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Final clinical long case 33

Created: 11/2/2011
An 80-year-old female presents for elective laparoscopic fundoplication for a hiatus hernia. She has a 3-day history of vomiting, dehydration, electrolyte imbalance (low potassium and low magnesium) and epigastric discomfort. She has recent-onset atrial fibrillation following an upper respiratory tract infection, and is currently digitalised.

Past medical history


Chest X-ray: Fluid level (hiatus hernia) + collapse
ECG: Sinus 95; left ventricular strain; widespread T inversion
Urea & electrolytes as above; normocytic anaemia; raised white cell count and C-reactive protein

1. What is the differential diagnosis of epigastric discomfort?
2. What does the ECG indicate?
- Describe the signs, symptoms and management of digoxin toxicity.
- What is the mechanism of action of digoxin?
- What are the American Heart Association cardiac risk factors?
3. What are the different types of hiatus hernia?
4. What is the differential diagnosis for anaemia?
- What are the transfusion guidelines of the Association of Anaesthetists of Great Britain and Ireland (AAGBI)?
5. Discuss the assessment and management of dehydration and electrolytes.
6. Describe the cardiovascular effects of laparoscopy.
7. Describe a plan for induction and monitoring.
8. Discuss the management of hypotension at induction.
9. Discuss the management of postoperative bradycardia, and hypoxia in recovery.

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