1 / 55

OSCE answers

OSCE answers. JCM 1Feb2017 POH Joseph Tse. Case 1 . 49/F Good past health. Not on medication C/O Epigastric pain for 2 hours BP 210/90 SpO2 100% on room air Abdomen soft Name 3 life threatening ddx. Life threatening ddx Acute Coronary syndrome Acute Aortic syndrome Pancreatitis

bosticf
Download Presentation

OSCE answers

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. OSCE answers JCM 1Feb2017 POH Joseph Tse

  2. Case 1 49/F Good past health. Not on medication C/O Epigastric pain for 2 hours BP 210/90 SpO2 100% on room air Abdomen soft Name 3 life threatening ddx

  3. Life threatening ddx • Acute Coronary syndrome • Acute Aortic syndrome • Pancreatitis • Diabetic Ketoacidosis • Mesenteric ischemia • Ruptured viscera eg PPU • Pregnancy complications: HELLP/ ectopic

  4. Describe ECG. Worrisome?

  5. Describe the ECG • SR. normal Axis. Normal PR, QRS, QT interval • LVH (R aVL>11mm , S v1+ R v5 >35mm) • Ventricular ectopics • STE aVR, v1, v2 • ST depression I, II, aVL, v5-6 • Twi I, II, aVL v3-6 Worrisome features: • Wide spread horizontal ischemia • STE in AVR • Left main/ proximal LAD, Tri-vessels disease. Diffuse subendocardial ischemia • Ventricular ectopics close to T wave • R-on-T

  6. Concave vs convex ST LVH and the diagnosis of STEMI - how should we apply the current guidelines? Journal of Electrocardiology 2014:47,655-60. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine https://drsvenkatesan.com/2009/12/12/how-to-differentiate-lv-strain-pattern-from-primary-lv-ischemia/

  7. While taking the CXR, she was found unresponsive What is this? What is the treatment?

  8. Polymorphic ventricular tachycardia • same strategy as VF • Resuscitation ACLS 2015 • Immediate Defibrillation • High Quality CPR • Amiodarone/ Lignocaine • Cardiac reperfusion • Consider ECPR

  9. What is the in-patient mortality in STEMI? • STEMI 5-6% • NSTEMI 2% Long term (1yr) mortality similar • What are the causes of early mortality? • Lethal arrhythmia • Ongoing infarct • Cardiogenic shock • Mechanical complications • Ruptured Mitral valve papillae • Septum/ Wall rupture • Aneurysm embolic event • Others • Pericarditis. Dressler Syndrome • Bleeding after thrombolytic • What are the high risks group? • Disease Factor: cardiac arrest. Prior MI. Killip class. Hypotension. tachycardia • Patient : Age. DM. chronic kidney disease. smoking • Modifiable: Time to reperfusion O’Gara et al.2013 ACCF/AHA STEMI Guideline. JACC Vol. 61, No. 4, 2013

  10. Timeline for AMI complications GW Reed, JE Rossi, CP Cannon. Acute myocardial infarction. Lancet 2016 11

  11. Timeline for AMI complications GW Reed, JE Rossi, CP Cannon. Acute myocardial infarction. Lancet 2016 12

  12. Case 2 56/M Hypertension on Atenolol/ Norvasc/ Acertil C/O chest pain radiated to back BP 96/53 P72 RR20 SpO2 96% on room air ECG normal. Hb 12.8 Comment on the vital signs Name 2 important physical signs Suggest a Point-of-care investigation

  13. Comment on the vital signs • In Shock • Pulse rate not raised (B-blocker effect) • Tachypnea Name 2 important physical signs • Vascular insufficiency • Murmur (AR early diastole) • Pulse deficit (radio-radial, radiofemoral delay) • Tamponade • Beck’s Triad: distended neck veins. muffled heart sound • Pulsus paradoxus Suggest a Point-of-care investigation Ultrasound- cardiac probe • Parasternal long axis (Aortic root, effusion) • Suprasternal notch (Aortic arch)

