Choose your patient Each case is a bedside decision path drawn from real ICU practice. Every choice changes the monitor, the ventilator and the results screen. Best choices keep the patient alive; harmful ones create a complication you must rescue. You get a debrief with the evidence at the end.
Pneumonia after the floods Septic shock What this teaches: Recognise septic shock at the bedside and put the first-hour priorities in the right order. Mr H., 58, from Michenzani. Three days of cough and fever after wading through flood water. Brought to ER by boda-boda, drowsy. Beginner registrar Sepsis & infection ~9 min Cerebral malaria with hypoglycaemia Severe falciparum malaria Mrs K., 24, 20 weeks pregnant, from Pemba. Four days of fever, now unrousable. RDT positive, parasitaemia 9%. GCS 8, one generalised seizure in ER. consultant Sepsis & infection ~9 min Autonomic storm on the ventilator Severe tetanus Mr M., 34, farmer from Unguja, unvaccinated. Trismus and back spasms 6 days after a wound from a hoe. Now generalised spasms every few minutes. consultant Sepsis & infection ~9 min Fever, coma and a rash Bacterial meningitis Ms R., 21, student. Headache and fever for a day, now GCS 9 with neck stiffness and a spreading purpuric rash on her legs. registrar Sepsis & infection ~7 min Leptospirosis on the ventilator Severe ARDS Mrs S., 45, 165 cm, ideal body weight 57 kg. Fever, myalgia and jaundice ten days after the floods. Intubated in ER for hypoxaemia. Now on ICU. registrar Respiratory ~8 min Gas trapping on the ventilator Near-fatal asthma Mr J., 27, known asthmatic, two previous ICU admissions. Wheezy for two days, now silent chest, drowsy, SpO₂ 84% on 15 L. Salbutamol, ipratropium, hydrocortisone and magnesium already given in ER. consultant Respiratory ~9 min Sudden high pressure alarm Tension pneumothorax on the ventilator What this teaches: Recognise sudden deterioration on a ventilator and know when it is an emergency that cannot wait for an X-ray. Mr O., 62, day 4 of ventilation for COVID-type ARDS, PEEP 12. Night nurse calls: high-pressure alarm, SpO₂ falling, BP dropping. Beginner registrar Respiratory ~6 min Stridor after the tube comes out Failed extubation Mrs D., 58, ventilated 9 days after abdominal sepsis, 6 kg positive balance. Passed a spontaneous breathing trial this morning. Extubated 20 minutes ago. consultant Respiratory ~7 min Three shocks in an hour after an infarct VT storm Mr L., 61, anterior STEMI thrombolysed 36 hours ago (no cath lab available). EF 25%. Third episode of VT in the last hour, each needing a shock. consultant Cardiac ~9 min Syncope in the corridor Complete heart block Mrs F., 74, on bisoprolol and diltiazem for AF, collapsed in the outpatient corridor. GCS 14, cold peripheries. registrar Cardiac ~7 min The "septic" patient who is not septic Cardiac tamponade Mr E., 38, HIV positive on ART, 3 weeks of night sweats and progressive breathlessness. Referred as "septic shock not responding to fluids". Neck veins full, heart sounds soft. consultant Cardiac ~7 min Collapse on day 6 after surgery Massive pulmonary embolism Mrs G., 52, 6 days after a hysterectomy, no prophylaxis charted. Sudden collapse on the ward: BP 74/50, SpO₂ 86%, RV dilated with a D-shaped septum on echo. consultant Cardiac ~8 min Insulin ran out in the flood Diabetic ketoacidosis What this teaches: Work through the first hours of diabetic ketoacidosis in a safe order and learn which monitoring prevents harm. Mr A., 19, type 1 diabetes, 60 kg. Could not reach the pharmacy for 4 days during the floods. Vomiting, abdominal pain, deep sighing breathing. Beginner registrar Metabolic & endocrine ~8 min Missed dialysis, wide QRS Hyperkalaemia What this teaches: Recognise dangerous potassium on the ECG and learn the order: protect the heart, shift the potassium, then remove it. Mr B., 46, on haemodialysis, missed two sessions after the ferry stopped running. Weak, nauseated. HR 42, QRS broad. Beginner registrar Metabolic & endocrine ~6 min Fever, AF and delirium after a chest infection Thyroid storm Mrs N., 41, known Graves disease, stopped carbimazole 3 months ago. Pneumonia this week; now temperature 40.2, AF at 160, agitated and confused. consultant Metabolic & endocrine ~7 min Seizure with a sodium of 112 Severe hyponatraemia Mr P., 66, on hydrochlorothiazide, three days of vomiting after eating street food. Brought in confused, then a 3-minute generalised seizure in triage. consultant Metabolic & endocrine ~7 min Still seizing after two doses of diazepam Status epilepticus What this teaches: Treat a prolonged seizure step by step and keep the airway protected while you do. Ms T., 29, known epilepsy, ran out of carbamazepine. Seizing