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OSCE Answer 02/2015

OSCE Answer 02/2015. TMH AED. Question 1. M/69 Known history of HT, IHD, PVD Sudden onset of constant low back pain BP 162/85mmHg P 78/min. Question 1. Suggest 5 differential diagnosis of acute low back pain Mechanical spinal disease Non-mechanical spinal disease Visceral disease.

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OSCE Answer 02/2015

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  1. OSCE Answer 02/2015 TMH AED

  2. Question 1 • M/69 • Known history of HT, IHD, PVD • Sudden onset of constant low back pain • BP 162/85mmHg • P 78/min

  3. Question 1 • Suggest 5 differential diagnosis of acute low back pain • Mechanical spinal disease • Non-mechanical spinal disease • Visceral disease

  4. Mechanical Spinal Disease • Lumbar strain • Degenerative spine • Spondylolisthesis • Spinal stenosis • Prolapsed intervertebral disc • Osteoporosis • Fracture or facet joint dislocation

  5. Non-Mechanical Spinal Disease • Neoplasia • Multiple myeloma • Bone metastasis • Lymphoma and leukemia • Spinal cord tumour • Infection • Osteomyelitis • Septic discitis • Epidural abscess • Inflammatory arthritis • Ankylosing spondylitis • Psoriatic spondylitis • Reiter disease • Paget disease

  6. Visceral Disease • Pelvic • Chronic pelvic inflammatory disease • endometriosis • Renal • Nephrolithiasis • Pyelonephritis • Perinephric abscess • Gastrointestinal • Acute pancreatitis • Acute cholecystitis • Abdominal aortic aneurysm • Psoas abscess

  7. Red Flag Symptoms

  8. Question 1 • Bedside abdominal USG was performed

  9. Question 1 • What’s the sonographic diagnosis? • 7cm in diameter abdominal aortic aneurysm with concentric hyperechoic lesion signifying thrombus

  10. Question 1 • How to measure the size of the lesion? • Outer to Outer wall • Longitudinal view • Perpendicular to the long axis of aorta

  11. Question 1 • How to classify the type of the lesion using ultrasound? • Identify the origin of the SMA, 2cm below should be the origin of renal arteries • Classify according to the location of the aortic aneurysm • Suprarenal • Juxtarenal • Infrarenal (Ultrasound Clin 2 (2007) 437–453)

  12. Question 1 • State the microbe that is most commonly associated with this condition? • A study in southern Taiwan from 1996 to 2006 on mycotic aneurysm • Salmonella (34.6%) • Klebsiella (11.5%) • Staphylococcus aureus (11.5%) (J MicrobiolImmunol Infect 2008;41(4): 318-324)

  13. Question 2 • F/40 • Good past health • Sudden onset of right sided weakness 1 hour before • BP 180/93 mmHg • P 104/min • GCS 15/15

  14. Question 2 • Urgent CT brain was performed

  15. Question 2 • Described the CT finding • Lossofinsularribbonsign • Aloss of definition of the gray-white interface in the lateral margin of the insular cortex (Radiology. 1990;176(3):801)

  16. Question2 • Suggest 3 more hyperacute stroke CT signs • Hypodensity of basal ganglia

  17. Question 2 • Dense MCA sign

  18. Question 2 • Cortical Sulcal Effacement

  19. Question 2 • Outline subsequent management plan for this patient • Stabilization, history taking and physical examination • Baseline investigations like blood tests, ECG, CXR • Consult neurologist for assessment • Stroke management • Reperfusion therapy and anti-platelet agent EmergMed Clin North Am. 2012 Aug;30(3):713-44

  20. Stroke Management • Fluid • Hypovolemia reduce cerebral perfusion • Hypervolemia cerebral edema • Look for SIADH with hyponatremia • Glucose • Hypoglycemia stroke mimics • Hyperglycemiapoor functional outcome • (Stroke. 2001;32(10):2426)

  21. Stroke Management • Head position • Lying flat would increase mean flow velocity of cerebral artery by 20% in one study (Neurology. 2005;64(8):1354) • Prop up 30° in patients with • Raised intracranial pressure • Risk of aspirations • Cardiopulmonary disease or oxygen desaturation

  22. Stroke Management • Blood pressure control • Blood pressure control within 7 – 10 days post stroke leads to increase 30 days mortality (The Lancet. 22/10/2014 open access) (http://dx.doi.org/10.1016/S0140-6736(14)61121-1) • Goals of blood pressure control • Thrombolytic therapy: SBP < 185mmHg, DBP < 110mmHg • No thrombolytic therapy: SBP <220mmHg, DBP < 120mmHg

  23. Reperfusion Therapy • Intravenous alteplase (tPA) within 4.5 hours from onset • Intra-arterial alteplase (tPA) within 6 hours from onset • Mechanical thrombolysis

  24. Antiplatelet treatment • Aspirin 160 to 320mg daily within 48 hours would decrease recurrent of stroke within 14 days and death within 28 days (International Stroke Trial (IST) and Chinese Acute Stroke Trial (CAST)) • ?Dual antiplatelet treatment with aspirin and clopidogrel (300mg loading, then 75mg daily) for high risk patient (ABCD2 score ≥ 4) (CHANCE trial)

