Difficult access in the anaesthetic room leads to a difficult diagnosis

A 50 year old man was admitted for laser ablation of the left long saphenous vein to treat his symptomatic varicose veins. In the anaesthetic room he was noted to have unusually tough skin and rather large hands during cannulation. This was confirmed when the operating surgeon attempted to cannulate the long saphenous vein to perform the endovenous laser ablation—the thickness of his skin made this difficult. He also had bigeminy on heart monitoring and a prominent jaw.

In clinic he said that he had always had large hands and put this down to being “muscly,” having worked in a garage all his life. He had surgery for carpal tunnel decompression in 2005, and he had longstanding muscle aches. His visual fields were normal, his shoe size was 9, and he snored excessively at night.