2010, Hot Cases 1

Alfred Hospital
  • A middle aged man on V-A ECMO post MI who also had MODS and renal failure. Candidates asked to assess patient and comment on methods of assessing global and tissue perfusion
  • A 60 year old lady readmitted to ICU post cardiac arrest due to a PE after an AVR and a CABG and had been discharged to the ward. Candidates were asked to examine the patient and have an approach towards differential diagnosis of cardiac arrest post surgery and have management plan about PE post cardiac surgery.
  • A young man who had suffered a cardiac arrest during a rugby match and had suffered hypoxic cerebral injury. Candidates were asked to assess neurology and discuss prognosis
  • A young man found collapsed at home following a SAH. Patient ventilated, EVD in place, reduced GCS. Candidates were asked to assess neurology and discuss SAH and its complications and management.
  • A diabetic with nephropathy who had collapsed at home. Had evidence of brainstem signs and an encephalopathy. Also had a murmur of aortic sclerosis. Also had a temperature and an infected IV site. Candidates asked to assess neurology and formulate a plan.
  • A young woman admitted with a reduced GCS due to a rebleed from an AVM. Candidates were asked to comment on the neurological assessment and management of cerebral oedema.
  • A young man in a MVA, severe TBI and also had a vascular injury to the lower limbs and had ischemic rhabdomyolysis and associated pelvic injuries. Candidates asked to examine patients and formulate a plan.
  • A young man involved in a MVA, had severe TBI and had ongoing issues of sepsis, MODS with slow neurological recovery. Candidates asked to examine patients and formulate a plan.
  • A 70 year old lady who had residual abdominal fistula following a complicated abdominal surgery. Had become deconditioned and was slow to wean. Globally weak, but had brisk reflexes. Problem was one of slow to wean.
Austin Hospital
  • 41 year old male in ICU following an emergency valve replacement for bacterial endocarditis of a pulmonary valve (previous Ross procedure). Had clear signs of peripheral emboli with significant R lung consolidation and lung abscesses. The patient was fully conscious and extubated on 40% inspired oxygen. Candidates were told the patient had had emergency valve replacement and were required to evaluate his current clinical situation.
  • 55 year old man with diabetic ESRF and peripheral vascular disease (a-v fistula insitu). Day 1 post CAGS. Making good progress. Vascath in situ but not being used. Not intubated. Candidates told post CAGS and were asked to formulate a management plan.
  • 81 year old man with a brain stem haemorrhage and clear neurological signs including sixth nerve palsy, weak gag (absent on soft palate) and right sided facial weakness. Breathing spontaneously through a tracheostomy on low insired oxygen and pressure support. Fine bore nasogastric tube in situ. Asked to evaluate why he was slow to wean from ventilation.
  • Deconditioned 69 year old male who had problems following CABG resulting in tracheostomy and a VATS procedure. Patient awake and breathing spontaneously on a tracheostomy shield. Reduced air entry L lung and chest drain in situ. Candidates were told patient had had recent thoracic surgery and had had a near arrest after early extubation. They were asked to assess whether the patient was fit for transfer to the ward. Chest X ray and clinical examination showed poor aeration L lung.
  • 58 year old male intubated following a late leak from a lobectomy stump. Septic with marked acididosis. Lung not re-expanded on CXR, significant effusion. Still intubated. Candidates asked to formulate a management plan.
  • 61 year old lady with multiple surgical interventions following bariatric surgery years earlier. Currently admitted with pneumonia for which she was ventilated. There were multiple potential causes for respiratory failure. Candidates were told she had been in the surgical ward for one month and had been admitted to ICU last night. Candidates were asked to do a general assessment with a focus on her respiratory status
  • 80 year old lady with cardio-pulmonary compromise (obstructed expiratory flow and stigmata of steroid use, heart failure) who experienced respiratory failure following hip replacement under epidural. Significant post operative troponin rise. Candidates were asked to explain why they think this might have happened. X ray showed significant hiatus hernia (but otherwise clear lung fields) and flow trace on the ventilator showed marked obstruction, ECG showed LBBB.
  • 26 year old man 3 days post liver transplant for familial hypercholesterolaemia. Fully awake and extubated. Widespread xanthalasma and arcus. Sternotomy scar and leg scars from vein harvesting (previous CAGS and MVR). Scar and dressing from liver transplant surgery. Prosthetic valve sounds. Inplanted plasmapheresis port in situ. Prostacyclin infusion in progress. Candidates were told that he had had a liver transplant 3 days earlier for familial hypercholesterolaemia and were asked to assess whether he could be discharged to the ward.

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