2011, Hot Cases 2

Prince of Wales Hospital
  • 79-year-old female, 5 days post laparotomy for small bowel obstruction with division of adhesions and small bowel resection. Background AF and hypothyroidism. Slow to wake and wean from invasive respiratory support. GIT failure with intolerance of enteral feeds, on TPN and new onset abdominal wound discharge. Candidates were directed to examine the patient with respect to assessment of nutritional status and fluid balance and failure to establish enteral feeds
  • 85-year-old female day 3 post elective AVR and CABG complicated by bleeding, vasoplegic shock and pulmonary hypertension. Candidates were asked to identify the current issues and formulate a management plan
  • 69-year-old male admitted the previous day with community-acquired pneumonia and septic shock requiring non-invasive ventilation and low dose vasopressors. Candidates were directed to review the patient's respiratory status and formulate a plan for ongoing management
  • 75-year-old male, ICU day 12 with community-acquired pneumonia, septic shock and multi- organ failure, on CPAP/PS via oral ETT, anuric on CRRT and requiring low dose vasopressor support. Candidates were directed to assess the patient with a view to planning for weaning from ventilatory support
Royal North Shore Hospital
  • 48-year-old man with multi-trauma following motorbike crash with chest and intra-abdominal injuries
  • 20-year-old male with severe traumatic brain injury secondary to fall from skateboard, decompressive craniotomy, intracranial hypertension, aspiration pneumonitis with lower zone collapse/consolidation, ventilated with NO
  • 79-year-old male 3 days post CABG, failed extubation for respiratory failure, AF treated with amiodarone and cardioversion, acute on chronic renal impairment.
  • 78-year-old female post emergency CABG for NSTEMI with ongoing inotropic support, right frontal subacute infarct with left hemiplegia, fluid overload, slow wean from ventilatory support.
  • 52-year-old female day 17 ICU with 45% burns requiring debridement and grafting.
  • 55-year-old male day 3 ICU, known epileptic, with 35% burns from hot water following a seizure in the shower. Awaiting C-spine clearance, hypotensive on inotropes, febrile, signs of underlying COPD.
  • 18-year-old male with 10% burns to face and hands, intubated for airway oedema, febrile with likely ventilator associated pneumonia, weaning sedation
  • 77-year-old male with meningitis and also head injury following fall, recent NSTEMI, pneumonia, liver lesions under investigation and chronic leukaemia.
  • 64-year-old male day 5 ICU following out of hospital VF arrest, revascularised, treated with hypothermia
Royal Prince Alfred Hospital
  • 83-year-old female day 11 ICU with ARDS post TKR. Slow progress with encephalopathy and weakness. Candidates were directed to assess the patient with a view to discussing prognosis
  • 30-year-old female, day 3 ICU with a diagnosis of TTP who presented with fever, headaches, vomiting for one day and decreased conscious state. Candidates were asked to examine the patient to determine the differential diagnosis.
  • 70-year-old IVDU admitted with respiratory failure. On examination severely deconditioned and wasted, awake and responsive, ventilated with low FiO2, CXR showing 3/4 quadrant involvement with interstitial infiltrate. Candidates were directed to assess the patient with a view to identify current problems and how to progress patient management
  • 22-year-old male, day 12 with severe traumatic brain injury. Urgent right lateral craniectomy, posterior fossa decompression and evacuation of SDH on admission. GCS 4 off sedation. New onset fever. Candidates were asked about assessment and management of fever and weaning plan
  • 69-year-old male with prolonged admission to ICU for septic shock for E coli liver abscess. Failed ward discharge and re-admitted with new fever. Findings include cachexia and generalized weakness, signs of COPD, tracheostomy, delirium, right chest drain for pleural effusion, abdominal drain with old drain sites. Candidates were directed to examine the patient with a few to making a differential diagnosis for the cause of the new fever
  • 55-year-old male admitted with septic shock secondary to right lower lobe pneumonia. Candidates directed to determine cause of septic shock
  • 70-year-old male admitted with multi-organ failure and intra-abdominal sepsis secondary to perforated duodenum post lap cholecystectomy. Candidates were directed to assess the patient with a view to determining the current problems and making a management plan for the next 24-48 hr. Discussion points included intra-abdominal sepsis, antibiotic choice, use of vasopressors, anticoagulation for CRRT, nutrition plan and CXR and ABG
St George Hospital
  • 71-year-old female with multi-trauma following pedestrian versus car. Candidates were directed to assess patient and make a management plan
  • 23-year-old male with multi-trauma including traumatic brain injury with refractory intracranial hypertension despite decompressive craniotomy, sedation, paralysis and hypothermia. Candidates were asked to assess the patient and discuss management of intracranial hypertension
  • 62-year-old male post re-do CABG with persisting low cardiac output state on IABP with background ESRF on peritoneal dialysis. Candidates asked to assess patient and make a management plan
  • 33-year-old male post abdominal surgery for mesothelioma complicated by bleeding and intracranial hypertension requiring a repeat laparotomy. Candidates were asked to assess him for suitability for extubation.

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