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.
Continue reading “Case of the Month #22”
A 55 year old man presented to hospital with acute onset shortness of breath, cough and a multiple episodes of small volume haemoptysis. The patient reported several months of rhinitis, sinusitis, arthralgia, myalgia, fever and weight loss. Past medical history includes hypertension for which ramipril is taken.
Continue reading “Case of the Month #21”
A 40 year old female presents to the Emergency Department with acute onset breathlessness, palpitations and haemoptysis. She is in acute respiratory distress and an ICU review is requested as she remains hypoxaemic on high-flow oxygen.
Continue reading “Case of the Month #20”
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.
Continue reading “Case of the Month #19”
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.
Continue reading “Case of the Month #18”
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.
Continue reading “Case of the Month #17”
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.
Continue reading “Case of the Month #16”
A 48 year old woman recently commenced chemotherapy for a new diagnosis of acute myeloid leukaemia. She attends the Day Bed Unit to have routine bloods checked prior to her next dose of chemotherapy. Since her last assessment, she sprained her ankle and is taking regular ibuprofen.
Continue reading “Case of the Month #15”
A 34 year old woman presented to the Emergency Department with a two day history of progressively worsening double vision, followed by ataxia and slurred speech. She reports a diarrhoeal illness eight days ago, though this has now resolved. She is normally fit and well and takes no regular medication.
Continue reading “Case of the Month #14”
A previously well 48 year old male, presents to ED with a 48 hour history of severe epigastric pain radiating to his back. On surgical examination he is extremely tender with guarding.
Continue reading “Case of the Month #13”
A 65 year old woman has a cardiac arrest at home. She is in VF and receives 2 DC shocks by the paramedics before return of spontaneous circulation (ROSC) is established. She is intubated at the scene and is taken to her local hospital.
Continue reading “Case of the Month #12”
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).
Continue reading “Case of the Month #11”
You are asked to review a 25-year-old female office worker who has presented to ENT with a sore throat and a progressive dysphagia.
She is apyrexial, haemodynamically stable and fully concious. A full examination reveals extensive wounds across her thighs due to subcutaneous heroin injection.
Continue reading “Case of the Month #10”
You are called urgently to A&E to assist with a patient who is 36 weeks pregnant with a low GCS. She collapsed in front of her husband after complaining of severe abdominal pain.
Continue reading “Case of the Month #9”
A 63 year old man with a history of hypertension and ischaemic heart disease has been admitted to the intensive care unit with refractory hypotension due to severe sepsis. Inflammatory markers are raised and CXR has revealed a right lower and middle lobe pneumonia.
Continue reading “Case of the Month #8”
A 74 year old female with a background of hypertension presented to the emergency department with gradually increasing breathlessness and pleuritic chest pain following a recent long haul flight.
An unresponsive 76-year-old male is admitted to the intensive care unit. He has a past medical history of bipolar affective disorder (treated with lithium and valproate), self-harm and previous suicide attempts.
Continue reading “Case of the Month #6”
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.
Continue reading “Case of the Month #5”
- What is your differential diagnoses?
- How would you investigate further?
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.
Continue reading “Case of the Month #4”
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?
Continue reading “Case of the Month #3”
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?
Continue reading “Case of the Month #2”
25 year old male is admitted to critical care following a motorcycle
accident. He hit a car travelling at
60mph, was thrown over the roof and skidded 20m down the road. His injuries include a fractured pelvis,
unilateral rib fractures from 6-10 on the left, and a fractured lateral
malleolus also on the left.
Continue reading “Case of the month #1”