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Final clinical long case 40

Created: 27/2/2012
A 76-year-old lady with fungating breast tumour presents for mastectomy and total axillary node clearance. She smokes 20 cigarettes per day and has severe chronic obstructive pulmonary disease (COPD), and she sleeps sitting upright. She has signs of right heart failure (enlarged liver and ankle oedema). She had an aortic valve replacement 10 years ago. She is on warfarin, salbutamol, ipratropium, co-amilofruse and tamoxifen.

Examination/blood results
ECG: prolonged PR interval
FEV1: 0.94 L
PaO2 9.2 mmHg
PaCO2: 5.3 mmHg
Bicarbonate: 27 mmol/L
Base excess: 2.4
Elevated urea and creatinine
pH: 7.45
INR: 1.7
White blood cell count: 13 x 109/mm3

1) Discuss optimisation.
2) Discuss your anaesthetic management.
3) What analgesia would you give?
4) Discuss the arterial blood gas and pulmonary function test results.
5) Discuss the patient’s ECG. [showed first-degree heart block]
6) Discuss the patient’s current drug regimen
7) How would you monitor the patient during surgery?
8) Discuss postoperative weaning.

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