Trial Short Case 2 April 2022

Case Summary

36y Male

Immigrant from India 20 years ago

Admission to ED on with:

- Reduced level of consciousness, raised anion-gap metabolic acidosis, hyperglycaemic with shock and acute kidney injury (Creat 200)

- Last seen well last night by flatmate. This am declined coffee, and was then found unresponsive by flatmate around 12:30pm

- Suspected DKA with no diagnosis of diabetes, but apparently recently suspected according to family.

Positive COVID PCR

Transferred from ED to ICU. Managed in isolation

New diagnosis of Type 1 Diabetes with Diabetic Ketoacidosis

Reduced level of consciousness necessitated intubation and ventilation admission day 1

Developed shock requiring multiple vasopressors

Infero-lateral ST segment elevation on ECG. Troponin 2000.

Proceeded to cardiac catheterisation. No obstructive lesions

Echocardiogram. LV thrombus. LVEF 20%. Inferolateral RWMA. Commenced on warfarin.

Diagnosed with COVID myocarditis

Neurologically intact and extubated admission day 4

Echocardiogram improved with no further regional wall motion abnormalities and improved LVEF to 59%

Commenced on meropenem after consultation with Infection Disease team

Critical illness polymyopathy

2 weeks of continued progress with improvement of polymyopathy and control of sepsis.

Off ionotropes. Out of COVID isolation. No respiratory support required.

Sudden deterioration in breathing requiring high flow nasal prong oxygen therapy admission day 15

Multiple chest drains inserted with some improvement of pleural space

Pleural aspirate positive for staph aureus

Antibiotics changed to flucloxacillin

Summarise this patients presentation and discuss the relevant findings on the series of chest x-ray and CT images.
What are your considerations in the management of this patient before and after proceeding to surgery
Describe the operation you would perform on this patient