in a patient on carbimazole?

What more information do you want about this patient before proceeding to surgery?

Why do you refer these patients to the ENT surgeon? Tell me about vocal cord palsies.

Would you anaesthetize this patient now? Are you sure you want to postpone this lady who has been admitted 48 hrs previously? She is already on 60 mg /day of carbimazole? How else could you control her thyrotoxicosis?

What physical factors would affect your anaesthetic management? (Obesity, hoarseness, dyspnoea on supine, dysphagia)

She had her surgery and is in recovery and she develops resp distress. What are the causes?

How will you manage a wound hematoma?

What is carpopedal spasm? Why does it occur post thyroidectomy?

A 68 year old gentleman presents for elective abdominal aortic aneurysm surgery. Hypertensive for the past 10 years. History of angina - past 2 years. On enalapril, frusemide isosorbide. Had chest pain 2 months ago. No evidence of myocardial infarction on investigation.

On examination

BP - 160/90 mmHg

Jugular venous pressure not raised

Rales on auscultation, both bases

Liver just palpable below the right costal margin

Investigations: Positive findings

White cell count = 12,000/ml

Creatinine - 170 micromol/L

Potassium - 3.2 mmol/L

ECG - T wave inversion v3 - v6, avF

X-Ray chest - mild cardiomegaly

QUESTIONS

Summarise the case.

Do you think his blood pressure is adequately controlled?

What is enalapril/how does it act/what are its side-effects?

What do you think his chest pain was due to (give a differential diagnosis)?

What are the implications if the chest pain had been due to myocardial infarction?

What do you think about his potassium level/why is it low/do you think it is acute/will you correct it before surgery/how will you correct it/what happens if you do not correct it?

Will you be happy to go ahead with the anaesthetic?

What further investigations will you do/why?

How will an echocardiogram help?

Do you think he is in heart failure/does he have a chest infection?

Differential diagnosis for hepatomegaly

What do you find in his ECG?

Did you determine the axis of the heart?

Is there any evidence of MI in the past?

What are the findings on the chest X-ray/how do you say the film is PA view/how did you determine that there is cardiomegaly/how do you measure CT ratio?

What will be your anaesthetic management

Why did you choose to do an epidural

Will you be concerned about something (heparin) that you will be giving intraoperatively?

What are the benefits (of the epidural)?

What will you give in your epidural?

What monitoring will you undertake and why?

59 year old man for transurethral resection of the prostate

Ex-smoker, 20 cigarettes/day

Had 'shadow on lung' 2 years ago

Treated with radiotherapy and drugs - no further information available

Now coughing up blood

Diabetic

Drugs - glibenclamide 5 mg daily

On examination:

1.75 m

72 kg

Pulse: 80/min
BP: 150/90 mmHg
Respiratory rate: 20/min

Chest:
- trachea deviated to right

- bronchial breathing and reduced breath sounds heard in the right upper chest

Abdomen:
- 10 cm bladder palapable

Investigations:

Hb	16.0 g/dl
WBC	7.1 x 109/L
Platelets	271 x 109/L
MCV	normal
Differential	normal
Na	135 mEq/L
K	3.5 mEq/L
Urea	14.6 mmol/L
Creatinine	237 umol/L
Glucose	11 mmol/L
CXR	No cardiomegaly Trachea deviated to right Right upper zone shadowing and loss of volume on right

Lung function tests:

	Predicted	Measured
FEV1	3.06 L	1.62 L
FVC	4.18 L	3.18 L
FEV1/FVC	69%	51%
PEFR	533 L/min	250 L/min

QUESTIONS

- Summarise the problems.

- Summarise the positive findings on examination.

- Does a BP of 150/90 mmHg bother you?

- Comment on the investigations.

- How would the raised urea and creatinine affect your management? (Give an example)

- What do you think of a blood glucose of 11 mmol/L?

- What does the CXR show and what is the differential diagnosis?

- Do the lung function tests show a restrictive picture?

- What else would you ask for regarding the lung function tests?

- Would you be happy to anaesthetise this patient now?

- What premedication would you prescribe and why?

- What is your management of his diabetes?

- What anaesthetic would you give and why?

- How would you perform spinal anaesthesia?

A 52 year old male presents electively for transurethral resection of the prostate. He has a history of non-insulin-dependent diabetes, and 2–3 months ago underwent chemotherapy and radiotherapy for 'a shadow on the lung'. He has been a life-long smoker, and recently had an episode of haemoptysis. He is currently taking glibenclamide 5 mg once daily.

