Write a case presentation on a patient name Mr Vishal Sharma hailing from Dibrugarh age 65 yrs Old male Diagnose with inguinal hernia being planned for Herniorephy,write case presentation for Anesthesiology MD exam

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CASE PRESENTATION FOR ANESTHESIOLOGY MD EXAMINATION

PATIENT PROFILE

Parameter	Details
Name	Mr. Vishal Sharma
Age	65 years
Sex	Male
Address	Dibrugarh, Assam
Occupation	Retired (ex-tea garden worker)
Religion	Hindu
Admission Date	[Date]
Informant	Patient himself (reliable)

PRESENTING COMPLAINT

Mr. Vishal Sharma presented with a swelling in the right groin for the past 8 months, associated with a dragging discomfort that worsens on standing, straining, and lifting heavy objects. The swelling reduces spontaneously on lying down.

HISTORY OF PRESENTING ILLNESS

Mr. Sharma is a 65-year-old retired male from Dibrugarh who noticed a progressively enlarging swelling in his right groin 8 months ago. The swelling initially appeared on straining and coughing, reducing on its own in the recumbent position. Over the months, it has increased in size and now requires manual reduction. He denies any features of irreducibility, intestinal obstruction (no nausea, vomiting, or absolute constipation), or skin changes over the swelling. There is no previous history of hernia or hernia surgery on the opposite side.

PAST HISTORY

Hypertension - Known hypertensive for 10 years; on Tab. Amlodipine 5 mg OD + Tab. Atenolol 50 mg OD; well controlled (BP on admission: 136/84 mmHg)
Type 2 Diabetes Mellitus - Diagnosed 7 years ago; on Tab. Metformin 500 mg BD + Tab. Glipizide 5 mg OD; HbA1c 7.4%
No history of ischemic heart disease, cerebrovascular accident, COPD, asthma, renal or hepatic disease
No prior surgical history or previous anesthesia exposure
No known drug allergies

PERSONAL HISTORY

Diet: Mixed (non-vegetarian)
Appetite: Adequate
Sleep: Adequate
Bowel/Bladder: Regular; mild nocturia x2 (suggestive of benign prostatic hyperplasia - to be evaluated)
Tobacco: Ex-smoker; smoked bidis for ~35 years, quit 5 years ago
Alcohol: Occasional social drinker; quit 3 years ago
Exercise tolerance: Can walk on flat ground without dyspnea; climbs one flight of stairs before mild breathlessness - NYHA Class I-II
Dental: Partial dentures (upper arch) - noted for airway management

FAMILY HISTORY

Non-contributory. No family history of ischemic heart disease, malignancy, or anesthesia-related complications (no family history of malignant hyperthermia or pseudocholinesterase deficiency).

SYSTEMIC REVIEW

CVS: No chest pain, palpitations, or ankle edema
Respiratory: Occasional productive cough in the mornings (chronic bronchitis pattern); no wheeze, hemoptysis, or orthopnea
GIT: No dysphagia, heartburn, or hematemesis
CNS: No seizures, syncope, or focal neurological deficits
Urological: Nocturia x2; mild hesitancy and weak stream (BPH to be ruled out)
Endocrine: Polyuria/polydipsia controlled; no features of hypoglycemia

GENERAL PHYSICAL EXAMINATION

Conscious, cooperative, and oriented to time, place, and person
Build: Moderately built; mild kyphosis (age-related)
Nutrition: Adequate
Height: 165 cm; Weight: 68 kg; BMI: 24.9 kg/m² (normal)
Pallor: Absent
Icterus: Absent
Cyanosis: Absent
Clubbing: Absent
Lymphadenopathy: Absent
Edema: Absent
Pulse: 76 beats/min, regular, good volume, all peripheral pulses palpable
Blood Pressure: 136/84 mmHg (Right arm, sitting)
Respiratory Rate: 16/min
SpO2: 98% on room air
Temperature: Afebrile

ANESTHESIA-SPECIFIC ASSESSMENT

1. Airway Assessment (LEMON / Wilson Score)

Parameter	Finding
Mouth opening	3 finger breadths (adequate; >3 cm)
Mallampati Class	Class II (soft palate, fauces, and uvula visible)
Thyromental distance	7 cm (adequate; >6 cm)
Sternomental distance	14 cm (adequate; >12.5 cm)
Neck movements	Slightly reduced extension (age-related cervical spondylosis)
Dentition	Partial upper denture; remaining teeth firm
Jaw protrusion	Adequate
Neck circumference	38 cm (normal)

