2009, Hot Cases 2

Prince of Wales Hospital
  • 67 year old male ptresents with increasing shortness of breath and difficulty in swallowing. Issues for discussion: Respiratory assessment, discussion of findings of CREST syndrome, CXR (patchy pneumonitis), antibiotic and weaning management.
  • 81 year old male with OSA and CCF presents with respiratory failure. Issues for discussion: Management of heart failure, BIPAP, OSA, interpretation of CXR and ABG.
  • 65 year old obese patient with ischaemic heart disease presenting with urosepsis, shock and MODS. Issues for discussion: Managememnt of shock, nephrostomy, CRRT, inotrope therapy, weaning plan.
  • 65 year old male with T4 paraplegia following trauma. Issues for discussion: Respiratory management, weaning, nutrition, feeding, antibiotic therapy.
Royal North Shore Hospital
  • A 40 year old man with TBI 3 months ago was sent to rehab unit where his tracheostomy was decannulated and developed severe respiratory distress resulting in a readmission. Candidates asked to examine his neurology and other a systemic examination and formulate a plan.
  • A 43 year old lady with GBS, ongoing respiratory failure, and slow respiratory wean
  • A young man 11 days post severe TBI making poort neurological progress. His family want a meeting to discuss withdrawal of care. Candidates asked to examine him and discuss how they would approach this case.
  • A 76 year old gentleman who had had cardiac surgery 3 weeks ago, has had a complicated post op course. Candidates asked to assess him and provide a plan of management.
  • A 70 year old male with COPD, who has been unwell for a week with fever and became progressively weak 2 days ago. He is cyrrently intubated. Sedation has now been ceased and candidates asked to determine if he is suitable for extubation. Findings of C5/6 quadriparesis.
  • A 61 yr old male found unconscious after going on a "binge". He was admitted 5 days ago with intracerebral bleed and the neurosurgeons want to wake him up and extubate him. Candidates asked to assess suitability for extubation.
Royal Prince Alfred Hospital
  • A 73 year old man with chronic bronchiectasis and a left lower lobectomy, admitted to ICU post lung biopsy for diagnosis of BOOP. Findings: clubbing, tracheal deviation to left, stony dullness, poor chest compliance. Issues for discussion: Septic shock, difficult to ventilate, poor nutrition, discussion of PFT
  • A 56 year old man admitted with sepsis, shock and encephalopathy in the setting of a recent diarrhoeal illness. Current issues: Findings of liver disease, decompensated chronic liver disease, encephalopathy, spontaneous bacterial peritonitis,
  • A 50 year old man admitted with GI bleed. Current issues: Linton tube, signs of chronic liver disease, TIPS procedure
  • A 68 year old man who had been in ICU for about a week, admitted with septic shock. Past history of TB meningitis, and DM and SLE. Current issues: Septic shock, disseminated cryptococcal disease, ARF on CVVHDF, poor nutritional state, liposomal amphotericin
  • A 58 year old male admitted to ICU after aspiration in recovery post laparotomy. Current issues: Failed trial of ECMO wean, worsening lung infiltrates, barotraumas, multi organ failure and hypothermia
  • A 54 year old lady admitted following a collapse secondary to an intracranial bleed. Findings: Left hemiparesis, EVD, fluctutating sensorium, CT scan showing hydrocephalus. Discussion issues: Managmeent of hydrocephalus, EVD infection, respiratory wean
  • A 61 year old lady admitted following an MVA. Current issues: Traumatic brain injury, pelvic lumbar and LL fractures, renal impairment with single kidney, persistently low Hb, rising Na.
  • A 64 year old man with previous Parkinsonian features following a traumatic brain injury admitted to ICU with decreased conscious level. Discussion topics: Parkinsonian features, septic encephalopathy, prognostication, management of wean.
  • A 76 year old man who presented with unstable angina and had an urgent CABG 4 days ago.  
    Bedside findings were:

    a) Sternotomy and saphenous venotomy scars
    b) Raised A-a gradient
    c) PAFC
    d) Haemodynamic data
    e) CVVHDF on citrate anticoagulation
    f) High dose inotrope requirement

    Current issues were:
    a) vasodilatory shock
    b) Discussion of hypoxia
    c) ARF – causes and management
St George Hospital
  • Bilateral traumatic leg amputation + head injury following ingestion of illicit drug. Discussion of the causes and management of fever.
  • Post elective CAGS in an 83 year old man who had experienced early complications and slow progress. Ongoing inotrope requirement, marked oedema in the face of intravascular volume depletion. Significant sedation. Marked transaminitis. Candidates asked to outline a plan of management.
  • Head and face trauma age 62. Sub-dural haematoma. IVD/craniotomy Poor waking. Not fit to extubate. Discussion of medium/long term plan including tracheostomy.
  • Community pneumonia + flu in a man with longstanding weakness due to polio. Multiple issues contributing to difficult wean – barrel chest, scoliosis, abdominal distension, bleeding tracheostomy, weak cough, pulmonary hypertension. Discussion of long term ventilatory support options.