for 25 minutes. Two doses of IV diazepam given by the ambulance crew. Still convulsing. Beginner registrar Neuro ~8 min Boda-boda crash, GCS 6, blown pupil Severe traumatic brain injury Mr W., 24, motorcycle crash without a helmet. GCS 6 (E1 V1 M4), right pupil 6 mm fixed. CT: right acute subdural haematoma with 9 mm midline shift. Neurosurgery is 3 hours away. consultant Neuro ~9 min Wide QRS and a seizure Tricyclic overdose Ms C., 33, took an unknown number of her mother's amitriptyline 2 hours ago. Drowsy, dilated pupils, dry mouth, tachycardic. Seized once in the ambulance. registrar Toxicology ~7 min Farmer drenched in pesticide Organophosphate poisoning Mr Z., 38, drank pesticide from a soft-drink bottle after a family dispute. Vomiting, drooling, pinpoint pupils, wheeze, HR 46, fasciculating. Smells of garlic. consultant Toxicology ~8 min Black mamba or puff adder? Snakebite envenomation Boy, 14, bitten on the ankle in a maize field 3 hours ago. Village healer applied a tourniquet and cut the site. Now ptosis, drooling, weak neck, swelling to the knee. consultant Toxicology ~7 min Dala-dala rollover, pelvis and spleen Haemorrhagic shock Ms V., 27, passenger in a rolled minibus. Pelvic fracture on the X-ray, FAST positive in the left upper quadrant. BP 74/40, HR 138, cold, confused. No surgeon in theatre for 40 minutes. consultant Trauma & obstetric ~8 min Seizing at 36 weeks in the corridor Eclampsia What this teaches: Recognise eclampsia, protect the mother and her airway, and know the first priorities and who to call. Ms Y., 19, primigravida, 36 weeks, no antenatal care. Headache since yesterday. Generalised seizure on arrival. BP 176/118. Proteinuria 3+. Beginner registrar Trauma & obstetric ~8 min Ceftriaxone at the cannula, then collapse Refractory anaphylaxis What this teaches: Recognise anaphylaxis fast and learn why the first drug, its route and calling for help matter most. Mr Q., 44, on atenolol for hypertension. Two minutes after IV ceftriaxone for a chest infection: flushing, wheeze, stridor, BP 60/30. Beginner registrar Trauma & obstetric ~6 min Haematemesis in a man with schistosomiasis Variceal haemorrhage Mr S., 47, hepatosplenic schistosomiasis, known varices, no beta-blocker. Two large haematemeses at home. Pale, confused, melaena on the trolley. consultant Trauma & obstetric ~8 min Anterior infarct, no cath lab tonight Cardiogenic shock after STEMI Mr R., 55, 4 hours of crushing chest pain. ST elevation V1–V5. Cold, clammy, confused, crackles to mid-zones. Nearest PCI centre is 5 hours away by road. consultant Cardiac ~8 min Ascending weakness after diarrhoea Guillain–Barré syndrome Ms I., 31, two weeks after a diarrhoeal illness. Legs weak for 3 days, now arms, and she cannot lift her head off the pillow. Speech soft. registrar Neuro ~7 min The malnourished man who got a full feed Refeeding syndrome Mr U., 52, 39 kg (BMI 14), oesophageal cancer, almost nothing by mouth for 3 weeks. Admitted for a feeding jejunostomy. Full-rate feed started last night. registrar Metabolic & endocrine ~6 min Late presentation, encephalopathy Paracetamol-induced acute liver failure Ms E., 26, took 30 g of paracetamol 3 days ago and told no one. Now vomiting, jaundiced, confused. INR 5.8. consultant Metabolic & endocrine ~8 min "Cellulitis" that hurts too much Necrotising fasciitis Mr D., 49, diabetic, small cut on the shin 4 days ago. Referred as cellulitis. Pain out of proportion, spreading in hours, skin dusky with bullae, crepitus. BP 84/50. consultant Sepsis & infection ~7 min ROSC after 22 minutes in the market Post-cardiac arrest care Mr T., 58, collapsed at Darajani market. Bystander CPR, AED shock ×2 by the ambulance crew, ROSC after 22 minutes. Arrives GCS 3, intubated by the crew. consultant Cardiac ~8 min Kerosene stove explosion Burns with inhalation injury Mrs J., 34, 60 kg, kerosene stove explosion in a closed kitchen. Burns to face, chest, both arms. Singed nasal hair, hoarse voice, carbonaceous sputum. registrar Trauma & obstetric ~7 min Seizure during a brachial plexus block Local anaesthetic systemic toxicity Mr K., 70 kg, receiving an axillary block with 30 mL of 0.5% bupivacaine for a wrist fracture. Two minutes in: tinnitus, metallic taste, then a generalised seizure. registrar Toxicology ~5 min Charcoal smoke, drowsy on 15 litres COPD with hypercapnic failure What this teaches: Give oxygen carefully in COPD, recognise a tiring patient and know when to escalate. Mr H., 64, thirty years of cooking on charcoal indoors and twenty of cigarettes. Three days of worsening breathlessness and green sputum. Arrived on a non-rebreather at 15 L/min from the ward; now drowsy. Beginner registrar Respiratory ~8 