Airway Assessment Conclusion: Anticipated NORMAL airway. No features of difficult intubation. Dentures to be removed prior to induction. (Predicted Grade I-II laryngoscopy by Cormack-Lehane classification)

2. Cardiovascular Assessment

Heart sounds: S1 and S2 heard; no murmurs or added sounds
JVP: Not elevated
ECG: Normal sinus rhythm; no ST-T changes; mild LVH pattern (voltage criteria); no Q waves
ECHO (if indicated): Not done; functional status suggests adequate cardiac reserve
2D Echo: Left ventricular ejection fraction (LVEF) >55% (if done)
Lee's Revised Cardiac Risk Index (RCRI): Score = 1 (diabetes on insulin - N/A here; Cr >177 - N/A; IHD - absent; CHF - absent; CVA/TIA - absent; high-risk surgery - absent) = RCRI Score: 0-1 → Low cardiac risk (<1%)

3. Respiratory Assessment

Chest expansion: Bilaterally equal; slightly reduced
Percussion: Resonant bilaterally
Auscultation: Vesicular breath sounds; occasional scattered rhonchi in bilateral lung bases (likely post-smoking chronic changes)
Pulmonary Function Tests (PFTs): Advised; expected mild obstructive/mixed pattern (ex-smoker)
CXR: Mildly increased bronchovascular markings; no consolidation, pleural effusion, or cardiomegaly

4. Abdominal Examination (Surgical Finding)

Inspection: 5 x 4 cm swelling in right inguinal region, extending toward scrotum; visible on coughing/standing
Palpation: Swelling is soft, non-tender, and reducible; cough impulse positive; deep ring occlusion test: swelling controlled on deep ring occlusion (indirect inguinal hernia)
Percussion: Tympanitic over swelling (bowel content present)
Auscultation: Bowel sounds heard over swelling
Transillumination test: Negative (distinguishes from hydrocele)

Surgical Diagnosis: Right indirect inguinal hernia, reducible - planned for Open Lichtenstein Hernioplasty (Herniorrhaphy)

INVESTIGATIONS

Hematological

Test	Value	Normal Range
Hemoglobin	13.2 g/dL	13-17 g/dL
TLC	8,400/mm³	4,000-11,000/mm³
Platelet count	2.1 lakhs/mm³	1.5-4.5 lakhs/mm³
PT/INR	1.1	<1.3
aPTT	32 sec	28-38 sec
Bleeding time	2 min 30 sec	2-5 min
Clotting time	4 min	3-7 min

Biochemical

Test	Value	Normal Range
Blood glucose (fasting)	118 mg/dL	70-100 mg/dL
Blood glucose (PP)	164 mg/dL	<140 mg/dL
HbA1c	7.4%	<7.0% (diabetic target)
Urea	28 mg/dL	15-45 mg/dL
Creatinine	1.0 mg/dL	0.7-1.2 mg/dL
Na⁺	138 mEq/L	135-145 mEq/L
K⁺	4.1 mEq/L	3.5-5.0 mEq/L
Total bilirubin	0.8 mg/dL	0.2-1.2 mg/dL
AST/ALT	32/28 U/L	<40 U/L
Serum albumin	3.9 g/dL	3.5-5.0 g/dL
S. cholesterol	196 mg/dL	<200 mg/dL

Special Investigations

Test	Finding
ECG	Normal sinus rhythm; LVH by voltage criteria
Chest X-ray	Mildly increased bronchovascular markings; no active disease
Urine R/E	No albumin/glucose/casts
Blood group	B positive

ASA PHYSICAL STATUS CLASSIFICATION

ASA Grade: II A patient with mild systemic disease (controlled hypertension, controlled type 2 DM) without functional limitation and no risk of substantive morbidity from systemic disease. (Miller's Anesthesia, 10e - ASA-PS classification system)

ANESTHETIC ASSESSMENT AND PLAN

Pre-anesthetic Considerations

1. Elderly Patient (65 years):

Reduced physiological reserve across all organ systems
Reduced MAC (minimum alveolar concentration) for volatile agents by ~6% per decade after age 40
Reduced hepatic blood flow and renal clearance - prolonged drug action
Reduced protein binding - increased free drug fractions
Sensitive to opioids and sedatives - prone to postoperative cognitive dysfunction (POCD)
Increased risk of hypothermia
Reduced response to hypoxia and hypercapnia

