Case of the Month #24

Grace Hoey

A 53 year old male currently on the Haematology ward is referred because of type 1 respiratory failure. He was diagnosed with acute myeloid leukaemia (AML) 3 months ago following a brief, non-specific illness where a spurious blood test demonstrated pancytopenia. He has no other health problems and his performance status is 1.

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Case of the Month #23

Stuart Edwardson
Arlene Wise

A 34 year old primigravida of Asian ethnicity at a gestation of 36+4 and BMI 24 has presented to obstetric triage. She describes a persistent cough for the last 4 days which is getting worse and has been advised by her GP to attend for further investigation. She is otherwise fit and well, and has had a low-risk pregnancy with no concerning features.

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Case of the Month #22

Christopher Shaw

A 60 year old man is admitted to the intensive care unit with spontaneous bacterial peritonitis on a background of alcoholic liver disease. He is treated with appropriate antibiotics. However, following admission to the unit he continues to deteriorate and requires intubation. He becomes hypotensive requiring fluid resuscitation and vasopressor support, oliguric and requires high ventilatory pressures. Examination reveals decreased air entry bibasally, with a firm, distended and tense abdomen.

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Case of the Month #19

Rathai Anandanadesan

A 60 year old woman was admitted to hospital with a one week history of increasing confusion and malaise. She was discharged from hospital 2 weeks previously after receiving treatment for a non-ST-elevation myocardial infarction (with aspirin and ticlopidine). Abnormal findings on clinical examination are a low-grade temperature (37.4°C), GCS 12 (E3V4M5), jaundice, and petechiae over her arms and legs.

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Case of the Month #18

Lucy Powley

A 35 year old woman presents to the Emergency Department with 1 day history of fever, urinary frequency and left loin pain. She has a urine dip positive for leucocytes, nitrites, protein and blood and raised inflammatory markers. She is diagnosed with pyelonephritis and started on IV amoxicillin and gentamicin. 24 hours later she reports diplopia, dysphagia and breathlessness. On further questioning she describes a 2 month history of diplopia towards the end of the day which she put down to needing new glasses and too much screen time.

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Case of the Month #17

Matthew Wright

A 74 year old gentleman is admitted to the critical care unit following a 3 week admission on the medical wards with pyrexia, malaise, lymphadenopathy and thrombocytopenia.  A diagnosis of sepsis of unknown origin has been made and he has been treated with multiple courses of antibiotics.  No clear focus of infection has been ascertained.  He has now developed multi-organ failure with a worsening transaminitis, an acute kidney injury, an increasing CRP and a pancytopenia.

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Case of the Month #16

Oliver Robinson

A 22 year old woman presents to hospital with a 3 day history of abdominal pain and vomiting. Examination reveals that the patient is jaundiced and acutely confused (GCS 14/15). Blood results demonstrate pH 7.25, lactate 6.7, glucose 2 mmol/L, Na 135 mmol/L, K 3.2 mmol/L, urea 2 mmol/L, creatinine 69 μmol/L, ALT 7050 U/L, ALP 132 U/L, Bilirubin 82 μmol/L, INR 7.

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Case of the Month #11

Louise Hartley

A 40 year old male was admitted to intensive care unit requiring intubation and ventilation for community acquired pneumonia. He developed acute respiratory distress syndrome (ARDS) and on day 2 commenced an atracurium infusion for worsening hypoxaemia.

Despite two sessions of prone ventilation he failed to improve and required high ventilatory pressures. On day 5 he was placed on venovenous extracorporeal membrane oxygenation. (VV ECMO).

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Case of the Month #5

Colin McAdam

A previously well 76-year-old male presents to ED having been found on the floor at home by a relative. Collateral history reveals ‘flu-like’ symptoms and headache within the last week.

On arrival he is soiled, agitated and combative with a GCS of 9/15 (E2 V2 M5). There are no obvious localising neurological signs. Pupils are equal and reactive. Temperature is 39.0.A basic delirium screen in ED is negative (urine dip and chest x-ray). As you continue assessing the patient, he has a short-lived generalised tonic-clonic seizure.

  1. What is your differential diagnoses?
  2. How would you investigate further?
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Case of the Month #4

Pete Hersey

A 67 year old man has been admitted overnight to the intensive care unit.  He presented with flu-like symptoms and a non-productive cough.  His wife reported that he had been ‘seeing things’.  Investigations revealed hypoxaemia, lobar consolidation, neutrophilia and a raised lactate dehydrogenase.

You suspect the patient may have Legionnaires’ disease.

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Case of the Month #3

Rosaleen Baruah

A 54 year old woman with a history of hypertension presented to the emergency department with a sudden onset severe headache. Her GCS was E3 V3 M6 on arrival, but deteriorated over the next 2 hours to E3 V2 M5. A CT brain demonstrated an intracerebral haemorrhage and a CT angiogram confirmed a ruptured middle cerebral artery aneurysm. She was intubated and ventilated for transfer to the regional neurosciences unit where she underwent a successful endovascular coiling procedure the following morning. On sedation hold she is now GCS E1 VT M1. 

What are the potential causes of her reduced level of consciousness?  

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Case of the Month #2

Kyle Gibson

A 40 year old male was found unresponsive in the garden. Initial GCS was 9 (E3V2M4) which deteriorated to 7 (E2V2M3) on arrival to the emergency department. ECG and CT brain were both normal. An ABG demonstrated a high anion gap metabolic acidosis (pH 7.0) with an increased osmolal gap (>10mOsm/kg). In view of unexplained decreased level of consciousness along with high anion gap acidosis and high osmolal gap, ethylene glycol toxicity was considered to be the most likely diagnosis.

Q1 – How does ethylene glycol ingestion present?

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