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Final clinical long case 12

Created: 29/6/2005
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

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?

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