The Unconscious Patient

73-year-old male day 1 ICU admitted following a MET call for decreased conscious state that required intubation. He had been admitted with shortness of breath, fever, headache and collapse and found to have meningococcal meningitis. Background included ischaemic heart disease on dual anti-platelet therapy and COPD. Findings on examination included ecchymoses, bronchial breathing left lung, right upgoing plantar and the absence of meningism.

Candidates were directed to determine the likely cause for the decrease in conscious state.

Discussion points included interpretation of the CSF results, management of meningitis and the role of steroids.

54-year-old female, day 5 ICU, admitted with massive haematemesis from oesophageal varices on a background of Child’s B cirrhosis secondary to auto-immune hepatitis. Other co-morbidities included biventricular failure, atrial fibrillation, hypothyroid disease and polycythaemia. Findings on examination included generalised oedema, bilateral crackles on auscultation with decreased breath sounds at the bases, distended abdomen and neurological signs with brisk reflexes and ankle clonus.

Candidates were told that she had presented with upper GI bleeding that had been treated and were directed to examine her focussing on the neurological system and provide a differential diagnosis for her current clinical status.

Discussion points included interpretation of biochemistry, causes of encephalopathy and management of bleeding oesophageal varices.

24 - year - old male with a history of intravenous drug use and mitral valve endocarditis, which resulted in an embolic str oke. The patient subsequently had surgery for a mitral valve replacement from which he was recovering. Candidates were directed to perform a neurological examination and a relevant general examination.

44 - year - old female with acute liver failure and hypox ia on a background of alcohol excess and heavy smoking. Transferred from a peripheral hospital and intubated on arrival for hypoxia and delirium . Candidates were directed to identify and discuss active issues and make a plan for the following week.

• 60-year-old male, day 6 ICU admitted with GCS 3, query cause, and persisting coma and a background history of alcohol abuse. Clinical findings included GCS 5-7 off sedation, brain stem reflexes present (except oculo-vestibular), weak extension of upper limbs to pain, global hyporeflexia with up going plantar responses bilaterally, and presence of skin abrasions and sacral pressure sore.
• Candidates were asked to examine him with a specific focus on his neurology with a view to establishing a differential diagnosis for his presentation and a management plan.

• 17-year-old male, day 50 in the ICU. Initially admitted with a reduced level of consciousness secondary to a new onset of a seizure disorder. Current clinical findings include GCS 3, ongoing benzodiazepine infusion, BIS monitor in-situ, intermittent clinical and EEG seizures, bilateral leg swelling, gross global muscle wasting, and still requiring mechanical ventilation via a tracheostomy.
• Candidates were asked to assess his current issues given his prolonged ICU stay.

• 65-year-old man, Day 10 ICU. Post operative sterotactic biopsy lesion right temporal lobe. Subsequently slow neurological recovery. Clinical findings included a VP shunt, VI cranial nerve lesion on the right, monoparesis of the right arm, upward plantar on the right.
• Candidates were informed the patient was slow to recover following a neurosurgical procedure. They were asked to assess his neurological state, provide a differential diagnosis, and outline a plan for his further management.

• 75-year-old female 5 days following right hemi-hepatectomy for a mass lesion that initially had an uneventful recovery but was readmitted for a decrease in conscious level. Clinical findings included jaundice, lower body swelling and encephalopathy with lateralising signs L>R. Candidates were directed to examine her and discuss the possible causes of her decreased conscious state.

• 69-year-old female day 19 ICU post SAH secondary to left peri-callosal aneurysm treated with craniotomy, clipping and insertion of EVD and with slow neurological recovery and failed extubation for fluctuating conscious state and retained secretions. Clinical findings included drowsiness but able to obey commands and no focal neurological signs and high urine output. Candidates were directed to examine her and provide a differential diagnosis for her fluctuating neurological state.

• 39-year-old male, day 3 ICU, following presentation with uncontrolled hypertension and subsequent right parietal bleed, and pulmonary oedema (now resolved), on a background of obesity, type 2 diabetes and chronic renal failure. Clinical findings included altered conscious state with no localising signs, reduced breath sounds at both bases, elevated CVP, pericardial rub and a gallop rhythm, generalised anasarca and the presence of a right femoral venous vascath. Candidates were told that he had presented 3 days earlier with altered sensorium and shortness of breath on the background of diabetic nephropathy and were asked to examine him and to identify the reason for his presentation. Discussion points included interpretation of imaging and investigations, contributing factors for his presentation and reasons for the elevated CVP.

• 53-year-old man with liver failure admitted with increasing confusion. Candidates were asked to determine the cause of his altered state.

• 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.

• 77-year-old male with meningitis and also head injury following fall, recent NSTEMI, pneumonia, liver lesions under investigation and chronic leukaemia.

• 77-year-old female admitted to ICU from the ward with decreased level of consciousness and respiratory distress requiring intubation. In hospital for one month following fall at home and subsequent problems with swallowing, confusion and delirium. Uncertain underlying diagnosis.

• A 64 year old man was 7 days in ICU post AVM resection. , returned to OT 3/7 later for a craniotomy.
  Candidates were asked to assess general examination, neurological state and outline plan of management.
  Areas of weakness identified by examiners: Failure to comment on ICP monitor, CT scan (extensive pneumocephalus), tracheostomy, nosocomial pneumonia.

• A 33 year old man with a history of schizophrenia was found unresponsive at home in a pool of vomit and faeces. He has been slow to wake up. Findings: A ventilated patient, low GCS, pressure areas, biochemical features of rhabdomyolysis and an old infarct on a CT scan.