On examination

– He is of average build
– Respiratory signs: respiratory rate: 18/min; trachea is deviated to the right; bronchial breathing can be heard in the right upper zone
– Cardiovascular signs: pulse: 80 bpm; blood pressure: 130/90 mmHg
– Gastrointestinal signs: palpable enlarged bladder

Investigations
- Haemoglobin 16 g/dl
- White blood cell count: 8 X 10⁶/ml
- Platelets: normal
- Urea 18: mmol/L
- Creatinine 180 µmol/L
- Na+ and K+: normal
- Liver function tests: normal
- Chest X-ray: right upper lobe collapse
- Pulmonary function tests: FEV1 1.9 L; FVC 3.75 L
- FEV/FVC ratio 0.53

1. Present the salient features of this case.
2. Describe the features of prostatic hypertrophy.
3. Describe the features of renal failure.
4. How might carcinoma of the prostate be diagnosed and treated?
5. Why might this patient have right upper lobe collapse?
6. Why might this patient have a raised haemoglobin level and what is the mechanism for this?
7. Describe the relevance of the lung function results.
8. How might this patient's chest condition be optimised prior to surgery?
9. How would you anaesthetise this man?
10. What are the options for controlling a diabetic patient's glucose perioperatively?
11. Describe the types of oral hypoglycaemic agents available.
12. How would you assess a diabetic patient preoperatively?

A 24 year old male, who is a known drug addict, has recently been admitted to medical ward. He was found unconscious at home with a history of ?heroin overdose. His conscious level improved with 200 mcg naloxone and he became agitated, with a Glasgow Coma Scale of 14. He is complaining of being unable to feel his legs and of generalised weakness. His blood pressure is 80/40 mmHg and his peripheries are cool. He has a past history of depression and alcohol abuse.

Investigations:

Arterial blood gases post-naloxone on air:	pO2	8.0 kPa
	pCO2	6.0 kPa
	pH	7.2
	HCO3-	20 mmol/L
Urea and electrolytes	Na	131 mEq/L
	K	7.8 mEq/L
	Ur	13.0 mmol/L
	Cr	331 umol/L
	CK	50,000 IU

ECG Rate 50 bpm sinus (abnormal intermittent p waves) Broad QRS peaked T waves

CXR CVP line in situ. Bilateral diffuse shadowing. R middle lobe collapse. No pneumothorax.

- Summarise the case.

- What may have made him unconscious other than heroin?

- What other drugs may he have taken?
- How would you determine this?

- What does the ECG show?

- Why can't he feel his legs and why is he weak?

- What may the cause of his raised K+ and his renal impairment?

- What is rhabdomyolsis and how does it cause renal failure?
- Why may he have it?

- How would you resuscitate him?

- How would you treat the K+ acutely and subsequently?

- What is the difference between haemofiltration and dialysis?
- How do they work, and which one would you use in this case, given the choice, and why?

A 64 year old man is undergoing right total hip replacement.
- He gives a history of asthma and chest pain.
- He is taking oxitropium bromide.

- He has been hospitalised 3 times for chest pain.
- The last hospitalisation was 6 months ago.
- He has a history of deep vein thrombosis after a previous operation and took Warfarin, which was stopped 3 months ago.
- He also has history of hiatus hernia, diagnosed after oesophagoscopy.

Examination

- He is moderately obese; his weight is 95 kg, his height is 1.65 cm.

- Apart from bilateral basal crepitations and diffuse wheezing, all over both lung fields are normal; first and second heart sounds normal, apex beat is not displaced.
- Blood pressure is 140/90 mmHg.

- Full blood count - NAD

- Lung function test - FEV1 - 65% of predicted value. FEV1/FVC - 50%. PEFR - 70% of predicted value.

- ECG - Bifacicular block. Inverted T waves in Leads 1, AVL, V1 to V4.

- CXR - shows minimal basal effusion. Lungs are not hyperinflated.

1. Summarise the case

2. Interpret the data

3. What further investigation would you carry out?

4. How would you anaesthetise this patient?

5. How would you prevent DVT?

A 62 year old male with significant cardiovascular and respiratory disease presents for right total hip replacement. He has previously been admitted several times with chest pain, which has been relieved by glyceryl trinitrate (GTN), but he continues to smoke 30 cigarettes a day. He is also obese, and has a hiatus hernia, decreased exercise tolerance and a past history of deep vein thrombosis (DVT). On examination, his blood pressure is 140/85 mmHg, and he has bilateral inspiratory crackles.

His ECG showed widened QRS complexes and a normal axis but did not show the classical signs of right bundle branch block.

