2013, Hot Cases 2

Liverpool Hospital
47-year-old female, almost 3 months in ICU with severe ARDS and multi-organ failure secondary to influenza A pneumonia and subsequent complications including anuric renal failure, pancreatitis with pseudocyst and critical illness weakness. Clinical findings included morbid obesity, generalized weakness, bibasal crackles, significant peripheral oedema and the presence of a tracheostomy, dialysis catheter and abdominal drain. Candidates were told that she had presented with pneumonia 80 days previously and were asked to examine her with a view to determining why weaning had taken so long and how they would proceed from this point. Other points of discussion included interpretation of imaging, abnormal blood results and the management of pancreatitis
75-year-old female with MSSA mitral valve endocarditis admitted to ICU 5 days earlier following a MET call for a sudden fall in conscious state to GCS 4 and intubation in the ward Clinical findings included signs of left lower lobe consolidation, pansystolic murmur at the apex and marked oedema. Candidates were told that she presented with fever, delirium and hypotension and were asked to examine her with a view to establishing the diagnosis. Discussion points included the differential diagnosis, interpretation of investigations, treatment of endocarditis and drug dosing with CRRT.
24-year-old male day 27 in ICU with a background of Lennox-Gustaut syndrome and a recent diagnosis of acute promyelocytic leukaemia, admitted with neutropaenic sepsis and bilateral pulmonary infiltrates. He had failed weaning and had a recent deterioration with worsening hypoxia. Clinical findings included gross fluid overload, bilateral pleural effusions with left collapse/consolidation and pericardial effusion. Candidates were asked to assess him and formulate a management plan. Discussion points included weaning strategies, principles of CRRT and management of sepsis, including possible sources.
59-year-old female, day 5 in ICU, post in-hospital PEA arrest of unknown cause with a background of insulin-dependent diabetes and chronic renal failure. Clinical findings included a pansystolic murmur, peripheral oedema, left pleural effusion, hepatomegaly and Charcot's joints. Candidates were told that she had been admitted to hospital for insertion of a permacath for dialysis and subsequently had a PEA arrest in the ward. Candidates were asked to examine her and establish likely causes for the arrest. Other discussion points included interpretation of investigations and indications for dialysis.
70-year-old female day 2 post laparotomy for repair of obstructed ventral hernia and division of adhesions with a background of severe COPD. Clinical findings included kyphosis, wheeze and bronchial breathing, atrial fibrillation, right ventricular impulse, obstructed pattern on ETCO2 trace and presence of intra-abdominal pressure monitor. Candidates were asked to examine her with a view to planning further management. Other discussion points included interpretation of investigations, management of AF and COPD, ventilation weaning strategies, timing of tracheostomy, intra-abdominal hypertension and nutritional support.
55-year-old female, day 3 ICU, following SAH secondary to aneurysmal bleed. Clinical findings included an intubated, awake, responsive patient with a dense left hemiplegia and the presence of an EVD, arterial puncture site at the groin and a nimodipine infusion. Candidates were told that she had presented post collapse 3 days earlier and were asked to examine her neurological system. Discussion points included interpretation of the CT brain and ECG, the differential diagnosis for this patient and the management of SAH including complications and prognosis.
17-year-old male admitted overnight with multi-trauma from a motor vehicle crash. Clinical findings included an intubated but responsive patient with a laparotomy wound, painful hip/pelvis, seat belt marks and a dressing over his left knee. Candidates were told that he had been admitted overnight following a motor vehicle crash with GCS 13, hypotension, tachycardia and a positive FAST and underwent a splenectomy, and were asked to perform a tertiary survey. Discussion points included cervical spine clearance and management of the post-splenectomy patient.

