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Final clinical long case 9

Created: 7/4/2004

 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.

N.B. The history, ECG etc. for this case can be found in "The Clinical Viva" by Mills and Maguire.


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.

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