min Old TB cavity, blood in the basin Massive haemoptysis Mr O., 41, treated for pulmonary TB twice, a chronic right upper-lobe cavity. Coughing frank blood since dawn — about 400 mL in the last hour. HIV negative. consultant Respiratory ~7 min The "inferior STEMI" with a pulse deficit Acute aortic dissection Mr P., 52, hypertensive, non-adherent. Sudden tearing chest pain radiating to the back one hour ago. ECG: inferior ST elevation. Right arm BP 190/110, left arm 120/70. Diastolic murmur. consultant Cardiac ~8 min Two weeks of headache, new HIV diagnosis Cryptococcal meningitis with raised ICP Ms W., 29, two weeks of worsening headache, now vomiting and seeing double. HIV test positive today, not previously known. CD4 32. consultant Sepsis & infection ~8 min Shock that ignores the noradrenaline Adrenal crisis Mrs F., 46, prednisolone 15 mg daily for three years for pemphigus, stopped a week ago when the pharmacy ran out. Two days of vomiting and abdominal pain, now collapsed. registrar Metabolic & endocrine ~6 min Thunderclap headache, then a second collapse Aneurysmal subarachnoid haemorrhage Ms B., 47, hypertensive smoker. The worst headache of her life during a church service, vomited, briefly lost consciousness. Now GCS 14, neck stiff, BP 178/104. consultant Neuro ~9 min Gongo at a funeral, blind by morning Methanol poisoning Mr N., 38, drank home-distilled spirit at a funeral two nights ago with twelve others. Blurred vision "like a snowstorm" since dawn, vomiting, breathless. Two of the others are also unwell. consultant Toxicology ~7 min Twins delivered, uterus like a sack Massive postpartum haemorrhage Mrs Z., 33, para 4, vaginal delivery of twins 40 minutes ago after a long labour. Bleeding has not stopped — 2 L in the basin. Uterus soft and above the umbilicus. consultant Trauma & obstetric ~8 min Cannot swallow, cannot count past 8 Myasthenic crisis Ms A., 27, myasthenia gravis on pyridostigmine, started ciprofloxacin for a UTI three days ago. Now slurred speech, nasal regurgitation, and breathless lying flat. registrar Neuro ~7 min Gallstones, then a belly like a drum Severe acute pancreatitis Mrs K., 44, gallstones on a scan last year. Two days of epigastric pain radiating to the back, vomiting. Lipase 4,200. Now breathless, oliguric, HR 128. consultant Surgical & GI ~8 min Three weeks of fever, then peritonitis Perforated typhoid Mr S., 19, three weeks of fever treated with amoxicillin at a dispensary. Sudden abdominal pain 12 hours ago. Now rigid abdomen, HR 136, BP 80/46. consultant Surgical & GI ~7 min Ruptured ectopic, 14 litres later Abdominal compartment syndrome Ms G., 24, ruptured ectopic pregnancy, 3 L haemoperitoneum, salpingectomy overnight. Received 8 L crystalloid and 6 units of blood. Now on ICU: abdomen tense, urine 5 mL/h, Ppeak 44. consultant Surgical & GI ~6 min Dry cough for a month, saturations fall on walking Pneumocystis pneumonia Mr C., 36, one month of dry cough, weight loss and breathlessness on exertion. Oral thrush. Chest film: bilateral perihilar ground-glass. HIV positive today, CD4 48. registrar Respiratory ~7 min Yellow vision, slow AF, potassium 6.2 Digoxin toxicity Mrs N., 74, rheumatic mitral stenosis and AF on digoxin 250 µg. Diarrhoea for a week, then vomiting, confusion and "yellow halos around the lights". Creatinine has risen to 210. registrar Toxicology ~6 min Glucose 58, sodium 162, and a leg that will not move Hyperosmolar hyperglycaemic state Mr E., 68, type 2 diabetes, ran out of metformin two weeks ago. Drinking sugary sodas for thirst. Found confused at home, a week of polyuria. Glucose 58 mmol/L. registrar Metabolic & endocrine ~7 min Propranolol and amlodipine, a pulse of 34 Beta-blocker and calcium-channel blocker overdose Ms R., 32, took 60 × 40 mg propranolol and 30 × 10 mg amlodipine 2 hours ago after an argument. HR 34, BP 62/30, drowsy. consultant Toxicology ~7 min Sickle cell, painful crisis, now a white lung Acute chest syndrome Mr J., 22, sickle cell anaemia (HbSS). Admitted two days ago with a painful crisis of the back and legs on morphine. Now fever, chest pain, SpO₂ 86%, new bilateral lower-zone shadows. registrar Respiratory ~7 min Three weeks of headache, then a sixth-nerve palsy Tuberculous meningitis Mr L., 34, HIV positive on ART for 2 months (CD4 was 90). Three weeks of headache, night sweats and weight loss, now confused with a right sixth-nerve palsy. Na 121. consultant Neuro ~8 min Day 5 of fever, the fever broke and then she collapsed Dengue shock syndrome Ms P., 19, Dar es Salaam outbreak. Five days of fever, myalgia and rash; fever settled yesterday. Today abdominal pain, vomiting, cold hands, pulse pressure 15 mmHg. registrar Sepsis & infection ~7 min Dived into the shallow end, warm and bradycardic Cervical spinal cord injury Mr Y., 24, dived into a shallow pool. Pulled out unable to move his legs or hands. Arrives on a spinal board: BP 78/44, HR 48, warm peripheries, breathing with his abdomen. registrar Trauma & obstetric ~7 min Right-sided weakness at breakfast, in the window Acute ischaemic stroke What this teaches: Recognise a stroke, check the glucose, note the time and know when the patient needs a scan and a senior. Mrs O., 61, hypertensive, in AF not anticoagulated. Sudden right arm and face weakness and inability to speak at 07:40, witnessed. Arrives at 08:50. BP 196/108. Glucose 7.2. Beginner registrar Neuro ~7 min Diclofenac for the knee, then a bucket of blood Non-variceal upper GI bleed What this teaches: Resuscitate a bleeding patient first, then think about the source: airway, access, blood and who to call. Mr Q., 58, diclofenac daily for osteoarthritis, also on aspirin after a stent last year. Haematemesis twice tonight, melaena, syncope on standing. HR 118, BP 88/56. Beginner registrar Surgical & GI ~6 min Pain out of proportion in a woman with AF Acute mesenteric ischaemia Mrs V., 71, AF, stopped warfarin a month ago after a nosebleed. Six hours of severe central abdominal pain, vomited twice, one loose bloody stool. Abdomen soft and barely tender. consultant Surgical & GI ~7 min Breathless at two weeks post-partum, "it must be anaemia" Peripartum cardiomyopathy Ms M., 29, two weeks after her third delivery. Ten days of increasing breathlessness, cannot lie flat, swollen legs. Sent from the clinic as "postnatal anaemia". SpO₂ 86%. consultant Cardiac ~7 min Collapse at the moment of delivery Amniotic fluid embolism Mrs T., 36, induced at 41 weeks. Minutes after rupture of membranes and during a strong contraction: agitation, "I can't breathe", then collapse. SpO₂ 62%, BP unrecordable, fetal bradycardia. consultant Trauma & obstetric ~6 min Collapsed at kilometre 38 of the marathon Exertional heat stroke Mr I., 27, collapsed near the end of a marathon on a 34 °C afternoon. Confused, combative, then unconscious. Rectal temperature 41.8 °C. Skin hot and dry. registrar Metabolic & endocrine ~6 min Building collapse, freed after nine hours Crush injury Mr G., 30, trapped under a collapsed wall by both legs for nine hours. Rescuers are about to lift the slab. He is talking, HR 118, BP 108/70. consultant Trauma & obstetric ~7 min Rheumatic valve, fever for a month, now a stroke Infective endocarditis with heart failure Ms D., 38, known rheumatic mitral regurgitation. A month of fever and weight loss treated with three courses of oral antibiotics. Today: breathless, and a sudden left arm weakness. consultant Cardiac ~8 min Epigastric pain at 34 weeks, platelets 38 HELLP with hepatic haematoma Mrs S., 31, 34 weeks, first pregnancy. Two days of epigastric pain and vomiting, sent from a health centre with BP 172/112. Platelets 38, ALT 640, LDH high, schistocytes on the film. consultant Trauma & obstetric ~7 min Vomited, then chest pain, then the surgical emphysema Oesophageal perforation Mr W., 55, heavy drinker. Forceful vomiting after a party last night, then severe chest pain. Sent home from an ED as "gastritis". Now, 20 hours later: crepitus in the neck, fever, shock. consultant Surgical & GI ~6 min Day 6 of ventilation, new fever and a new shadow Ventilator-associated pneumonia Mr B., 45, ventilated 6 days after a road crash (chest and pelvic injuries). New fever 38.9, purulent secretions, FiO₂ up from 0.35 to 0.6, new right lower lobe consolidation. registrar Sepsis & infection ~7 min Day 4: "he keeps pulling at the tube, so we gave more midazolam" ICU delirium and deep sedation Mr F., 68, ventilated 4 days for pneumonia. Overnight he pulled at the tube; the night team increased midazolam and started haloperidol. This morning: RASS −4, no sedation hold for 3 days, tied at the wrists. consultant Neuro ~7 min Rat-poison tablets, garlic breath, refractory shock Aluminium phosphide poisoning Ms X., 22, swallowed three tablets of a grain fumigant ("rat poison") 90 minutes ago after a family dispute. Vomiting, garlic-like odour, BP 70/40, HR 118. No antidote exists. consultant Toxicology ~6 min Fixed pupils on day 3 after the haemorrhage Brainstem death and organ donation Mr Z., 41, massive intracerebral haemorrhage 3 days ago, not for surgery. Ventilated. This morning: pupils fixed and dilated, no cough on suction, no response to pain. Temperature 34.8, Na 158, on propofol until 2 hours ago. consultant Neuro ~7 min Pulled from the surf at Coco Beach, breathing again Drowning Mr N., 17, submerged for about 4 minutes in the surf, bystander CPR on the beach, coughing