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Final clinical long case 61

Created: 28/7/2017
A 75-year-old man undergoing a work-up for a lobectomy presents with sudden onset of neck pain. He has a history of hypertension, a small hiatus hernia. On examination he is found to have an ejection systolic murmur at the left sternal edge and rhonchi at the right base.

Echocardiogram: Showed moderate aortic stenosis with a peak gradient of 39 mmHg,
LV function/size: Both normal
ECG: RSR pattern in V1 and V2, normal QRS duration, normal PR interval
Pulmonary function tests: Mild reduction in PEFR, normal forced expiratory volume in 1 second/forced vital capacity (FEV1/FVC)
Arterial blood gases: pH 7.45; pCO2 4.3 kPa; pO2 9.5 kPa; H2CO3 24 mmol/L
X-ray of C-spine: C1 displaced over C2, partial loss of C2 and anteverted odontoid peg, lucency in the body of C2, degenerative changes elsewhere.

1. Summarise the case.
2. What are the differential diagnoses for neck pain? Describe the neurological examination you would perform.
3. Is the aortic stenosis significant?
4. What additional information is required?
5. What are the complications associated with lung cancer?
6. Discuss the pre-optimisation of this patient.
7. How would you anaesthetise him for posterior fusion of the spine?
8. Describe the technique for awake fibreoptic intubation.
9. Would you extubate him or transfer him ventilated to the intensive care unit?
10. Discuss the management of postoperative respiratory failure in recovery.

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