Diary of Practical Training

1. 1
Diary of Practical Training
Case 1
21/07/2016
Subject: Patient A
Age: 65
Presenting Complain: Constipation, neutropenia.
On Examination: The patient has a sever sore throat and constipation post chemotherapy. She
was advised by her oncologist to take regular laxatives after each chemotherapy cycle. ECG iS
normal. CT of the abdomen and pelvic cavity reveal that the right hemicolon is distended and
faecally loaded. At the level of mid transverse colon there is a gaseous distention of the distal
transverse colon and the descending colon. The sigmoid colon also demonstrates variable
collapse and gaseous distention. The rectum contains fluid and no structural obstruction is
identified. A stent is seen at the gastro-oesophageal junction. A left hepatic lobe resection is also
noted. No hydronephrosis. No enlarged retroperitoneal or pelvic side wall lymph node present.
Bowel obstruction is noticed. No free intraperitoneal fluid or gas is noticed. Bilateral adnexal cysts
and multiple uterine fibroids are present. Lung base show emphysematous changes. Bony review
is unremarkable.
Treatment Plan: Hyoscine Hydrobromide, 20mg tds, p.o., 7 days. Orabase protective paste, 1bd,
top, 7 days. Fluconazole, 100mg od, p.o., 7 days. Docusate sodium, 200mg bd, p.o., 7 days.
Senna, 15mg bd, p.o., 7 days. The patients chemotherapy drug was changed from vincristine
(know to cause constipation) to vinblastine on advisement from the oncologist.
Case 2
22/07/2016
Subject: Patient B
Age: 39
Presenting complain: Nausea, vomiting, loss of weight (around 20kg), increasing pain in RUQ
(increases when eating), difficulty in eating, difficulty in breathing.
On Examination: Tenderness in the RUQ. On palpation the patient complains of a radiating pain
to the back. The ECG appears normal. Urine analysis shows no increase in inflammatory markers.
The patient was sent for an ultrasound to identify gallstones.
Treatment Plan: Pain Management until the diagnostic ultrasound results is acquired. Co-
codamol, 530mg tds, p.o..
Case 3
31/07/2016
Subject: Patient C
Age: 16
Presenting Complain: Vehicular Accident (Motor Cross) – the patient went off a ramp at high
velocity and smacked his face on the ground. The emergency services immobilized the patients
head as a precaution (possible C-spine injury).
On Examination: A complete neurological work up and test of consciousness level was
performed. The lock-roll was utilized to mobilize the patient as a precaution in case the patient had
a spinal injury – the patient had no neurological/consciousness deficits. The patient presented with
a clavicular fracture which was protruding outward – on examination the fractured area appears to
have no vascular deficit (risk of avascular necrosis).
Treatment Plan: The patient was given morphine and paracetamol onsite by the emergency
services. The patient is continued to be immobilized and additional paracetamol is given to
manage the pain. A CT scan of the head and the spine is ordered. If the results are unremarkable
the patient will be given a sling and sent home with adequate pain management.

