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I know it's oral board season so I thought I'd post this case for everyone to discuss that was very similar to some of the oral board scenarios I saw when studying. I don't remember all the lab values exactly so I'm only going to list the important ones. I'd hope that some of the more senior attending could wait a bit to chime in so that residents others still studying for the orals have a chance to voice their opinions first.
72 y/o male here for a lap chole
PMH - s/p MIx2, DM, ESLD, cirrhotic liver. Hx of esophageal varies s/p banding, ascities, s/p AICD (pacer/shocker)
PE - External airway anatomy grossly normal, fumanchu mustache, MP3, good c-spine ROM, good TM dist. Pt states he is not very ambulatory, gets SOB < 4 mets, denies chest pain or SOB @ rest. Pts belly looks like he's 9 months pregnant, no LE edema noted. Pt denies hemotemesis since variceal banding
VS - 160/90, HR 70s, Sat 94% on RA
Labs - Chemistry mostly unremarkable, K+ 3.5, H/H 12/36, Plt - 47 but has just been transfused a unit on the floor. INR 1.27. Old stress test from 2007 states EF 25-30% no myocardium at risk, cardiology note confirms this. No echo on file but cards note states that he doesn't have any significant valvular disease. EKG - paced rythem. CXR unremarkable
Lines - 20g in R hand
Are you going to place an A-line? why/why not? If you plan on placing an a-line should you do it pre or post induction? What type of IV access do we need? Should we place a central line?
Do we need to worry about the AICD? Should we call cards to reprogram it?
How will you induce this patient? What are your concerns? How does his ESLD affect your choice of drugs? Nimbex is not stocked in your hospital, what is your choice of muscle relaxant?
Are there any special intraop concerns for this patient outside of the ordinary? How do you plan on manageing them?
Are there any drugs to avoid post op? How will you manage his pain?
72 y/o male here for a lap chole
PMH - s/p MIx2, DM, ESLD, cirrhotic liver. Hx of esophageal varies s/p banding, ascities, s/p AICD (pacer/shocker)
PE - External airway anatomy grossly normal, fumanchu mustache, MP3, good c-spine ROM, good TM dist. Pt states he is not very ambulatory, gets SOB < 4 mets, denies chest pain or SOB @ rest. Pts belly looks like he's 9 months pregnant, no LE edema noted. Pt denies hemotemesis since variceal banding
VS - 160/90, HR 70s, Sat 94% on RA
Labs - Chemistry mostly unremarkable, K+ 3.5, H/H 12/36, Plt - 47 but has just been transfused a unit on the floor. INR 1.27. Old stress test from 2007 states EF 25-30% no myocardium at risk, cardiology note confirms this. No echo on file but cards note states that he doesn't have any significant valvular disease. EKG - paced rythem. CXR unremarkable
Lines - 20g in R hand
Are you going to place an A-line? why/why not? If you plan on placing an a-line should you do it pre or post induction? What type of IV access do we need? Should we place a central line?
Do we need to worry about the AICD? Should we call cards to reprogram it?
How will you induce this patient? What are your concerns? How does his ESLD affect your choice of drugs? Nimbex is not stocked in your hospital, what is your choice of muscle relaxant?
Are there any special intraop concerns for this patient outside of the ordinary? How do you plan on manageing them?
Are there any drugs to avoid post op? How will you manage his pain?