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Final clinical long case 14

Created: 24/11/2005
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).

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