and breathing on arrival. GCS 12, SpO₂ 82%, foam at the mouth. Water temperature 27 °C. registrar Respiratory ~6 min Confused, dehydrated, calcium 4.1 — and a breast lump Hypercalcaemic crisis Mrs H., 58, two weeks of thirst, constipation and vomiting, now confused and drowsy. A breast lump she has hidden for a year. Calcium 4.1 mmol/L (corrected), creatinine 260. registrar Metabolic & endocrine ~6 min Back pain, collapse, a pulsatile mass — and 2 hours to a vascular surgeon Ruptured abdominal aortic aneurysm Mr K., 72, smoker, hypertensive. Sudden severe back and abdominal pain, collapsed at home. Pale, sweating, BP 78/50, HR 116. A pulsatile mass. Ultrasound at the bedside: 8 cm aorta with free fluid. consultant Surgical & GI ~6 min Tramadol plus the new antidepressant, now 40 °C and rigid Serotonin syndrome Ms C., 24, started sertraline 10 days ago; given tramadol and ondansetron for a dental abscess yesterday. Tonight: agitation, sweating, tremor, diarrhoea, temperature 39.6 and rising. registrar Toxicology ~6 min EtCO₂ climbing under a sevoflurane anaesthetic Malignant hyperthermia Mr E., 19, healthy, under sevoflurane for an open fracture fixation. Forty minutes in: EtCO₂ 62 and rising despite doubling the minute ventilation, HR 130, masseter spasm was noted at induction after suxamethonium. consultant Toxicology ~6 min Hypothermic, bradycardic, sodium 118, "just a chest infection" Myxoedema coma Mrs T., 71, found drowsy and cold at home in July by her daughter after a week of "flu". Thyroidectomy 20 years ago, stopped her levothyroxine when it ran out months ago. Temperature 32.4 °C. consultant Metabolic & endocrine ~7 min Platelets 12, schistocytes, and a stroke in a 30-year-old Thrombotic thrombocytopenic purpura Ms R., 30, three days of headache, bruising and dark urine. This morning: a transient right-sided weakness and confusion. Platelets 12, Hb 68, creatinine 140, LDH very high, schistocytes 5% on the film. consultant Haematology & oncology ~7 min Ten minutes into the second unit: rigors, back pain, red urine Acute transfusion reaction What this teaches: Know the first minutes of a suspected transfusion reaction: stop, support, check and report. Mr O., 45, admitted with an upper GI bleed. Ten minutes into the second unit of red cells: rigors, loin pain, hypotension, the urine in the catheter turns red. The ward is busy and the units were "checked at the desk". Beginner registrar Haematology & oncology ~6 min Burkitt lymphoma, first dose of chemotherapy, potassium 7.1 Tumour lysis syndrome Master J., 14 (52 kg), Burkitt lymphoma with a large abdominal mass. Received the first dose of cyclophosphamide and vincristine 12 hours ago. Now vomiting, cramps, urine output falling, K 7.1. registrar Haematology & oncology ~6 min Post-op day 2, sweating, seeing rats on the wall Alcohol withdrawal and delirium tremens Mr M., 48, admitted for an emergency hernia repair 2 days ago. Drinks "a few" beers daily — actually a bottle of Konyagi. Now: tremor, sweating, HR 128, BP 178/100, terrified, picking at the sheets, seeing rats. registrar Toxicology ~6 min Boda-boda versus lorry: paradoxical breathing and a white left lung Flail chest and haemothorax Mr K., 34, motorcycle rider struck by a lorry. Left chest wall moves paradoxically. SpO₂ 86%, HR 128, BP 92/60. Chest film: fractures of left ribs 3–9, some in two places, and a white left hemithorax. consultant Trauma & obstetric ~7 min Rice-water stools all night, no pulse at the wrist Cholera with severe dehydration What this teaches: Recognise severe dehydration and replace fluid quickly, then keep reassessing. Mr S., 40, from a camp with an outbreak. Twenty watery stools and vomiting overnight. Arrives carried, eyes sunken, skin pinch goes back very slowly, no radial pulse, drowsy. Weight ~60 kg. Beginner registrar Sepsis & infection ~6 min Day 14 after the cardiac arrest, the family asks what happens now Withdrawal of life-sustaining treatment Mrs A., 66, out-of-hospital arrest 14 days ago, 30 minutes of CPR. Ventilated since. Off sedation for 10 days: no eye opening, extensor posturing, myoclonus, bilaterally absent N20 on SSEPs, EEG burst suppression, MRI with diffuse cortical injury. consultant Neuro ~7 min Charcoal brazier in a closed room, three people unconscious Carbon monoxide poisoning Ms F., 26, found unconscious with her two children beside a charcoal brazier in a closed room on a cold night. GCS 9. SpO₂ 98% on the finger probe. Children at the paediatric unit. registrar Toxicology ~6 min Found in a ditch after the rains, core 26 °C, "no pulse" Severe accidental hypothermia Mr B., 55, homeless, found in a flooded ditch in Mbeya at dawn after a night at 8 °C. Unresponsive, rigid, no palpable pulse. Oesophageal temperature 26.2 °C. Monitor: slow, wide complexes at 24/min. consultant Metabolic & endocrine ~7 min On warfarin for a metal valve, INR 4.2, and a 30 mL bleed Anticoagulant-associated intracerebral haemorrhage Mrs J., 62, mechanical mitral valve on warfarin. Sudden headache and left-sided weakness 90 minutes ago. BP 210/118. CT: 30 mL right basal ganglia haemorrhage, no intraventricular extension. INR 4.2. consultant Neuro ~7 min Post-partum headache, then a seizure, then "a stroke that bleeds" Cerebral venous sinus thrombosis Ms N., 27, ten days after a normal delivery. A week of worsening headache, now a generalised seizure and a right arm weakness. CT: left parietal haemorrhage with surrounding oedema, not in an arterial territory. registrar Neuro ~6 min Hypertensive crisis in theatre, then shock when the tumour comes out Phaeochromocytoma crisis Mr A., 39, booked for a "renal cyst" excision. On handling the mass: BP 260/140, HR 150, pulmonary oedema on the table. The surgeon stops. Nobody had heard of his episodic headaches and sweats. consultant Metabolic & endocrine ~6 min Haloperidol for agitation, three days later: rigid, febrile, mute Neuroleptic malignant syndrome Mr G., 32, schizophrenia, admitted acutely psychotic and given IM haloperidol repeatedly for 3 days. Now: temperature 40.1, lead-pipe rigidity, mute, HR 130, BP labile 90/60 to 180/110, CK 22,000. registrar Toxicology ~6 min Fever for three weeks, ferritin 42,000, everything failing Haemophagocytic lymphohistiocytosis Mr T., 28, HIV negative. Three weeks of fever, now pancytopenia, hepatosplenomegaly, jaundice and hypotension. Treated for malaria (negative), typhoid, then "culture-negative sepsis" with four antibiotics. Ferritin 42,000. consultant Haematology & oncology ~7 min Bipolar disorder, a diarrhoeal illness, and a new tremor that became a coma Lithium toxicity Mrs P., 54, on lithium for 15 years, also bendroflumethiazide and ibuprofen for a knee. Five days of gastroenteritis. Now: coarse tremor, ataxia, confusion, then a seizure. Lithium 3.6 mmol/L, creatinine 260. registrar Toxicology ~6 min Loin pain, rigors, and a stone that nobody drained Obstructed infected kidney Mrs L., 48, diabetic. Two days of left loin pain and rigors, vomiting. Now: temperature 40.1, BP 78/46, HR 132, lactate 5. Ultrasound: left hydronephrosis; CT: 9 mm stone at the pelvi-ureteric junction. registrar Surgical & GI ~6 min Day 12: failed three breathing trials, the family asks "why not just take the tube out?" Difficult weaning and the tracheostomy decision Mr O., 66, COPD and heart failure, ventilated 12 days for pneumonia. Pneumonia resolved. Three spontaneous breathing trials failed with tachypnoea and sweating within 20 minutes. Sedated lightly, weak, RASS −1. consultant Respiratory ~7 min A dog bite six weeks ago, now hydrophobia Rabies encephalitis Mr M., 34, bitten on the hand by a stray dog six weeks ago; washed it, no vaccine. Three days of fever and tingling in the hand, now agitation, spasms when offered water, hypersalivation. consultant Sepsis & infection ~6 min Fever and bleeding in a nurse back from an outbreak district Suspected viral haemorrhagic fever Ms K., 29, a nurse who returned 9 days ago from a district with confirmed Marburg cases. Fever 39.8 for 3 days, vomiting, diarrhoea, now bleeding gums and a petechial rash. She walked into the emergency department. consultant Sepsis & infection ~7 min Home-preserved fish, then descending paralysis and dilated pupils Botulism Ms W., 41, ate home-fermented fish at a family gathering 2 days ago. Now: double vision, drooping eyelids, difficulty swallowing and speaking, dry mouth, and her arms are getting weak. Alert. Two relatives have the same. consultant Neuro ~6 min Her mother's pregnancy tablets, and a deceptive quiet phase Iron overdose Ms E., 17, took 60 ferrous sulphate 200 mg tablets (≈ 65 mg/kg elemental iron) 3 hours ago after an argument. Vomited four times, abdominal pain, one bloody stool. Now "feels better". registrar Toxicology ~6 min 32 weeks, collapsed on the ward, RV the size of the LV Massive pulmonary embolism in pregnancy Mrs U., 30, 32 weeks pregnant, admitted 3 days ago with a swollen left leg treated as cellulitis. Collapsed walking to the toilet: SpO₂ 82%, BP 76/48, HR 138. Echo: dilated RV, septal bowing, McConnell sign. consultant Trauma & obstetric ~7 min The central line came out with the patient sitting up Venous air embolism Mr H., 58, day 7 in ICU after pancreatitis. A nurse removes his internal jugular central line while he is sitting up at 45°, breathing spontaneously. He gasps, becomes agitated, then collapses. SpO₂ 78%, BP 70/40, a "mill-wheel" murmur. registrar Cardiac ~5 min Grandmother's glibenclamide, and the glucose that keeps falling Refractory hypoglycaemia Mr D., 74, type 2 diabetes on glibenclamide and metformin, creatinine 190. Poor intake for 3 days with a chest infection. Found unresponsive at home: glucose 1.4. Given 50 mL of 50% dextrose by the ambulance — woke, then fell asleep again. registrar Metabolic & endocrine ~5 min Influenza season, P/F 70, and the question of proning Viral pneumonia with severe ARDS Mr V., 44, obese (BMI 38), 5 days of influenza-like illness. Now on high-flow nasal oxygen 60 L/min FiO₂ 1.0: SpO₂ 86%, RR 38, bilateral infiltrates. Influenza A PCR positive. No vaccine this year. consultant Respiratory ~8 min Started ART two weeks ago, now worse than before HIV–TB and paradoxical IRIS Ms G., 33, diagnosed with HIV (CD4 22) and disseminated TB 6 weeks ago; TB treatment started, ART (TLD) started 2 weeks ago as per guidelines. Now: fever 39.6, worsening breathlessness, enlarging neck nodes, and drowsy. consultant Sepsis & infection ~7 min Missed dialysis for two weeks: fits, a pericardial rub, and no urine Uraemic emergency Mr B., 50, on haemodialysis for hypertensive nephropathy; missed 6 sessions because the family could not pay. Brought in confused, breathless, with a generalised seizure. Urea 62, K 7.4, pericardial rub. registrar Metabolic & endocrine ~6 min Day 10 after chemotherapy, a temperature of 38.2 and "she looks fine" Neutropenic sepsis Ms A., 46, breast cancer, docetaxel 10 days ago. Rang the ward with a temperature of 38.2 and shivers; told to take paracetamol and come in the morning. Arrives at 06:00: HR 124, BP 88/54, neutrophils 0.1. registrar Haematology & oncology ~6 min White count 240, breathless, and a headache that is a warning Hyperleukocytosis and leukostasis Mr J., 24, two weeks of fatigue and bruising. WBC 240 ×10⁹/L, blasts on the film — acute myeloid leukaemia. Breathless, SpO₂ 88%, headache, blurred vision, priapism. consultant Haematology & oncology ~6 min Platelets halved on day 7 of heparin, and a new clot on the old clot Heparin-induced thrombocytopenia Mrs Q., 58, ICU day 8 after a hip fracture repair, on unfractionated heparin prophylaxis. Platelets 260 → 95 over 3 days. This morning: a new swollen right leg and a cold, painful left foot. consultant Haematology & oncology ~6 min Day 5 after the colectomy: AF, a fever, and a surgeon who says "ileus" Anastomotic leak Mr R., 67, anterior resection for rectal cancer 5 days ago. New AF at 140 overnight, temperature 38.7, abdominal pain worse, no flatus, creatinine rising. The team calls it a chest infection and an ileus. consultant Surgical & GI ~7 min A huge abdomen, a coffee-bean on the film, and blood on the tube Sigmoid volvulus with ischaemia Mr E., 70, from a village with a high-fibre diet, previous episodes of "twisted bowel". Three days of absolute constipation and a massively distended abdomen. Now vomiting, HR 120, and the rectal tube brought back dark blood. registrar Surgical & GI ~6 min Three antibiotics, a bloated abdomen, and a white count of 40 Fulminant Clostridioides difficile colitis Mrs H., 62, treated for a diabetic foot infection with 4 weeks of antibiotics, on a PPI. Ten days of diarrhoea, now less diarrhoea but a distended, silent abdomen, fever, confusion. WBC 42, lactate 3.8, creatinine 200. consultant Surgical & GI ~6 min Bruises, a nosebleed that will not stop, and a marrow full of promyelocytes Acute promyelocytic leukaemia with DIC Ms K., 31, two weeks of bruising and gum bleeding, today a nosebleed for 3 hours. Hb 72, platelets 18, WBC 3.2 with abnormal promyelocytes with Auer rods on the film. Fibrinogen 0.6, INR 2.4, D-dimer very high. consultant Haematology & oncology ~6 min A 19-year-old with a hemiparesis, and a transfusion that made her Hb fall Sickle cell stroke and hyperhaemolysis Ms O., 19, HbSS. Sudden left hemiparesis and dysarthria this morning. Hb 70 (baseline 78), transfused twice in the past year. CT: no haemorrhage. MRI/MRA: right MCA infarct with vasculopathy. consultant Haematology & oncology ~6 min Back pain for a month, legs weak since yesterday, and a prostate nobody examined Malignant spinal cord compression Mr P., 68, thoracic back pain for a month treated as "muscular", now unable to walk since yesterday evening, numb from the nipples down, and has not passed urine today. A hard, craggy prostate. registrar Haematology & oncology ~5 min A swollen purple face, a mediastinal mass, and an airway that closes lying down Superior vena cava obstruction with stridor Mr N., 28, three weeks of cough and night sweats. Today: a swollen face and neck, dilated chest-wall veins, and he cannot lie flat — stridor