Final long case 1

59 year old man for transurethral resection of the prostate. He is an ex-smoker and used to smoke 20 cigarettes/day.He was told he has a 'shadow on lung' 2 years ago for which he was treated with radiotherapy and drugs. He is a known diabetic and is on glibenclamide. Now coughing up blood

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:

Lung function tests:

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?

Final clinical long case 2

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 not being able 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: 

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

.

QUESTIONS

·        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?

Final clinical long case 3

A 64 year old man is admitted to undergo right total hip replacement. He is known to have asthma and chest pain.He is takes oxitropium bromide. He has been hospitalised 3 times for chest pain. The last hospitalisation was 6 months back. 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.

 QUESTIONS

·        Summarise the case

·        Interpret the data

·        What further investigation would you carry out?

·        How would you anaesthetise this patient?

·        How would you prevent DVT?

Final clinical long case 4

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:

   X-Ray
   Urea and electrolytes
   Na+
   K+
   Creatinine

QUESTIONS

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. Is the child dehydrated?
7. How would you manage this child?
8. How would you anaesthetise this child?

Final clinical long case 5

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.
The result of investigations are as follows:

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

QUESTIONS
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?

Final clinical long case 6

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

QUESTIONS

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?

Final clinical long case 7

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?

Final clinical long case 8

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.

Final clinical long case 9

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.

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

Final clinical long case 10

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 x10⁶/ml
Na+ 131  mEq/L
Urea 7.5 mmol/l

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?

Final clinical long case 11

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.

QUESTIONS
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?

Final clinical long case 12

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.

QUESTIONS
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).

Long case 13
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. She is on 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
Na+/K+/ urea/creatinine: normal
ECG: AF 75-100 with possibly old infarct (q waves in V1 and V2)
Chest X-ray: Superior mediastinal widening with gross tracheal deviation, plus free fluid under the abdomen.

QUESTIONS
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?

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14Section: Article