His chest X-ray showed flattened hemidiaphragms. He had a normal cardiothoracic ratio, and his lung function tests revealed an obstructive picture. The patient’s blood tests were all normal, with a haemoglobin level of 15 g/dl.

1. Summarise the main issues regarding this case.
2. What other investigations would you undertake?
3. Which cardiovascular investigations should be carried out?
4. What can you glean from the patient’s baseline arterial blood gases?
5. Would you refer this patient to a cardiologist?
6. What can you say about the patient’s blood pressure, and how would this affect your treatment?
7. What other information would you need from his lung function tests?
8. What would you be concerned about in the full blood count?
9. What is the mechanism of the development of polycythaemia in such patients?
10. How should this patient be optimised, for example in terms of preventing DVTs?
11. How would you treat the patient’s hiatus hernia?
12. Would you anaesthetise him by general or regional anaesthesia? Why?
13. Discuss the patient’s postoperative care.

A patient presents for a radical nephrectomy for malignancy. He has a history of chronic obstructive pulmonary disease, ischaemic heart disease, a pacemaker and requires haemodialysis.

Investigations
Full blood count, urea and electrolytes, chest X-ray, ECG, echocardiogram, pulmonary function tests

What is the transfer factor? (discussion re: the pulmonary function tests)
How would you assess this patient's volaemic status?
Would you consider an epidural? Discuss the pros vs cons
How would you optimise this patient preoperatively?

A 62 year old male with significant cardiovascular and respiratory disease presents for right total hip replacement. He has previously been admitted several times with chest pain, which has been relieved by glyceryl trinitrate (GTN), but he continues to smoke 30 cigarettes a day. He is also obese, and has a hiatus hernia, decreased exercise tolerance and a past history of deep vein thrombosis (DVT). On examination, his blood pressure is 140/85 mmHg, and he has bilateral inspiratory crackles. His ECG showed widened QRS complexes and a normal axis but did not show the classical signs of right bundle branch block. His chest X-ray showed flattened hemidiaphragms. He had a normal cardiothoracic ratio, and his lung function tests revealed an obstructive picture. The patient’s blood tests were all normal, with a haemoglobin level of 15 g/dl.

QUESTIONS

1. Summarise the main issues regarding this case.

2. What other investigations would you undertake?

3. Which cardiovascular investigations should be carried out?

4. What can you glean from the patient’s baseline arterial blood gases?

5. Would you refer this patient to a cardiologist?

6. What can you say about the patient’s blood pressure, and how would this affect your treatment?

7. What other information would you need from his lung function tests?

8. What would you be concerned about in the full blood count?

9. What is the mechanism of the development of polycythaemia in such patients?

10. How should this patient be optimised, for example in terms of preventing DVTs?

11. How would you treat the patient’s hiatus hernia?

12. Would you anaesthetise him, by general or regional anaesthesia? Why?

13. Discuss the patient’s postoperative care.

You are presented with a 7 year old male child with acute painful swelling in the left scrotum, vomiting and torsion of the testes. He has had a cough and been wheezing for 3 days. He had his last meal 4 hours ago. He has been asthmatic for the past 3 years and is currently taking salbutamol and beclomethasone inhalers.

On examination:

The child is found to be very anxious and in pain. He is mildly dehydrated, and weighs 19 kg.

Respiratory signs

– Respiratory rate: 28/min
– Left lower zone: air entry decreased
– Percussion note decreased
– Bilateral rhonchi
– Abdominal examination: scrotum – nothing abnormal detected

Cardiovascular signs

– Heart rate: >120 bpm
– Blood pressure: 110/60 mmHg
– Auscultation: nothing abnormal detected

The result of investigations are as follows:

– Haemoglobin: 10.6 g/dl
– White blood cell count: 14,600/ml
– Neutrophil count: 80 x 10⁶ ml (Normal range 2-7)
– lymphocyte count: 20 x 10⁶ ml (Normal range 1.5-4)
– Packed cell volume: 40%

Other investigations carried out:

– Chest X-Ray
– Urea and electrolytes
– Na+
– K+
– Creatinine

1. Summarise the patient and identify the problems associated with this case.
2 Give the differential diagnosis.
3. Discuss childhood asthma.
4. How do you assess severity of asthma?
5. Comment on investigations.
6. How would you manage this child?
7. How would you anaesthetise this child?

A 68-year-old man has an implanted pacemaker and a past history of angina-like chest pain. He also has chronic obstructive pulmonary disease but maintains that he can climb stairs and has a reasonably active life. He has been smoking 20 cigarettes a day for many years. He is scheduled for an elective right nephrectomy for renal cell carcinoma and has recently undergone haemodialysis. He is on perindopril 20 mg once daily, frusemide 500 mg once daily and aspirin 75 mg twice daily. On examination, he has pitting pedal oedema and is wheezing.

