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JCM OSCE

JCM OSCE. QMH A&E Feb 2014. Case 1. F/32 LBP for one week No fever, no neurological deficits PE unremarkable Xray LS spine. Case 1. Question 1. What is the Xray finding? What could be the DDx?. Question 2. What could be causative organism?. Xray Findings.

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JCM OSCE

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  1. JCM OSCE QMH A&E Feb 2014

  2. Case 1 • F/32 • LBP for one week • No fever, no neurological deficits • PE unremarkable • Xray LS spine

  3. Case 1

  4. Question 1 • What is the Xray finding? • What could be the DDx?

  5. Question 2 • What could be causative organism?

  6. Xray Findings • Loss of L2/L3 disc height. • Erosion with increase sclerosis noted at L2 and L3. Increase left psoas shadow is seen. Pedicle is still preserved.

  7. DDx • Infective vs malignancy • Infective more likely in view of increased psoas shadow and patient’s age

  8. Infective spondylo-discitis • Infection that involves 1 or more of the extradural components of the spine • Organisms: • Staphylococcus aureus (in 60% of patients) and Enterobacter species • Tuberculosis • Fungal (cryptococcus), in immocomprised patient

  9. Progress • Admitted to orthopaedics • CT guided drainage • Pus x C/ST: +ve for AFB • Undergoing Anti- TB treatment

  10. Case 2 • M/20 • Complained of R sided chest pain for one day • No SOB • No history of trauma • PE showed decreased breath sound over R lung

  11. Questions • What are the findings? • How do you manage him? • What are the indications for surgical treatment?

  12. Xray finding • R hydropneumothorax • Trachea and mediastinum is shifted to L side • Absence of pneumomediastinum

  13. Management • Haemodynamic support, oxygen • Early CTS consultation, may need early thoracotomy • Insertion of large bore chest drain (>32 Fr) • Blood (include type and screen)

  14. Indication for surgical treatment • Signs of hypovolemic shock • Continuous bleeding (>100mL/hr) • Persistent air leak • Persistent pneumothorax • Impaired lung expansion • Pachypleuritis • Different from ATLS guideline for traumatic haemothorax (>1500mL first drain or 200mL/hr for >2hr)

  15. Progress • Chest drain inserted, blood drained • Consulted CTSU • emergency VATS clot evaculation, pleurodesis done • Discharge D5

  16. Case 3 • F/21 • PMH: Schizophrenia • Sudden onset of colicky generalised abdominal pain again since after lunch • Small amount BO • PE: abd distension

  17. AXR

  18. Questions • What are the findings? • Name a few differential diagnoses • What is the diagnosis?

  19. Findings • Coffee bean sign noted with apex pointing towards LUQ. • Differential: • Other causes of intestinal obstruction, e.g. bezoar formation (hx of schizophrenia), ileosigmoid knot • Ischemic bowel, ureteric colic, ectopic pregnancy… • Diagnosis: sigmoid volvulus

  20. Progress • Flexible sigmoidoscopy and flatus tube • decompression performed • Discharged D2

  21. Case 4 • F/50 • Found collapsed in hospital canteen • On arrival GCS 14/15 • BP 160/70, P 60 • Tenderness and swelling over right face

  22. CT face

  23. Questions • Please describe the CT scan finding • What do you need to look for in physical examination? • If CT scan is not available, what Xray view will you order? Any pitfall in this view?

  24. CT bone window: • Fracture of lateral wall and floor of Rt orbit • Lateral and medial walls of Rt maxillary sinus. Opacification of Rt maxillary sinus with air-fluid(blood) level

  25. Physical Examination • Signs of extra-ocular muscle entrapment, especially diplopia on upward gaze • Signs of ocular injury, including hyphaema, rupture of eyeball, visual acuity • Causes of her collapse… and injuries in other parts of her body

  26. If CT scan is not available, what Xray view will you order? • Water’s view • Pitfall: Maxillary fluid level may not be appreciated in supine patient lying on stretcher

  27. Progress • seen by EYE • no clinical evidence of muscle entrapment • no globe injury • no indication for ocular intervention • Discharged D4

  28. Case 5 • M/77 • Trip and fell with head and neck injury • Brief LOC • PE: GCS 15/15 • Tenderness over R neck • RUL power 4/5, LUL 5/5

  29. CT brain + neck

  30. CT reconstruction

  31. Questions • What are the CT findings? • What do you need to look for in physical examination • What is the classification of this injury? • What are the possible long term complications in this injury? • Name 2 clinical prediction rules for predicting cervical injury requiring Xray

  32. CT findings: • Fracture odontoid process with posterior displacement of the upper portion -> Hangman’s fracture • Comminuted fracture of the posterior arch of C1 -> Jefferson fracture

  33. Physical examination • Signs of spinal cord compression: • Breathing effort (Diaphragmatic breathing) • Limb numbness/weakness • Anal tone • Distended bladder

  34. What is the classification of this injury? Classified by location of fracture (Anderson and D’Alonzo classification) • Type I (<5%) • Tip of dens at insertion of alar ligament which connects dens to occiput • Usually stable but may be associated with atlanto-occipital dislocation • Type II (>60%) • Most common dens fractures • Fracture at base of dens at its attachment to body of C2 • Type III (30%) • Subdentate—through body of C2 • Does not actually involve dens • Unstable fracture as the atlas and occiput can now move together as a unit

  35. What are the possible long term complication in this injury? • Non-union • Due to limited vascular supply • May occur in 30-50% of Type II fractures, especially in elderly • Malunion • Pseudarthrosis • Neurological deficit from cord injury

  36. Name 2 clinical prediction rules for predicting cervical injury requiring Xray • Canadian C-Spine Rules • NEXUS criteria

  37. Progress • MRI C spine: • No significant cord compression at C1/2 level

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