2. Comorbidities:

Hypertension: Amlodipine and beta-blocker to be continued till morning of surgery with a sip of water. Anticipate hemodynamic lability at laryngoscopy/intubation. Avoid abrupt beta-blocker withdrawal.
Type 2 DM: Metformin to be withheld 48 hours pre-op (risk of lactic acidosis if contrast given; standard pre-op protocol). Glipizide withheld on the day of surgery. Target intraoperative blood glucose: 140-180 mg/dL. Monitor glucose 2-hourly.
Ex-smoker / Chronic bronchitis: Pre-op chest physiotherapy, incentive spirometry. Short-acting beta-2 agonist (salbutamol) nebulization pre-op if bronchospasm anticipated.
Partial dentures: To be removed before induction.
Possible BPH: Urological evaluation advised pre-op; regional anesthesia may be complicated by post-spinal urinary retention - catheterization may be planned post-op.

CHOICE OF ANESTHESIA

Preferred technique: Subarachnoid Block (SAB) / Spinal Anesthesia

Justification:

Inguinal herniorrhaphy is a lower abdominal procedure well within the dermatome distribution of spinal block (T10 level required)
Avoids risks of general anesthesia in an elderly patient with respiratory compromise (ex-smoker)
Maintains spontaneous respiration - particularly advantageous in chronic bronchitis
Reduced incidence of postoperative nausea and vomiting (PONV)
Excellent muscle relaxation for the surgical field
Lower DVT and pulmonary embolism risk compared to GA
Early ambulation possible post-operatively
Better postoperative pain control
Avoids risk of aspiration in a patient with possible delayed gastric emptying (diabetic gastroparesis risk)
Reduced intraoperative blood loss
Cost-effective; suitable for day-care or short stay surgery

(Bailey & Love's Surgery 28e - Spinal anaesthesia: "used extensively for lower limb, obstetric and pelvic surgery... Injection of a 'single-shot' local anaesthetic agent intrathecally produces intense and rapid block for surgery")

Alternative Technique: Local Anesthesia with IV Sedation (LA+Sedation)

For high-risk patients; can be used if contraindication to spinal exists
Ilioinguinal + Iliohypogastric nerve block + field infiltration

Technique avoided (unless necessary):

General Anesthesia - reserved if spinal fails or patient refuses

Spinal Anesthesia - Detailed Plan

Pre-operative preparation:

NBM (Nil by mouth) status: Solids for 6-8 hours; clear fluids for 2 hours pre-op (ASA fasting guidelines)
IV access: 18G IV cannula in right forearm
Pre-hydration: Ringer's Lactate 500 mL IV over 20-30 min (co-load) before or with spinal injection to prevent hypotension
Premedication: Tab. Ranitidine 150 mg PO the night before and morning of surgery (aspiration prophylaxis)
Tab. Midazolam 7.5 mg PO 1 hour before surgery (anxiolysis, with caution in elderly - reduce dose)

Monitoring (standard ASA monitoring):

Pulse oximetry (SpO2)
Non-invasive blood pressure (NIBP) every 3-5 min
5-lead ECG
End-tidal CO2 if sedation/GA used
Temperature monitoring
Urine output via Foley catheter

Patient position for block: Sitting or left lateral decubitus

Spinal technique:

Position: Sitting (preferred for obese/elderly for better midline identification) or lateral decubitus
Level of puncture: L3-L4 or L4-L5 interspace (below termination of spinal cord at L1-L2)
Needle: 25G or 26G Quincke or Whitacre pencil-point needle
Drug and dose: Hyperbaric Bupivacaine 0.5% - 2.5 to 3.0 mL (12.5 - 15 mg) + Fentanyl 25 mcg (for prolonged analgesia)
Level required: T10 dermatome (umbilicus) for inguinal hernia repair
Avoid excessive cephalad spread (risk of hypotension, respiratory compromise)

Management of spinal hypotension:

IV fluids (RL/NS bolus)
Vasopressors: Inj. Ephedrine 5-10 mg IV bolus (preferred; has both alpha and beta activity; maintains cardiac output); or Inj. Phenylephrine 50-100 mcg IV bolus as alternative
Head-down tilt (modified Trendelenburg) - use cautiously in elderly

Postoperative analgesia (multimodal):

Tab. Paracetamol 1g PO / IV TDS
Tab. Diclofenac 50 mg PO BD (if renal function adequate - with food; avoid in elderly with renal impairment; consider COX-2 selective)
Wound infiltration with Bupivacaine 0.25% by surgeon (ilioinguinal nerve block)
Avoid strong opioids if possible; if required, reduce dose by 30-50% in elderly

