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Final clinical long case 45

Created: 6/2/2013
A 55-year-old overweight West Indian woman presents for near total thyroidectomy. You are told that she is sickle cell trait positive, hypertensive, and taking enalapril and bendrofluazide; atenolol gives her chest tightness.

Height: 160 cm
Weight: 80 kg
Chest X-ray: shows a large right paratracheal mass with tracheal compression and deviation.
ECG: flat T waves and poor R wave progression.
Full blood count: microcytosis (haemoglobin 13.7g/L)
Thyroid stimulating hormone: lower limit of normal
fT4 and fT3: both within normal limits.
There are no details in the history of thyroid symptoms. You are told that she has a short neck with a large mass, which makes examination difficult.

1. Summarise the case.
2. Discuss the ECG and chest X-ray and blood results.
3. What further investigations would you carry out, and why?
4. What is her BMI?
- Define obesity
- What problems are associated with obesity?
5. How would you anaesthetise her?
- Discuss positioning, intravenous access, monitoring and general intraoperative care in this case.
6. How would you induce/intubate her?
7. How would you extubate?
- Discuss deep and awake extubation, and the merits of each.
8. What are the causes of stridor postoperatively?
- How would you diagnose and manage haematoma, oedema, tracheomalacia, nerve palsies, signs of hypocalcaemia, Chvostek's and Trousseau's signs, treatment of hypocalcaemia?
- How many mmol are in 10 ml calcium chloride?
9. What would be your plan for postoperative analgesia?

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