  14. Parasternal long axis http://www.echocardiographer.org/TTE.html

  15. Suprasternal notch Image http://echocardiographer.org/TTE.html

  16. Describe the abnormal CXR • Widened mediastinum • Left lung field opaque • Abnormal aortic contour (bulging left hilum) • Name 3 CXR signs • Pleural effusion/ Apical capping • Calcium sign • Deviated trachea/ main bronchus • (NG tube deviation)

  17. Describe the CT Contrast • Coronal • flap from descending aorta down to at least the renal artery • Out-Bulged descending thoracic aorta • Surrounded by acute hyperdense hematoma • Axial • Periaortic hematoma • Left hemothorax • What is the diagnosis? • dissection of descending aorta complicated with rupture

  18. Name the disease spectrum. • Acute aortic syndrome SA LeMaire, L Russell, Epidemiology of thoracic aortic dissection. Nature. Review Cardiol. (2011)10,1038 RE Clough, CA Nienaber. Management of acute aortic syndrome. Nature. Review. Cardiol.(2015) 12, 103–114

  19. 2010 AHA Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease. Circulation. RE Clough, CA Nienaber. Management of acute aortic syndrome. Nat. Rev. Cardiol.(2015) 12, 103–114

  20. What is the classification? • Debakey III/ Stanford B • Cut off at left subclavian artery What is the treatment? Complicated Type B • Early definitive Tx (TEVA/ open repair) • Supportive • Pain control. Less catecholamine. Less shearing • Permissive hypotension with Balanced transfusion What are the indications for operation? Aortic rupture, malperfusion (liver, kidney, mesentery, limbs), Failed medical treatment (pain, uncontrolled HT, expanding size) 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases. European Heart Journal (2014) 35, 2873–2926

  21. Case 3 • 46/M fell while climbing down from lorry driver seat • C/O left ankle pain • Difficult to walk

  22. Describe X-ray. 2 Classifications. Stable?

  23. Describe the X-ray • AP ankle: • Fractured left medial malleolus • Soft tissue swelling • Oblique radiolucent line in proximal left fibula • Tibiofibular clear space widened. Tibiofibular overlap diminished (best to compare the normal site) • Lat: Fractured posterior malleolus • Name 2 Classification systems • Mechanism • Lauge-Hansen: Foot Position. Force applied • Anatomical • Danis-weber: fibular fracture site relative to syndesmosis • AO: Weber + fragments sites • Pott’s: Parts involved • Isolated/ bimalleolar • Bimalleolar equivalent: lateral malleolus + deltoid ligament injury • Tri-malleolar: (lateral + medial + posterior)

  24. Stable or not? Ring fails if breaks >=2 point structure surrounding the talus: tibial plafond, medial malleolus, deltoid ligaments, calcaneus, lateral collateral ligaments, and syndesmotic ligaments. Simon RR, Koenigsknecht SJ:Emergency Orthopedics: The Extremities, 2nd ed. Norwalk, Conn,Appleton & Lange, 1987.

  25. syndesmosis Stiehl JB: Ankle fractures with diasthesis. Instr Course Lect 39[III]:79, 1990

  26. Re-attended

  27. Diagnosis? • Maisonneuve fracture. Weber C unstable fracture • Mechanism of injury? • Pronation External rotation • sequence: • medial malleolus #, syndesmosis injury • proximal fibular # (Force transmitted through the interosseous membrane) • posterior malleolus # (avulsion from posterior tibiofibular ligament ) • Treatment? Pain control, immobilization admit for • ORIF to medial malleolus • +/- posterior malleolus • syndesmosis screw fixation • Similar condition in upper limb 1. Galeazzi fracture (GFR) 2. Monteggia fracture (MSU) 3. Essex-Lopresti fracture

  28. Case 4 M/51 Good past health. No recent travel Chills for 1 week Hiccup and abdominal bloating discomfort 2 days Temp 37 What is hiccup?