Nepean Hospital
67-year-old male, re-admitted to ICU 26 days earlier following a MET call for reduced level of consciousness. He was admitted initially post decompressive craniotomy for a spontaneous SDH and his first ICU stay had been complicated by refractory intracranial hypertension, failed extubation, non-convulsive status epilepticus and DVTs. Clinical findings included right hemiparesis and the presence of a right-sided craniectomy and a tracheostomy. Candidates were asked to examine him and assess whether he was ready for discharge to the ward. Further discussion points included interpretation of CT and MRI brain, the discrepancy between the anatomical site of the SDH and clinical findings, management of tracheostomy, DVT prevention and management and prognosis.
62-year-old female, with a long-term tracheostomy for airway patency following CVA, admitted to ICU two weeks earlier with hypoxic respiratory failure. Clinical signs included morbid obesity, reduced breath sounds bibasally, left pleural effusion, atrial fibrillation and right hemiparesis. Candidates were asked to assess her with respect to her failure to wean. Other points for discussion included interpretation of CXR, management of AF, CCF and infection, nutritional support and the plan should weaning be unsuccessful.
69-year-old female with a history of recurrent falls, two weeks in ICU following a fall resulting in left-sided rib fractures, pneumothorax and surgical emphysema. Clinical findings included cachexia, reduced breath sounds left base and the presence of a tracheostomy. Candidates were told that she had presented with respiratory failure following a fall and were asked to examine her and assess why she was failing to wean. Discussion points included interpretation of investigations and management of weaning.
43-year-old male, day 5 in ICU for an aneurysmal SAH and subsequent clipping of two aneurysms. Clinical findings included left hemiplegia, oliguria and the presence of bilateral EVDs and a nimodipine infusion. Candidates were asked to identify why he was slow to wake. Discussion points included interpretation of CT brain and CSF microscopy, causes of decreased level of consciousness and management of vasospasm.
72-year-old man, day 2 in ICU, following presentation with ARDS on the background of a recent admission with H. influenza pneumonia. Clinical findings included high ventilatory requirements, bilateral crackles and wheezes and signs of left upper lobe consolidation on auscultation. Candidates were asked to examine him and give a differential diagnosis. Additional points for discussion included interpretation of CXR, ventilatory management, choice of antibiotic and diagnostic criteria for ARDS

Westmead Hospital
33-year-old male, day 17 ICU, admitted with haemorrhagic shock from multiple stab wounds, including liver laceration and perforated bowel. Clinical findings included decreased bibasal breath sounds, moderate oedema, polyuria, open abdomen with VAC dressing and the presence of a tracheostomy. Candidates were asked to examine him, identify the current issues and formulate a management plan. Other discussion points included management of weaning and nutritional support.
59-year-old male, day 5 ICU, following laparotomy for ischaemic bowel with decompensated liver cirrhosis. Clinical findings included reduced GCS, jaundice and the presence of an open abdomen with tension sutures and 2 drains and a heparin infusion. Candidates were asked to examine him, identify the issues and formulate a management plan. Other discussion points included interpretation of imaging, weaning plan, management of coagulation status and nutritional support.
20-year-old male, scheduled for a left hemicolectomy, with a background including congenital myopathy with severe neuromuscular weakness and restrictive lung disease, ventilator dependence and permanent tracheostomy and frequent hospital admissions for recurrent chest infections. Clinical findings included kyphoscoliosis, wasting and weakness of all muscles with preserved sensation, signs of restrictive lung disease and the presence of a tracheostomy and a PEG. Candidates were asked to identify the key issues for his peri- operative management. Other discussion points included interpretation of investigations and imaging and aspects of his chronic co-morbidities.
49-year-old male, day 2 ICU, with mesenteric and retroperitoneal bleed following emergency coronary angiogram and anti-platelet and anticoagulation therapy for inferior STEMI. Clinical findings included a distended tender abdomen and the presence of a right groin arterial puncture site. Candidates were told he had been given multiple anti-platelet agents for ACS and had developed respiratory failure and been intubated and was now oliguric with elevated creatinine. Candidates were asked to determine the reasons for his deterioration. Discussion points included interpretation of the ECG and CT abdomen, cause for his abdominal distension, cause for his renal failure, management of his coagulation status and suitability for extubation.
81-year-old male admitted 17 days earlier with SAH secondary to ruptured right PCOM aneurysm with bradycardia and AICD malfunction and new onset fever. Clinical findings included signs of biventricular failure, left upper limb weakness and the presence of craniotomy wound, EVD and permanent pacemaker/AICD. Candidates were told he had presented with a headache and altered conscious state and now had a fever and were asked to examine him and determine a management plan. Discussion points included interpretation of imaging and investigations, the differential diagnosis and causes of fever.
70-year-old female, one month in ICU, with failure to wean following elective surgery for MVR and tricuspid valve annuloplasty. Clinical findings included ventricular pacing with cannon a waves, parasternal heave,systolic murmur at the left sternal edge and mid-diastolic murmur at the apex, tender hepatomegaly and the presence of a tracheostomy and a midline sternotomy scar. Candidates were told that she had difficulty weaning from ventilatory support following TV annuloplasty and MVR 4 weeks previously and were asked to examine her focussing on the cardio-respiratory system. Discussion points included reasons for failure to wean post MVR, mechanism of cannon a waves and management issues specific to the case.
51-year-old female, day 2 ICU, with large retroperitoneal bleed and resolved haemorrhagic shock related to dual anticoagulation for right lower leg DVT and arterial occlusion. Clinical findings included bronchial breath sounds at the left base, ischaemic right leg and abdominal bruising. Candidates were asked to assess her suitability for extubation. Discussion points included interpretation of imaging and management of her coagulation status.
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.

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