  25. Question 2 • State 3 etiologies for young onset stroke • Cardiac • Congenital heart disease • Endocarditis, cardiomyopathy, prosthetic valve replacement • Haematologic • sickle cell disease • Prothrombolic conditions like antiphospholipid syndrome, protein C deficiency, protein S deficiency etc

  26. Question 2 • State 3 etiologies for young onset stroke • Vasculopathy • Moyamoya disease (primary or secondary) • Dissection • Vasculitis • Substance abuse

  27. Question 2 • Cerebral angiogram was performed after stabilization

  28. Question 2 • Describe the finding • Puff of smoke appearance • Due to collateral vasculature • What is the diagnosis? • Moyamoya disease

  29. Moyamoya Disease • Bilateral stenosis or occlusion of vessels around circle of Willis with prominent collateral circulation • Moyamoya is Japanese, meaning hazy like a puff of smoke in the air • Can lead to both ischemic and haemorrhagic stroke

  30. Question 3 • F/56 • Good past health • Vehicle-pedestrian collision with left knee injury • BP 153/79mmHg • P 95/min

  31. Question 3 • Left knee X-ray was taken

  32. Question 3 • Describe the X-ray finding • Fracture over lateral tibial plateau of the left knee • No depression • What is the classification of the above condition? • Schatzker classification • Which type this patient belonged to? • Type I

  33. Schatzker Classification

  34. Question 3 • What is the mechanism of the injury? • Valgus force with axial loading

  35. Question 3 • Name 4 potential complications • Early complications • Compartment syndrome • Vascular injury (popliteal artery) • Nerve injury (peroneal nerve) • Infection • Deep vein thrombosis

  36. Question 3 • Name 4 potential complications • Late complications • Knee stiffness • Knee instability • Osteoarthritis • Malunion, nonunion • Angular deformity • Late collapse

  37. Question 4 • M/72 • History of DM, HT, SSS on pacemaker • Sudden onset of severe chest pain for 3 hours, only partially relieved by TNG • BP 164/88 mmHg • P 62/min

  38. Question 4 • ECG was performed

  39. Question 4 • Describe the ECG findings • Widen QRS complex with heart rate 60/min (pacemaker beat) • ST elevation in I, aVL, V4-V6 • Reciprocal ST depression in III, aVF

  40. Question 4 • State an ECG criteria for assistance of diagnosis • Sgarbossa criteria • What is the diagnosis? • Acute anteriolateral ST elevation myocardial infarction

  41. Sgarbossa Criteria

  42. Modified Sgarbossa Criteria

  43. Sgarbossa Criteria • ST elevation ≥1 mm in a lead with a positive QRS complex (ie: concordance) - 5 points • ST depression ≥1 mm in lead V1, V2, or V3 - 3 points • ST elevation ≥5 mm in a lead with a negative (discordant) QRS complex - 2 points • ≥3 points, sensitivity 36%, specificity 90% (NEJM 334(8):481-487)

  44. Modified Sgarbossa Criteria • at least one lead with concordant STE (Sgarbossa criterion 1) or • at least one lead of V1-V3 with concordant ST depression (Sgarbossa criterion 2) or • proportionally excessively discordant ST elevation in V1-V4, as defined by an ST/S ratio of equal to or more than 0.20 and at least 2 mm of STE. (this replaces Sgarbossa criterion 3 which uses an absolute of 5mm) • Sensitivity 91%, Specificity 90% (Annals of Emergency Medicine 60 (6): 766–776.)

  45. Question 4 • Outline the management in AED • Recognize emergency condition and manage in resuscitation room with resuscitation equipments standby • Monitoring devices • Set up large bore IV access, blood tests, CXR • Consult cardiologist for assessment • MONA • Reperfusion therapy • Antithrombotic therapy and antiplatelet therapy

  46. Primary PCI • Door to balloon time • 90 minutes in PCI capable hospital • 120 minutes in non-PCI capable hospital • Patients presented more than 12 hours, with cardiogenic shock, electrical instability or persistent ischemic symptoms (2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction)

  47. Thrombolytic therapy • Symptoms within 12 hours with primary PCI not available within 120 minutes • Door to needle time less than 30 minutes • Facilitated PCI is not recommended • Rescue PCI if failed fibrinolysis (2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction)

  48. Thrombolytic therapy • First generation fibrinolytic agents (eg streptokinase) indiscriminately induce activation of circulating plasminogen and clot-associated plasminogen • Second generation fibrinolytic agents (eg t-PA) preferentially activate plasminogen in the fibrin domain • Second generation fibrinolytic agents improve 24 hours, 30 days and 1 year mortality rate in GUSTO trial (Circulation. Oct 10 2000;102(15):1761-5.)

  49. Antithrombotic therapy • Enoxaparin 0.5mg/kg significant reduced clinical ischemic outcome compared with unfractionated heparin in STEMI patient undergoing primary PCI (ATOLL trial. Lancet. Aug 20 2011;378(9792):693-703.)

  50. Antiplatelet agents • Aspirin should be given immediately • Adding clopidogrel 300mg (CLARITY-TIMI 28) is safe and effective • Increase clopidogrel to 600mg in patient with STEMI prior to primary PCI was associated with a smaller infarct size (ARMYDA-6 MI) (J Am CollCardiol. Oct 4 2011;58(15):1592-9.)

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