Biochemistry– Na+: 138 mEq/L
– K+: 3.5 mEq/L
– Cl–: 110 mEq/L
– Urea: 30 mmol/L
– Creatinine: 524 µmol/L
– Liver function tests: within normal limits (WNL)

Haematology

– Haemoglobin: 7.5 g/dl
– Haematocrit: 25%
– Platelet count: 227 X 10⁶
– White blood cell count: 5.5 X 10⁶

Pulmonary function tests
– FEV1: 1.8 L
– FEV1/FVC: 55%
– TLCO Within normal limits
– Flow–volume loop: an obstructive pattern loop was provided

Chest X-ray findings
– Implanted pacemaker
– Chronic venovenous haemofiltration (CVVH)
– Right subclavian lines
– Right internal jugular vein central line
– Cardiac/pulmonary fields within normal limits

ECG findings
– Completely paced rhythm 60/min
– Left axis deviation
– Wide QRS complexes >3 mm
– ST elevation with tall T waves in V2-V5

1. Summarise the case
2. What physiological system should be discussed here?
3. The surgeon wants to operate immediately for fear of metastasis if postponed – would you anaesthetise? If not, why not? When would you deem it appropriate to operate? What more information do you require?
4. Discuss the results of all of the investigations above
5. What would be your anaesthetic plan?

An 81-year-old woman presents to the Accident & Emergency Department following a fall, in which she sustained a supracondylar fracture of the right humerus. She is breathless, with a respiratory rate of 20 breaths per min, a blood pressure of 110/70 mmHg, and is in pain. She underwent local excision and radiotherapy for a mass in the right breast a few years previously. She is hypertensive and hypothyroid, and is currently on atenolol 50 mg and thyroxine 100 mcg. Investigations show the following results:

Weight: 50 kg
Height: 1.50 m
Chest X-ray: right pleural effusion
ECG: Sinus rhythm, with borderline left ventricular hypertrophy
Haemoglobin: 9.9 g/dl
White blood cells: 10.3 ? 106/ml
Na+ 131 (135–145) mEq/L
urea 7.5 mmol/l (3.5–6.5)
BM 7.5 random

Questions
1) Summarise the patient’s condition.
2) Why is she breathless?
3) Present her chest X-ray
4) Describe the ECG findings.
5) Would you drain the effusion?
6) How would you drain the effusion?, describe your technique.
7) Why is the patient anaemic?
8) What do the biochemical values tell you?
9) How would you proceed from here? Would you carry out any further investigations?
10) What are the risks associated with regional anaesthesia (interscalene)?
11) Would you give this patient a general anaesthetic?
12) What r the features of hypothyroidism?
13) How would you treat a thyroid coma?

A 60-year-old woman presents for multiple dental extractions. She underwent an open mitral valvotomy 40 years ago. She is currently on warfarin, digoxin and frumil. She also has a history of shortness of breath on exertion and is short of breath when lying flat. On examination, her observations are normal and her chest is clear. She has a normal body mass index. A diastolic murmur is detected. Her blood results, urea and electrolytes, and full blood count are all normal, and her international normalised ratio is 2.5. Her ECG shows atrial fibrillation (rate controlled). Her chest X-ray shows cardiomegaly, an enlarged left atrium and evidence of pulmonary oedema.

1. Discuss the patient’s blood results and investigations.
2. Discuss any evidence of mitral dysfunction.
3. Discuss the pathophysiology of mitral valve disease.
4. Discuss how you would assess cardiovascular status.
5. What further investigations would you perform?
6. Discuss antibody prophylaxis.
7. Discuss preoperative optimisation in this patient.
8. Discuss how you would correct this patient’s abnormal coagulation.
9. How would you assess the patient’s airway?
10. Discuss the conduct of anaesthesia.
11. Discuss how you would extubate the patient (bearing in mind her shortness of breath when lying flat, and implications for airway safety).