  29. What is hiccup? • Involuntary, spasmotic contraction of diaphragm and intercostal muscles • Results in sudden inspiration and ends in abruption closure of glottis • What is the reflex arc? • Afferent: phrenic, vagus nerve, sympathetic chain • Central mediator: cord c3-5, brainstem, hypothalamus • Efferent: phrenic nerve to glottis and intercostal muscle • Name 2 drugs for symptomatic relief of hiccup • Chlorpromazine (Largactil ) • Metoclopramide (Maxolon) • Baclofen/ nifedipine/ valporate/ gabapentin/ haloperidol Tintinalli’s Emergency Medicine, 2016. Chapter 62 Respiratory distress p.433

  30. 2 alarming features. 2 causes

  31. What are the 2 alarming features? • Hypoalbuminemia • Raised ALP • What are the causes? Give 2 in each feature • Reversed AG ratio (normal 1.2-1.7) • Low albumin • Production (malnutrition/ liver cirrhosis) • Loss (renal: nephrotic. GI: enteropathy) • Raised globulin: infection, paraproteinemia • ALP • Bone vs Liver origin • GGT • isoenzymes. (Bone Burns, Liver Lasts) • Liver: cholestasis/ infiltrative SOL • Intrahepatic: drugs, abscess • Extrahepatic: cholangioCA/ pancreatic cancer • Bone: Paget’s disease. Myeloma. Bone metastasis.

  32. cholestatic AP alkaline phosphatase >1.5UNL 5’-Nucleotidase (5NT) KE Shipman, AD Holt, R Gama. Interpreting an isolated raised serum alkaline phosphatase level in an asymptomatic patient. BMJ 2013;346:f976

  33. USG: ill defined iso-to-hypoechoic mass

  34. Describe the CT • Axial CT with contrast, Arterial phase • Mass at right lobe with rim enhancement • Content hypodense • Perilesional edema • No gas collection

  35. What is the diagnosis? Liver abscess Name 3 risk factors? -Diverticulitis. CA colon. Biliary tract infection. -DM. immunocompromised. Alcoholics What to examine if culprit was isolated • Klebsiella pneumoniae? • Lungs, CNS, and eyes ( Empyema/ Meningitis/ Endophthalmitis) 2. Entamoeba histolytica? Travel history. HIV status. Peritoneum, Lung, Heart, CNS (ruptured colitis/ empyema/ pericardium rupture/ Brain abscess) Siu LK et al. Klebsiella pneumoniae liver abscess: a new invasive syndrome. Lancet infectious diseases (2012): 881-887. Stanley Jr SL. Amoebiasis. Lancet 2003;361:1025–34.

  36. Case 5 • 65/F ADL-I • Known HT, poor memory await psy • Noted disoriented to time, place, person for 2 days Afebrile. BP 120/80 P72 GCS 15. 4 limbs Power full Name 2 point-of-care investigations

  37. Give 2 point-of-care investigations • Hemoglucostix • I-stat for sodium What is delirium? How to differentiate from dementia? Name 4 components of mental state exam Name 2 assessment tools Suggest 3 red-flag signs in a confused patient Name 3 types of dementia

  38. Delirium • Diagnostic and Statistical Manual of Mental Disorders (DSM) 5th ed, 2013 • Acute onset • Inattention • Cognition disturbance (Memory. Disorientation. Language. Perception) • not explained by pre-exisiting neurocognitive disorder. not in the context of a severely reduced level of arousal • Due to medical condition, substance intoxication or withdrawal

  39. Comparison Tintinalli’s Emergency Medicine, 2016. Section 24 Psychosocial disorder p.1958

  40. Mental state exam • Objective • Appearance, behavior, speech, cognition • Subjective • Mood, thoughts, perception and insight

  41. Delirum Assessment tools

  42. Approach an elderly with altered mental state • Screen first, then test JH Han et al. Diagnosing Delirium in Older Emergency Department Patients: Validity and Reliability of the Delirium Triage Screen and the Brief Confusion Assessment Method. Annals of Emergency Medicine 2013;62:457-65

  43. Cognitive screening • Abbreviated Mental Test • Quick confusion Scale • Montreal Cognitive Assessment Other aspects • Suicidal (SAD PERSONS) • Depression (Halmiton rating scale for depression)

More Related