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Final clinical long case 1

Created: 8/4/2004

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.


  • enalapril
  • frusemide
  • isosorbide

Had chest pain 2 months ago. No evidence of myocardial infarction on investigation.

On examination

  • BP - 160/90 mmHg
  • Jugular venous pressure not raised
  • Rales on auscultation, both bases
  • Liver just palpable below the right costal margin


Positive findings

  • 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?

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