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Final clinical long case 16

Created: 14/3/2006
Updated: 4/6/2007
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

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

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.


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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