Clinical viva 1
A 68 year old gentleman presents for elective abdominal aortic aneurysm surgery.
- Hypertensive for the past 10 years.
- History of angina - past 2 years.
Had chest pain 2 months ago. No evidence of myocardial infarction on investigation.
- BP - 160/90 mmHg
- Jugular venous pressure not raised
- Rales on auscultation, both bases
- Liver just palpable below the right costal margin
- White cell count = 12,000/ml
- Creatinine - 170 micromol/L
- Potassium - 3.2 mmol/L
- ECG - T wave inversion v3 - v6, avF
- X-Ray chest - mild cardiomegaly
- Summarise the case.
- Do you think his blood pressure is adequately controlled?
- What is enalapril/how does it act/what are its side-effects?
- What do you think his chest pain was due to (give a differential diagnosis)?
- What are the implications if the chest pain had been due to myocardial infarction?
- What do you think about his potassium level/why is it low/do you think it is acute/will you correct it before surgery/how will you correct it/what happens if you do not correct it?
- Will you be happy to go ahead with the anaesthetic?
- What further investigations will you do/why?
- How will an echocardiogram help?
- Do you think he is in heart failure/does he have a chest infection?
- Differential diagnosis for hepatomegaly
- What do you find in his ECG?
- Did you determine the axis of the heart?
- Is there any evidence of MI in the past?
- What are the findings on the chest X-ray/how do you say the film is PA view/how did you determine that there is cardiomegaly/how do you measure CT ratio?
- What will be your anaesthetic management
- Why did you choose to do an epidural
- Will you be concerned about something (heparin) that you will be giving intraoperatively?
- What are the benefits (of the epidural)?
- What will you give in your epidural?
- What monitoring will you undertake and why?