ANESTHETIC RISK ASSESSMENT

Risk Parameter	Classification
ASA Physical Status	Grade II
Goldman Cardiac Risk Index	Class I (minimal risk)
Lee's RCRI	Score 0-1 (very low cardiac risk)
Mallampati Class	II (easy airway)
Anticipated blood loss	Minimal (<100 mL)
Procedure risk	Low-intermediate (elective, lower abdominal)
Overall anesthetic risk	LOW to INTERMEDIATE

SPECIAL CONSIDERATIONS

Geriatric Anesthesia Concerns:

Pharmacokinetics: Reduced hepatic and renal clearance prolongs drug half-lives. Reduce all drug doses by 20-30%.
POCD (Postoperative Cognitive Dysfunction): Risk is higher in elderly; prefer regional anesthesia to minimize. Avoid anticholinergics (atropine, scopolamine) - cause delirium.
Hypothermia: High risk in elderly; use warming blanket, warm IV fluids, warm OR.
DVT prophylaxis: Early ambulation; graduated compression stockings; consider LMWH in high-risk patients.
Fluid management: Avoid fluid overload (risk of pulmonary edema with diastolic dysfunction); CVP monitoring not routinely required for this procedure.
Pain management: Undertreated pain is as harmful as opioid overuse - use multimodal analgesia.

Diabetic Perioperative Protocol:

Perioperative glucose monitoring every 2 hours
Target glucose: 140-180 mg/dL (avoid both hypoglycemia and hyperglycemia)
Insulin sliding scale if glucose >180 mg/dL
Metformin withheld 48 hours pre-op; restart 48 hours post-op when oral feeding resumes

Antihypertensive Management:

Continue beta-blocker (Atenolol) perioperatively - abrupt withdrawal risks rebound hypertension and tachycardia
Continue Amlodipine on the morning of surgery with a sip of water
Be prepared for hemodynamic fluctuations during spinal placement

CONSENT

Informed written consent obtained from the patient after explaining the nature of the procedure, choice of anesthesia (spinal), risks and benefits, alternatives, and the possibility of conversion to general anesthesia.
Patient is mentally competent to provide consent.

SUMMARY

Mr. Vishal Sharma is a 65-year-old male from Dibrugarh, Assam, with a right indirect inguinal hernia planned for open Lichtenstein herniorrhaphy under subarachnoid block (spinal anesthesia). He is an ASA Grade II patient with controlled hypertension and type 2 DM, no evidence of significant cardiac or respiratory compromise, a normal predicted airway (Mallampati Class II), and adequate functional capacity. Peri-operative optimization includes continuation of antihypertensives, withholding oral hypoglycemics appropriately, pre-op chest physiotherapy (ex-smoker), glycemic monitoring, and multimodal post-operative analgesia. The overall anesthetic risk is LOW for this elective procedure.

POST-OPERATIVE INSTRUCTIONS (RECOVERY ROOM)

Monitor SpO2, NIBP, ECG continuously until fully awake and stable
Assess return of motor and sensory block - wait for return of straight leg raise before transfer to ward
Monitor for urinary retention (particularly relevant given possible BPH)
IV fluids until oral intake established
VAS (Visual Analog Scale) pain score monitoring; analgesia as per multimodal plan
Blood glucose monitoring at 2-hourly intervals
Early ambulation encouraged (within 8-12 hours post-op)
DVT prophylaxis - compression stockings
Discharge criteria (if day-care): stable vitals, oral intake, voided urine, pain controlled on oral analgesics, escort available

References: Miller's Anesthesia 10th Edition (ASA-PS Classification, Preoperative Risk Assessment); Bailey & Love's Short Practice of Surgery 28th Edition (Spinal Anaesthesia, Types of Anaesthesia); Barash, Cullen and Stoelting's Clinical Anesthesia 9th Edition; Morgan & Mikhail's Clinical Anesthesiology

This case presentation covers all domains typically examined in an Anesthesiology MD viva/written exam:

History taking (presenting complaint, comorbidities, personal/family history)
Pre-anesthetic assessment (airway, cardiac, respiratory, metabolic)
Investigation interpretation
ASA classification with justification
Choice of anesthesia with reasoning (spinal over GA)
Detailed technique (drug, dose, level, needle, position)
Complication management (hypotension, POCD, hypothermia)
Special population concerns (geriatric, diabetic, hypertensive, ex-smoker)
Perioperative drug management (antihypertensives, antidiabetics)
Post-operative analgesia (multimodal approach)

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