2009, Hot Cases 1

Princess Alexandra Hospital
  • A 65 year old man admitted with sepsis and multi-organ dysfunction 3 weeks previously.. Diagnosis of staph bacteremia and C5-6 discitis requiring surgery and is now in the recovery phase. Re-intubated within a few hours of extubation yesterday. Please assess and make a plan for the next week.
    Issues:
    • Awake patient with clear weakness in upper limb, proximal more than distal.
    • Long tract UMN signs
    • Fluclox rash
    • Raised a-a gradient
    • PICC line
    • Long term management issues regarding tracheostomy
  • Areas of weakness identified by examiners:
    • Performing a superficial PNS examination and failing to recognise that neurological exam was a core part of formulating a management plan.
    • Several candidates failed to identify UMN signs in the lower limbs including clonus, upgoing plantars and pathologically brisk reflexes. Several candidates, despite demonstrating brisk reflexes suggested CIPN as a diagnosis.
    • Several candidates missed a drug rash
    • Candidates were not able to come out and clearly say that patient needs a tracheostomy,
    • When shown a CXR with bilateral infiltrates, inability to comment on the possibility of aspiration or sputum retention as possible cause of readmission
  • 65 year old man, Day 26 in ICU, admitted with respiratory failure secondary to probable right
    lower lobe pneumonia (nil +ve micro / non infectious causes found) and acute on chronic renal
    failure. Background IHD with stents x 2; HT; left ICA stent

    °  Slow wean
    °  Comment on ongoing respiratory pathology
    °  Management of clopidogrel therapy

    Areas of weakness identified by examiners:  

    °  No coherent approach to a failure to wean case
    °  Poor approach to management of sepsis
    °  Candidates  did not have a rational approach to continuing clopidogrel therapy
  • 29 year old, Day 61 in ICU, presented following MVA with C6/7 fracture dislocation and compound fracture left 2nd metacarpal (ORIF)
    • Issues of quadriplegia
    • Slow respiratory wean
    • Left lower lobe collapse
  • Areas of weakness identified by examiners:
    • Poor neurological examination
    • Failure to outline complications of quadrilegia
    • No coherent approach to a failure to wean case
  • Gd V SAH ACOM aneurysm Severe neurogenic pulmonary oedema and shock over first 5 days precluded coiling
    Aneurysm remains unsecured
    • Identification of cause of collapse
    • EVD
    • Blood stained CSF
    • -Raised A-a gradient
    • Nimodipine infusion
  • Areas of weakness identified by examiners:
    • Inability to perform a proper CNS examination
    • Not being able to state a clear GCS
    • Missing the presence of an EVD
    • Lack of a management plan: - family discussion, prognostication
  • 37 year old lady presented with L hemiparesis GCS 8 due to medullary haemorrhagic CVA. CT shows hypodense pons; tonsillar herniation and ?dense basilar (though flow OK on CTA)
    Areas of weakness identified by examiners:
    • Inability to perform a proper CNS examination
    • Not being able to state a clear GCS
    • Lack of a management plan: - family discussion, prognostication
  • 81 year old lady, presented after a fall, => GCS dropped to 7 in ED with dilated left pupil and haemoserous fluid R ear. 
    °  Slow respiratory wean
    °  Focal neurology
    °  Failed NG feeds – plan for nutritional supplementation
    Areas of weakness identified by examiners: 
    °  Poor neurological examination
    °  No clear plan for nutritional management
    °  Few candidates mentioned post pyloric feeding
    °  Candidates commented on tracheostomy decannulation without establishing clearly the presence of a cough reflex.
  • Multitrauma
    °  Resuscitation from shock
    °  Uncleared C-spine
    °  Evidence of large arterial sheath femoral artery suggestive of angiogram +/- embolisation
    °  CT scan – interpretation
    °  ABG – mixed respiratory and metabolic acidosis

    Areas of weakness identified by examiners: 

    °  Several candidates missed a large arterial sheath and failed to identify the possibility of an angiogram +/-embolisation
    °  Inability to perform a clear neurological examination
    °  Patient had a clear pericardial sound, missed by a number of candidates.
    °  Candidates did not recognise a ruptured spleen on CT.
Royal Brisbane Hospital
  • A 36 year old lady who has had gastric bypass surgery, and follow up laparotomies for bleeding and failed to thrive. Candidates asked to assess patient, identify ongoing management issues.
  • Slow wean
  • Enterobacter in abd fluid
  • On TPN
  • Ongoing temperatures
    Areas of weakness identified by examiners:
    • Failure to identify multiplicity of problems
    • Lack of clear management plan
    • Lack of clear antibiotic plan
    • Candidates failed to clearly state how they would investigate new sepsis
  • A 61 year old man with DM, HT and PVD, presented with sepsis and renal failure. He is now recovering from this. Candidates asked to assess suitability for extubation.

