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Final clinical long case 60

Created: 27/5/2016
A 70-year-old man is scheduled for posterior cervical decompression. The MRI shows compression over C3-5. He has had sensory and motor weakness in all limbs, which has deteriorated over the previous 12 months. He had two myocardial infarctions (MIs) three years ago and had a stent fitted shortly afterwards. He also has rheumatoid arthritis.

Amlodipine, atenolol, azathiprine, prednisolone, statin, co-codamol, aspirin

Haemoglobin: 9.1 g/dL
Platelets: 120 × 109/L
Na+: 131 mEq/L
K+: 4.8 mEq/L
Urea: 9.8 mmol/L
Creatinine: 124 µmol/L
ECG: sinus rhythm, rate 75 bpm, Q waves in leads I, avL, V4-6, and T wave inversion in lateral the leads.

1. Summarise the case.
2. Discuss the blood results.
3. What are the causes of anaemia?
4. What are the causes of renal impairment?
5. Discuss the chest X-ray and the ECG. Where in heart did the MIs take place?
6. What further investigations would you carry out?
7. What might an echo show?
8. How would you anaesthetise the patient?
9. What intraoperative concerns might you have?
10. Discuss his postoperative care.
11. His ECG shows supraventricular tachycardia. How would you treat this? What would you do if he becomes unstable? What drugs would you use? How do they work?

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