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Final clinical long case 23

Created: 26/10/2007
A 70-year-old male presents 4 days postoperatively, following elective abdominal aortic aneurysm repair, now in the intensive care unit with respiratory distress.

Past history
Ischaemic heart disease
Osteoarthritis, with limited exercise tolerance
Peripheral vascular disease

Glyceryl trinitrate prn

ECG: two ECGs presented; the first showed normal sinus rhythm, the second showed fast atrial fibrillation.
Chest X-ray: diffuse haziness, increased at right base.

Blood results
Urea: 14 mmol/L
Creatinine: 170 µmol/L
Arterial blood gases:
PaO2 11 kPa
PaCO2 6.5 kPa
Bicarbonate: normal

1. Why is this patient in respiratory distress?
2. What are the causes of raised hemidiaphragm?
3. What is your interpretation of the arterial blood gas results?
4. Discuss the ECG results, comparing the two ECGs.
5. What are the causes of atrial fibrillation?
6. How would you manage atrial fibrillation:
a) if blood pressure is stable?
b) if blood pressure is unstable?
7. How would you manage his respiratory distress?
8. What are the causes of renal dysfunction?
9. Discuss your perioperative management of the patient if he was on your list.
10. Would he benefit from preoptimisation?

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