A 79-year-old female presents with lower abdominal pain, nausea and vomiting of 24 hours’ standing. She is admitted onto a ward and treated with analgesics and fluids, but the pain is still present. She underwent hemithyroidectomy 2 years ago and now, on examination, a large goitre is found with inspiratory stridor, although the patient is not in acute distress. The surgeon wants to take her to theatre to see if there is a large bowel obstruction.
Medication: thyroxine and aspirin

Observations/examination
Temperature: high
Pulse: 95 bpm
Blood pressure: 140/85 mmHg
Respiratory rate: 24 breaths/minute
Pulmonary artery: massive distension

Investigations
Haemoglobin: 15.2 g/dl
White blood cell count: 18.2 x 109/L
MCV: below normal
Amylase: <200>

1. Summarise the case.
2. What is the differential diagnosis for lower abdominal pain?
3. What fluids might this woman have received on the ward? What are the normal fluid requirements?
4. What are third space losses?
5. What is the composition of Hartmans solution and saline?
6. What are the disadvantages of using excessive saline?
7. Clinically, how can you judge that she is adequately resuscitated?
8. Would you carry out CO monitoring? Can you do this in an awake patient?
9. What blood investigations would you perform?
10. Is her haemoglobin elevated because of dehydration or is it pathological?
11. From the investigations, do you think she is adequately hydrated?
12. What can you tell from her ECG?
13. What can you tell from her chest X-ray?
14. What is the cause of mediastinal widening in this case?
15 What further investigations would you like to carry out?
16. What would be your general anaesthetic plan?
17. Would you use inhalational or intravenous induction?
18. What are the advantage and disadvantages for each?
19. For maintenance of anaesthesia, would you use total intravenous anaesthesia or inhalational anaesthesia?
20. What are the advantages and disadvantages for each?
21. What invasive and non-invasive monitoring would you perform?
22. What pain relief would you administer?
23. Would you give the patient an epidural?

A 74-year-old lady presents for an elective cataract surgery but refuses a local anaesthetic technique.

Past history
Myocardial infarction 6 years ago
Mastectomy >6 years ago
She was admitted last year with a mottled and painful white upper limb, which got better towards the evening, required admission.
She is now breathless on exertion.
Drugs
Frumil: Frusemide 40 mg/Amiloride
Digoxin: 125mcg
Warfarin: 8mg
Weight 51 kg

Blood results
Haemoglobin: 11.5 (lab range 13-15) g/dl)
Red blood cell count: lower side of normal
White cell count: normal
INR: 1.6 (Th. Range 2.0-4.0)
Na⁺: 142 mEq/L
K⁺: 5.5 (Range 3.5-5.0) mEq/L
Urea 10.0 mmol/L
Creatinine: 140 (range up to 120) µmol/L

Observations/examination
Pulse: 80/min, irregular
Blood pressure: 170/80 mmHg
Cardiovascular system: Pansystolic murmur at apex
Low-pitched diastolic murmur at apex
Apex beat slightly lateral to mid-axillary line
Respiratory system: Bilateral fine basal crepitations
Respiratory rate: 16/min
ECG: atrial fibrillation, severe left ventricular hypertrophy (LVH), heart rate <100>

A patient presents for dental clearance. He is on multiple drugs: a tricyclic antidepressant, lithium, an atypical antipsychotic agent and a calcium channel blocker for hypertension. He lives alone, has an unkempt appearance, and has dry mouth and tremor.

Observations/examination
ECG: essentially normal.
Chest X-ray: borderline cardiomegaly.
Full blood count: normal, degree of chronic renal failure.
Lithium level: upper limit of normal.

1. How appropriate is the patient for a day-case procedure?
2. Discuss the patient’s medications and their respective side-effects and interactions with anaesthesia.
3. What do his results suggest?
4. What further investigations are needed?

A 56-year-old coal miner requires sigmoid colectomy for carcinoma. He has a home nebuliser. His FEV1 is 0.68 litres, and he has 3% reversibility with salbutamol.

Observations/examination
Shortness of breath 50 yards.
Wheezy chest
Respiratory rate 30/min
Non-productive cough
Chest X-ray: bullous lung disease and prominent pulmonary arteries
ECG: normal
Saturations: 93% on air. PO2 12 kPa; PCO2 4.5 kPa
No FBC
No electrolytes

Drugs
He is currently taking 2.5 mg prednisolone (the dose was recently reduced)

Questions
1. Summarise the case.
2. What are the main issues?
3. How would you optimise this patient preoperatively?
4. What is the likely cause of his COPD?
5. Present the chest X-ray.
6. What are the chest X-ray findings in pulmonary hypertension?
7. Present the ECG.
8. What ECG findings might you find?
9. What are the ECG changes seen in heart strain (left and right)?
10. What are the criteria for pathological Q waves?
11. What is respiratory failure?
- Give blood gas definitions of type 1 and 2 respiratory failure
12. What are blue bloaters and pink puffers?
- Which is this patient?
13. How would you anaesthetise this man?