 
°  Ongoing encephalopathy
°  Productive sputum
°  Tachypnoeic, requiring high PS and low TV.

Areas of weakness identified by examiners:

°  Lack of a clear plan for when they would extubate a patient
°  No clear plan for when they would consider a tracheostomy

  • A 64 year old man was 7 days in ICU post AVM resection. , returned to OT 3/7 later for a craniotomy.
    Candidates were asked to assess general examination, neurological state and outline plan of management.
    Areas of weakness identified by examiners: Failure to comment on ICP monitor, CT scan (extensive pneumocephalus), tracheostomy, nosocomial pneumonia.
  • A 50 year old man who collapsed at a bus stop and was in a cardiac arrest when paramedics
    arrived.  Asses for possible causes of cardiac arrest

    Issues
    °  Causes of cardiac arrest
    °  Management post cardiac arrest
    °  C-spine clearance
    °  Complications of cardiac arrest

    Areas of weakness identified by examiners: 

    °  Missed Codman catheter
    °  Missed toxicology as a possible cause of arrest
    °  Poor exam technique
    °  Focussed only on the cardiac causes
  • A 33 year old man presented with weakness and progressed to developing respiratory failure. Candidates were asked to assess neurological state and determine cause of weakness.
    • D/D of LMN weakness expected
    • Criteria for intubation in GBS
    • Autonomic dysfunction
    • Neuropathic pain management
  • Areas of weakness identified by examiners:
    • Poor general neurological examination
    • Failure to recognise autonomic dysfunction
    • Failure to spell out when they would intubate a patient with GBS
  • A 45 year old male presented with unconsciousness 10 days ago. CT scan showed extensive SAH. Candidates were asked to assess neurological state and outline plan of management
  • 48 year old female, admitted last night with hypotension, respiratory failure and reduced LOC. She had left thumb cellulitis commenced on fluclox and she has now developed a generalised rash.
    Issues:
    °  Toxic epidermal necrolysis
    °  Morbid obesity
    °  SIRS/shock
    °  ARDS

    Areas of weakness identified by examiners: 

    Candidates did not look comfortable at the bedside; they looked like they don't examine a patient as part  of  their  daily  work.   These  candidates  fiddled  with  the  bed  sheets,  didn't  expose  the  patient adequately, missed skin biopsy site sutures, struggled to exam a morbidly obese patient from just the right side of the bed and performed disjointed exams moving from the hands to face to legs to chest to leg to face in an illogical sequence. Some took unsafe approaches with their discussion of technique to intubate the patient or overdosed the patient with dangerous amounts of intubating drugs, despite an opportunity presented to clarify their chosen drug amounts.
  • 47 year old man, brought in after an MVA. Has a T11 fracture, tear drop fracture C2 and an aortic injury. Candidates were asked to assess general examination, neurological state and outline plan of management.
    • Cause of weakness
    • Noscomial pneumonia
    • Criteria for extubation
    • DVT prophylaxis in acute phase

Areas of weakness identified by examiners: 

  • Poor general neurological examination
  • Could not clearly articulate criteria for extubation
  • Missed the presence of a pneumonia
  • Failure to have a DVT prophylaxis plan
  • 17 year old pedestrian admitted 48 hrs ago following an MVA. Deeply unconscious at the scene, difficulty in securing the airway due to blood in the airway. Candidates were asked to assess neurological state and outline plan of management.
    Other issues – comment on CT head, management of ICP, family discussions
    Areas of weakness identified by examiners:
    • Poor systematic examination of the relevant neurology.
    • Application of pain to a paralysed fully sedated patient.
    • CT scans: difficulty with simple diagnosis including distinguishing between an extradural and subdural
    • Inability to summarise the neurology and formulate a management plan including a realistic view of the prognosis for discussion with the family.
  • 65 year old lady presented with RIF pain and abdominal wall cellulitis. Assess her for ongoing management. Issues: Abdominal surgery, vac dressing, antibiotic cover, nutrition, ventilatory wean, tracheostomy