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Final clinical long case 29

Created: 8/5/2009
A 39-year-old man presents for full dental extraction. He is on lithium for manic depressive psychosis. He is a heavy smoker with wheeze. He is on diuretics for hypertension, and has been investigated for polyuria over the past 2 months.

He has resting tremors, ankle oedema and expiratory wheeze. His BMI is 34-35.

Other medications
Flupenthixol, amitriptyline.

X-ray: right atrial hypertrophy and cardiomegaly
ECG: right ventricular hypertrophy
Lithium level: 1.0 mmol/L (upper limit of normal)
Renal function: elevated urea and creatinine

1. Summarise the case.
2. What is the ASA grade?
3. What is the effect of obesity on anaesthesia?
4. Describe the pathophysiology of sleep apnoea syndrome.
5. What are the effects of smoking on the human body?
5. Discuss the X-ray and ECG findings.
6. What further investigations would you request?
7. What are the causes of renal impairment in this patient?
8. Describe the effects of lithium.
9. Would you anaesthetise this man? If not, why?
10. How would you optimise him?
11. What is your anaesthetic of choice?
12. Describe the relative merits of laryngeal mask airway (LMA) versus endotracheal tube. Why would you not use LMA in this case?
13. Describe postoperative pain relief in this patient. Would you avoid any agents? Why?
14. Would you stop lithium?
15. Would you stop him from smoking? Why?

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