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.