2010, Hot Cases 2

Flinders Medical Centre
  • A 64 year old male admitted with altered sensorium and jaundice. Candidates asked to discuss an approach to altered sensorium in this context.
  • A 65 year old male admitted with pneumonia and septic shock and MODS. Background h/o arthropathy requiring immunosuppression. Problems included: slow respiratory wean, MODS, CVVHDF, obvious features of steroid therapy and a deforming polyarthopathy 
  • A 46 year old female with a past history of antiphospholipid syndrome and a mechanical MVR admitted with ascending cholangitis complicated by a cardiac arrest. Required emergent re do MVR as well as an urgent laparotomy.
    Current problems included:

a) Slow respiratory wean

b) Ongoing tracheostomy bleed

c) CVVHDF for ARF

d) MODS

e) Evidence of intravascular hemolysis

  • A 76 year old male with a past history of IHD and CABG admitted with acute hyperkalemia and ARF in the contect of a recent hospitalization for pneumonia. Current issues included: VAP, RV dysfunction, and residual acute renal failure.
  • A 40 year old man with past history of psychiatric illness admitted with seizures and hyponatremia. Failed one extubation and required nasal reintubation. Candidates asked to assess suitability for extubation. Discussion on suitability of extubation, airway assessment, assessment of power and demonstration of a systematic approach.
  • A 45 year old male admitted with chronic liver disease and haematemesis. The discussion focusing on GI bleed management
Queen Elizabeth Hospital
  • A 71 year old male with previous h/o gastric cancer and liver metastases was admitted with a parapneumonic effusion and empyema requiring a thoracotomy. Post operative course complicated by hemoptysis. Ongoing problems included cachexia, pleural effusions, recent thoracotomy, management of hemoptysis and intercostal drains
  • A 38 year old man with severe respiratory failure secondary to H1N1 and complicated by ARDS.
  • A 59 year old male with a previous splenectomy presented with a 2/52 h/o leg pain and swelling following an insect bite. Current problems included aortic regurgitation , endocarditis and left above knee amputation and respiratory failure
Royal Adelaide Hospital
  • 79 year old male – D3 post Grade 5 SAH. Aneurysm coiled within 48 hrs of presentation. Candidates asked to perform a neurological examination and asked to discuss investigations and management of SAH, spasm and hydrocephalus.
  • 63 year old patient admitted following an MVA with severe thoracic injuries. Topics for discussion included EMST principles, flail chest, damage control surgery, DVT prophylaxis and ventilatory wean.
  • An 82 year old male admitted with NSTEMI and APO secondary to severe AS and CAD. He required emergent cardiac surgery. Discussion centred around management of cardio-respiratory wean, post op AF and role of levosimendan.
  • A 73 year old man with DM and dialysis dependent CRF. In ICU following elective AVR and CABG. Candidates were asked to discuss glycemic control, fluid management in dialysis dependant cardiac surgery and complications following cardiac surgery.
  • This is an 82 year old man with diabetes and hyperlipidaemia who underwent an aortic valve replacement and CABG 1 week ago. His pre-operative left ventricular ejection fraction was 20% and he required an intra aortic balloon pump post operatively. His post operative course was complicated by a brief asystolic arrest and he remains ventilated 1 week post operatively. Candidates were asked to assess the patient for causes of slow respiratory wean. Ongoing issues included – persistent inotrope requirement, encephalopathy, search for sepsis, consideration of diuresis +/- tracheostomy.
  • A 30 year old man admitted following an MVA. On presentation, awake but hemodynamically unstable requiring an urgent trauma laparotomy. Post op complicated by new onset respiratory failure requiring reintubation and found to have H1N1. Candidates asked to discuss management of respiratory failure secondary to H1N1 and nutritional management. .
  • A 40 year old lady with SLE and bilateral renal transplants admitted with high grade fever, productive cough and respiratory failure. Issues for discussion included differential diagnosis of pneumonia in immunocompromised patients, H1N1,CMV and role of NIV in pneumonia in immunocompromised patients.