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Final clinical long case 36

Created: 25/5/2011
A 16-year-old girl is on your list for cervical lymph node biopsy. She has a history of increasing neck swelling over past few weeks, exertional dyspnoea and coughing when lying flat, with difficulty breathing.

Full blood count: normal, but white cell count is 3.0
Clotting: normal
Chest X-ray: large mediastinal mass, trachea difficult to visualise
Computed tomography of the chest: mediastinal mass with extrinsic tracheal compression

1. Summarise the case.
2. What are your concerns?
3. What are the differential diagnoses for the swelling?
4. What further investigations would you carry out?
5. How would you anaesthetise the patient?
6. Following gas induction, you are unable to ventilate her - what would you do next?
7. Postoperatively, in the intensive care unit, how would you reduce the tumour size?
8. Following chemotherapy, her potassium level rises – differential diagnoses?
9. Discuss the management of tumour lysis syndrome and hyperkalaemia.
10. What are the options for extubation?

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