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Final clinical long case 31

Created: 11/3/2010
A 75-year-old man presents for cervical laminectomy for spinal stenosis. The patient has hypertension, had a cerebrovascular accident 6 years ago, has Parkinson's disease and chronic obstructive pulmonary disease (COPD) (he is an ex-smoker and has received multiple courses of antibiotics and steroids in the past). He has experienced a recent gait deterioration.

Nifedipine, fluticasone propionate
He has no known drug allergies.

Pulse 75 bpm
Blood pressure 108/50 mmHg
Auscultation: widespread wheeze and prolonged expiratory phase.
Bloods results: normal, apart from white blood cell count 12 × 109/L, with raised eosinophils
Arterial blood gases (on air): pH 7.46; pCO2 4.4 kPA; pO2 8.2 kPA; bicarbonate 23 mmol/L; base excess 0
Pulmonary function tests: peak expiratory flow rate and forced vital capacity (FVC) low, but within normal range; forced expiratory volume in one second (FEV1) 1.8 L; FEV1/FVC 43%
Chest X-ray: shows hyperextended lungs
ECG: sinus rhythm, left axis deviation.
Borderline first-degree heart block.

1. Summarise the case.
2. What are the causes of a raised eosinophil count, and what is the likely cause in his case?
3. What other tests would you perform?
4. How would you optimise his COPD treatment preoperatively?
5. Where should he be taken postoperatively?
6. How would you decide whether to extubate him or keep him ventilated?
- Why might he not breathe well at the end?
7. Discuss your assessment of the airway, induction and monitoring.
- Would you insert a central venous pressure line?
- Discuss positioning, securing tube, lines, eyes, pressure points, Montreal mattress etc.
8. Discuss spinal cord monitoring.

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