2. 2
Case 4
18/07/2016
Subject: Patient D
Age: 72
Background Information: The patient has known Takotsubo cardiomyopathy (transient cardiac
syndrome – left ventricular apical akinesis & mimics acute coronary syndrome) and COPD (40 year
smoking history). The patient has had a NSTEMI in the past. The previous echo of the patient’s
heart revealed that the patient has a normal LV cavity size with a severely impaired systolic
function (Simpsons Biplane: estimates EF at 44%. This was an overestimated reading due to the
basal segment over contractility. It was than visually estimated at 30-35% which is considered a
normal level upon arrival in patients with Takotsubo cardiomyopathy). The patient is on a lifelong
treatment of Ramipril (ACE Inhibitor). The patient is allergic to co-amoxiclav, erythromycin,
clarithromycin and azithromycin.
Presenting Complain: The patient complains of heart palpitations, nausea and difficulty in
breathing.
On Examination: An emergency ECG was performed – the patient has a sinus rhythm, poor R
wave progression and ST elevation in V2-V4 leads (ST elevation is not as great as STEMI) typical
of a Takotsubo cardiomyopathy episode. On arrival an ABG was performed which showed that the
patient had Type 2 respiratory failure (PaCO2 greater than 50mmHg and pH of blood of 7.25). The
patient also had elevated inflammatory markers: WBC=14.7 and CRP=48 which is typical of an
infection (physical stress trigger). The patient also has a positive troponin of 564 (could indicate an
acute myocardial event or a Takotsubo cardiomyopathy episode).
Treatment Plan: Asprin, Caverdilol (beta blocker), Morphine are prescribed. Emergency
angiogram is scheduled (to ensure the coronary arteries are not occluded and is in fact ballooned
typical of Takotsubo cardiomyopathy). Refer to patient’s cardiologist. Serial imaging echo studies
should be performed as an outpatient.
Case 5
14/08/2016
Subject: Patient E
Age: 45
Presenting Complain: Mitral Valve Prolapse.
Treatment Plan: Mini Mitral Surgery
Surgery Details: A pressure wire is inserted into the radial artery of both hands to monitor the
difference in pressure. The EndoVent Pulmonary catheter is than inserted. The EndoVent
Pulmonary catheter assist in decompressing the heart by removing blood from the pulmonary
artery in order maintain a dry operative field. Next the coronary sinus catheter is inserted. This
catheter occludes the coronary sinus, delivers retrograde cardioplegia and monitors the coronary
sinus pressure. A right anterior thoracotomy is performed (about 3-4 fingers wide between the
4th
/5th
intercostal space depending on the position of the heart. The working port is than inserted.
The soft tissue retractor is than placed. The right lung is than deflated to get a better access to the
heart. The thoracoscope is than inserted. The QuickDraw canulla is than inserted (A device
used for draining nonoxygenated blood from the venae cavae and/or right atrium during cardiopulm
onary bypass). With this the cardiopulmonary bypass is complete. The pericardium incision is then
made (lengthwise incision 1cm from the phrenic nerve). Stay sutures are than placed. The
EndoClamp Aortic catheter is then used to occlude the aortic root. This catheter also delivers
antegrade cardioplegia, vents the aortic root and monitors the aortic root and balloon pressure.
The incision is then made on the heart posterior to the atrial groove. The incision is than extended
with the tissue scissors. The atrial retractor is than place to get a good view of the mitral valve
pathology. After the valve has been repaired the atrium is closed and deaired. The patient is than
decannulated (given protamine to reverse the anti-clotting effects of heparin).

3. 3
Patient Contraindications
 Ascending aortic dilatation >4 cm (the balloon has a volume of 30-35ml)
 Severe aortic regurgitation
 Aneurysm of ascending aorta
 Aortic stent
 Grade III - IV aortic atheroma (possibility of dislodging plaques when the balloon is deflated)
 Obese patients (difficult to cannulate femoral blood vessels due to fatty obstructions)
Case 6
18/08/2016
Subject: Patient F
Age: 51
Background Information: Relatively healthy and has an unremarkable medical history.
Presenting Complain: Palpitations, pain, dyspnea and nausea. Ambulatory ECG suggested that
the patient had an acute coronary event. On the journey to the hospital the patient went into
cardiac arrest (possibly due to a dislodged thrombus).
On Examination: Patient was unconscious. Vitals were stable. Emergency x-ray showed signs of
ischemia in the heart.
Treatment Plan: Patient was taken for an emergency percutaneuous intervention. During the
intervention it was found that the patient had a subtotal occlusion of the left anterior descending
coronary artery, a total occlusion of the circumflex coronary artery and a total occlusion of the right
coronary artery. The proximal portions of these arteries appear to be calcified whereas the distal
portions appear to be normal. The RCA is only responsible for approximately 5% of myocardial
perfusion. As such the patient has a fairly good prognosis since the other 2 coronary arteries are
perfusing the heart sufficiently. The RCA was stented using a bare metal stent. No further
percutaneuous intervention was performed and the patient was referred for emergency surgery
due the high risk of further dislodging the thrombus.
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