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Final clinical long case 35

Created: 5/5/2011
A 90-year-old presents for elective open cholecystectomy. She has had recurrent bouts of abdominal pain over the past year. In her history, she says she has atrial fibrillation, a “bad chest” and arthritis.

Blood results
K+: low normal
Bilirubin: slightly raised
Alkaline phosphatase and alanine aminotransferase: normal
No clotting results supplied

Lung function tests: forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC) decreased (~ 60% predicted); FEV1:FVC ratio 120%
ECG: atrial fibrillation with left bundle branch block
Chest X-ray: obscured left diaphragm and visibly hyperinflated. Otherwise, nothing abnormal discovered.

1. How would you anaesthetise her and why?
2. How would you assess her airway?
3. What test do you know for assessing the airway?
4. How good are these tests?
5. What other tests would you want to perform?
6. What do the lung function tests show?
7. What does the chest X-ray show?
8. What does the ECG show?
9. What monitoring would you use?
10. How would you monitor her fluid status intra-operatively?

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