2012, Hot Cases 2

Monash Medical Centre
  • 63-year-old man with embolic stroke post vascular and cardiac surgery. Clinical findings included carotid surgical wound, median sternotomy wound, cardiac murmur, confusional state and unequal pupils. Candidates were asked to determine if the patient was suitable for a trial of extubation. Discussion related to the causes of neurological deterioration and interpretation of the MRI findings.
  • 35-year-old woman with intracranial haematoma and fever. Clinical findings included a head wound, withdrawal to painful stimulus, bilateral upgoing plantar reflex responses and thrombophlebitis of the right arm. Candidates were asked to perform a neurological exam and suggest a cause for the fever. Discussion included interpretation of the CXR findings and management of fever.
  • 61-year-old woman with Guillain Barre syndrome. Clinical findings included bilateral VII and XII nerve palsies, generalized hypotonia, quadraparesis, areflexia and intact sensation. Candidates were asked to provide a differential diagnosis for her weakness.
  • 45-year-old man with Guillain Barre syndrome. Clinical findings included motor weakness, areflexia and intact sensation. Candidates were asked to perform a neurological examination. The discussion related to the distinction between a myopathy and neuropathy and issues related to prolonged ICU admission
  • 70-year-old man with inflammatory response post coronary artery graft surgery. Clinical findings included bilateral lung crepitations, pericardial rub, groin haematoma, saphenous vein harvest site and milrinone infusion. Discussion related to the management of heart failure.
Royal Melbourne Hospital
  • 42-year-old man with bilateral community-acquired pneumonia. Clinical signs included subcutaneous emphysema of his upper trunk. Candidates were told that he had been ventilated for one week in ICU for severe hypoxaemic respiratory failure and were asked to assess his prognosis overall. Discussion points included the management plan, causes of the subcutaneous emphysema, deranged liver function and thrombocytopaenia.
  • 53-year-old female with severe sepsis, acute kidney injury and a new temporal lobe infarct. Candidates were asked to determine the source of sepsis.
  • 47-year-old man, day 4 in ICU following an out of hospital cardiac arrest. Clinical findings included GCS E3M6VT, dysconjugate gaze, hyporeflexia and ankle clonus, systolic murmur and renal replacement therapy. Candidates were asked to assess him from a neurological point of view. Discussion points included the neurological prognosis and the possible causes of the renal failure
  • 50-year-old female post motor vehicle crash with polytrauma including cervical spinal injuries, traumatic aortic dissection, chest trauma, liver and renal injuries and skeletal injuries. Candidates were asked to assess for suitability for weaning. Discussion included management issues in this patient and general criteria for extubation.
  • 39-year-old male with chest, abdominal, pelvic and spinal trauma following high-speed motor vehicle crash. Candidates were asked to assess him for extubation. Discussion included criteria for extubation and management of delirium.
Royal Melbourne Hospital
  • 20-year-old male post motor vehicle crash with polytrauma including facial, chest and lower limb injuries. Clinical findings included facial fractures and eye injury, surgical above knee amputation right leg, fever and agitation. Candidates were asked to identify the injuries and discuss a management plan.
  • 48-year-old male post high speed motor vehicle crash with traumatic brain injury, chest, abdominal and skeletal injuries. Clinical signs included poor neurological recovery off sedation. Candidates were asked to identify his injuries and assess his neurological prognosis.
  • 69-year-old female post complicated coronary artery graft surgery who failed extubation. Clinical signs included vasoplegic shock state, oliguria and raised lactate. Candidates were asked to address the key issues and formulate a management plan.
St Vincent’s Hospital
  • 78-year-old man with CLL who presented with fever, neck pain and confusion secondary to a cervical epidural abscess. Clinical findings included decreased conscious state, cervical laminectomy wound, decreased spontaneous movement and decreased reflexes in the left upper limb. Candidates were asked to examine him with a view to forming a differential diagnosis.
  • 37-year-old man with chronic liver failure and Gram negative sepsis who had an acute gastrointestinal haemorrhage. Clinical signs included stigmata of chronic liver disease, blood-stained airway and oliguria. Candidates were asked to examine him from the aspect of his acute GI bleed. Discussion related to the underlying causes and management of the GI bleed, coagulopathy in liver failure and hepato-renal syndrome.
  • 59-year-old man with hypotension, hypothermia and collapse secondary to a stroke and subsequent septic shock. Clinical findings included multi-organ failure, limb ischaemia, purpura fulminans, GCS 3, signs consistent with previous pneumonectomy and gas trapping. Candidates were asked to examine him with regard to the likely diagnosis and management issues.