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Final clinical long case 17

Created: 27/6/2006
Updated: 27/6/2006
A 74-year-old lady presents for an elective cataract surgery but refuses a local anaesthetic technique.

Past history
Myocardial infarction 6 years ago
Mastectomy >6 years ago
She was admitted last year with a mottled and painful white upper limb, which got better towards the evening, required admission.
She is now breathless on exertion.

Frumil: Frusemide 40 mg/Amiloride
Digoxin: 125mcg
Warfarin: 8mg

51 kg

Blood results
Haemoglobin: 11.5 (lab range 13-15) g/dl)
Red blood cell count: lower side of normal
White cell count: normal
INR: 1.6 (Th. Range 2.0-4.0)
Na+: 142 mEq/L
K+: 5.5 (Range 3.5-5.0) mEq/L
Urea 10.0 mmol/L
Creatinine: 140 (range up to 120) µmol/L

Pulse: 80/min, irregular
Blood pressure: 170/80 mmHg
Cardiovascular system: Pansystolic murmur at apex
Low-pitched diastolic murmur at apex
Apex beat slightly lateral to mid-axillary line
Respiratory system: Bilateral fine basal crepitations
Respiratory rate: 16/min
ECG: atrial fibrillation, severe left ventricular hypertrophy (LVH), heart rate <100 bpm, some ischaemic changes
Chest X-ray findings: Lower part of trachea deviated to right
Large heart shadow appearing to be LVH and left atrial hypertrophy
Basal lung fields - coarse shadows with prominent vasculature towards apices
Calcified aortic knuckle

1. What do you think is going on here?
2. What is the significance of the pansystolic murmur at the apex?
3. What is the cause of the diastolic murmur at the apex?
4. Is the patient adequately anticoagulated?
5. Why might she have had a painful limb and hospitalisation previously?
6. What are the causes of valvular lesions in the heart?
7. What are the signs of heart failure?
8. Do you think she is in renal failure?
9. Which other investigations would you carry out?
10. Now that her INR is only 1.6, which is just ideal for surgery, would you take her up for elective surgery before you try to ‘adequately’ anticoagulate her? (mind the trap!)
11. Assuming she is pre-optimised, what is your plan for a general anaesthetic?
12. What would you do about giving her warfarin in the perioperative period?
13. In regard to a general anaesthetic: laryngeal mask airway LMA vs endotracheal tube intubation?
14. Which monitors would you use perioperatively?
15. What complications would you look for postoperatively?

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