when he tries. Chest X-ray: a large anterior mediastinal mass. consultant Haematology & oncology ~5 min Day 4 post-MI: a new murmur, then flash pulmonary oedema Acute mitral regurgitation after infarction Mr S., 61, inferior STEMI 4 days ago, lysed late (no PCI locally). This morning: sudden breathlessness, a new pansystolic murmur at the apex, SpO₂ 82% on 15 L, BP 84/60. consultant Cardiac ~7 min AF at 160 on noradrenaline: rate, rhythm, or leave it? New atrial fibrillation in septic shock Mrs T., 70, pneumonia with septic shock, day 2, noradrenaline 0.3 µg/kg/min. Overnight: new AF at 160, BP fell from 104/60 to 82/50, urine output halved. registrar Cardiac ~6 min A 24-year-old with "gastroenteritis", an EF of 15%, and no cath lab Fulminant myocarditis Mr V., 24, a week of fever and diarrhoea, now chest pain, breathlessness and syncope. ECG: diffuse ST changes, low voltage. Troponin 9,000. Echo: EF 15%, thick oedematous walls, small effusion. BP 76/50. consultant Cardiac ~7 min Two days of "gastritis" in a man on diclofenac, now board-like Perforated peptic ulcer with delay Mr W., 58, diclofenac daily for back pain, no PPI. Sudden severe epigastric pain 2 days ago, treated at a dispensary with omeprazole and antacids. Now: rigid abdomen, fever, HR 128, BP 88/56. registrar Surgical & GI ~6 min Fresh blood, no source on scope, and a haemodynamically unstable man Massive lower GI bleed Mr Y., 72, on rivaroxaban for AF. Passing large volumes of fresh red blood since dawn. HR 118, BP 84/52 after 2 units. Upper endoscopy this afternoon: normal to the second part of the duodenum. consultant Surgical & GI ~6 min Right upper quadrant pain for two weeks, then a peritonitic collapse Ruptured amoebic liver abscess Mr Z., 38, two weeks of fever, right upper quadrant pain and a dry cough. Today: sudden severe generalised abdominal pain and collapse. Ultrasound: a 12 cm liver abscess in the right lobe with free fluid. consultant Surgical & GI ~6 min Charcot’s triad, then Reynolds’ pentad Acute ascending cholangitis Mrs I., 62, known gallstones. Two days of fever and right upper quadrant pain, today confused and jaundiced. BP 78/48, HR 128. registrar Sepsis & infection ~6 min New hypoxia minutes after a plasma transfusion Transfusion-related acute lung injury Mrs J., 55, receiving FFP for a coagulopathy before a procedure. Ninety minutes into the transfusion: acute breathlessness, SpO₂ 78%, fever, frothy secretions from the ET tube (she was already intubated for an unrelated reason). registrar Haematology & oncology ~6 min Chest pain and ST elevation the day after her husband’s funeral Takotsubo (stress) cardiomyopathy Mrs D., 68, no cardiac history, buried her husband yesterday. Sudden central chest pain and breathlessness this morning. ECG: anterior ST elevation. BP 88/56, HR 110. registrar Cardiac ~6 min Inferior STEMI, clear lungs, and hypotension that worsens with GTN Right ventricular infarction Mr S., 57, sudden central chest pain 2 hours ago. ECG: inferior ST elevation. Given sublingual GTN by the ambulance crew for the pain — BP fell from 110/70 to 76/48 immediately afterward. registrar Cardiac ~6 min A scarred uterus, a sudden pain that stopped, and a fetal heart that vanished Uterine rupture Mrs N., 32, para 2 (one previous caesarean), 39 weeks, attempting a vaginal birth after caesarean. Sudden severe abdominal pain during a strong contraction, then the pain paradoxically eased. The fetal heart rate has become undetectable. Contractions have stopped. BP 84/50, HR 128. consultant Trauma & obstetric ~7 min Floodwater, then jaundice, kidney failure and a bleeding lung Severe leptospirosis (Weil’s disease) Mr O., 34, waded through floodwater two weeks ago clearing a drain. Five days of fever and severe muscle aches (calves especially), now jaundiced with reduced urine output and today coughing blood-streaked sputum. consultant Sepsis & infection ~7 min A deliberate overdose 6 hours ago, and a nomogram to read correctly Paracetamol overdose within the treatment window Ms P., 19, ingested approximately 24 g of paracetamol (about 40 tablets) 6 hours ago after an argument, now presents feeling well with mild nausea. No other co-ingestants admitted. registrar Toxicology ~6 min A femur fracture, then a petechial rash and confusion two days later Fat embolism syndrome Mr Q., 26, closed femoral shaft fracture from a motorcycle crash 2 days ago, awaiting fixation. Today: acute confusion, breathlessness, and a petechial rash across the chest, neck and conjunctivae. registrar Respiratory ~6 min
🎲 Random patient 124 cases · no clock unless you switch on Challenge mode · best scores on this device; every finished case is also saved to your account