JCM OSCE PWH A&E 7 August 2019 Case 1 A 70-year-old man presents with low back pain for 1 month, with increased severity for 1 week. Vital signs at triage:
BP 120/75, Physical P 70, Temp 37.8 C, SpO2 98% examination showed tenderness on lumbar spine. Both lower limbs power Grade 4; both upper limbs power Grade 5. Describe the x-ray findings Describe the x-ray findings.
Rims of radiolucency over bilateral psoas shadows Decreased L1/2 disc space Depressed L2 superior endplate Retrolisthesis
L1/2 Degenerative changes in lumbar spine Describe the CT findings. Describe the CT findings. Numerous gas densities in L1 and L2 vertebral
bodies, L1/2 disc, intraspinal canal and bilateral psoas muscles. Focal erosions at L1/2 with depressed L2 superior endplate. Degenerative changes in the spine. What is the likely diagnosis? What is the likely diagnosis? Infective spondylodiscitis of L1-L2 with intraspinal and psoas extensions. What are the possible pathogens?
What are the possible pathogens? Enteric gram-negative bacilli, particularly following urinary tract instrumentation Pyogenic streptococci, including groups B and C/G, especially in patients with diabetes mellitus
Pseudomonas aeruginosa, coagulase-negative staphylococci, and Candida spp, especially in association with intravascular access, sepsis, or injection drug use Nonpyogenic streptococci, including viridans group, milleri group, Streptococcus bovis, and enterococci Tuberculous infection
How would you manage the patient in A&E? How would you manage the patient in A&E? Blood for CBC, ESR, CRP (WBC may be elevated or normal. ESR and CRP are useful for following the efficacy of therapy. Blood culture, urine culture
Analgesic Empirical IV antibiotics (after blood culture): Vancomycin plus (cefotaxime, ceftazidime, ceftriaxone, cefepime or ciprofloxacin) Admit orthopaedics
How would the patient be investigated after admission? How would the patient be investigated after admission? Spinal imaging (MRI spine preferred) (CT may miss early destructive changes and has a high false negative rate for epidural abscess) CT-guided needle biopsy of affected bone +/- aspiration
of abscess (if blood culture is negative and surgical intervention is not warranted) What are the indications for surgical intervention? What are the indications for surgical intervention? Surgical intervention if:
Presence of neurologic deficits Presence of epidural or paravertebral abscesses in need of drainage Threatened or actual cord compression due to vertebral collapse and/or spinal instability
Progression, persistence, or recurrence of disease (as documented by persistently positive blood cultures or worsening pain) despite appropriate antimicrobial therapy Case 2 A 62-year-old presents with sore throat, dry cough and low-grade fever for 2 days. Physical
examination showed hoarseness of voice, congested pharynx and clear chest. No stridor. Vital RA signs: BP 107/77, P 95, Temp 37.7C, SpO2 96% What are the differential diagnosis? What are the differential diagnosis?
Ludwig angina Angioedema Diphtheria Describe the Xray finding. What is the likely
diagnosis? What is the diagnostic sensitivity of a true lateral Xray? Describe the X-ray finding. What is the likely diagnosis? What is the diagnostic sensitivity of a true lateral X-ray? This shows the thumb print sign suggesting the diagnosis of epiglottitis. (It is caused by a thickened free edge of the epiglottis, which causes it appear more
radiopaque than normal, resembling the distal thumb.) The true lateral X-ray has a diagnostic sensitivity of about 75% What are the common aetiological agents? What are the common aetiological agents? Haemophilus influenza type B (HiB)
Group A beta haemolytic streptococci Haemophilus parainfluenza Streptococcus pneumonia
Staphylococcus aureus How would you manage this patient in A&E? How would you manage this patient in A&E? Avoid lying the patient flat and vigorous throat examination.
Supplementary O2 via face mask. IV line + IV antibiotic )Zinacef 1.5g or Augmentin 1.2g or 3 rd generation cephaolosporin), after sepsis work up. Consult ENT surgeon for direct diagnostic visualization of supraglottic are by means of indirect laryngoscopy or flexible laryngoscopy.
Consult ICU for monitoring in ICU where provision is made for emergency tracheal intubation or tracheostomy should cardinal signs of upper airway obstruction developed. Prophylactic intubation is not warranted in all patients. RSI should not be performed in the ED unless in critical condition after prompt and careful collaborative evaluation by a highly experienced
anaesthetist and an emergency physician. How will you manage if the patient deteriorates into respiratory arrest in ED before transfer? How will you manage if the patient deteriorates into respiratory arrest in ED before transfer? Open the airway by proper positioning.
BVM ventilation Intubate with an ET tube approximately one or two sizes smaller than estimated. If intubation failed, perform cricothyrotomy for establishment of a temporary emergency airway.
Adrenaline nebulizer (5ml 1:1000) can be considered in order to buy time to prepare for emergency intubation by experienced personnel. It should be given continuously. Stopping the adrenaline nebulizer abruptly will aggravate the upper airway obstruction. What would you manage differently if the patient were a child? What would you manage differently if the patient were a child?
Avoid any maneuvers that will agitate the child (eg. O2 mask, separation from mother, throat examination, forced recumbency, fearful events like temperature, venipuncture) Oxygen, if needed, should be held nearby but not by a tight fitting mask. Allow the child to assume his/ her preferred posture of comfort
Lateral neck x-ray is not necessary and by disturbing the child may add to the danger of sudden laryngeal obstruction. Prepare equipment for bag-valve mask (BVM) ventilation, endotracheal intubation and needle cricothyrotomy (or min-tracheostomy) Alert paediatrician, anaesthetist, ENT surgeon.
Arrange prophylactic endotracheal intubation in operating theatre (after slow gaseous anaesthetic induction with spontaneous breathing) Case 3 A 74-year-old lady fell from bed at 4am. She then complained of left shoulder pain, left chest wall pain and left buttock pain.
Physical examination showed diffuse tenderness on left lower chest wall. Abdominal examination showed mild tenderness on LUQ. There was no tenderness on left shoulder. Active range of motion of left shoulder was full. Vital signs: BP 147/108, P 56, Temp 37.3 C, SpO2 97% RA She complained of persistent left lower chest wall pain despite 2
doses of IM tramadol 50mg. Blood test showed haemoglobin 9.6 (baseline Hb 8 months ago: 12.7) FAST scan showed free intraperitoneal fluid in Morrisons pouch and perihepatic area. CXR was clear. There was no pneumothorax, pleural effusion or rib fracture. CT abdomen with contrast was requested. Describe the CT findings. Describe the CT findings.
Severe No ruptured spleen with perisplenic hematoma active extravasation to suggest active bleeding Moderate amount of fluid in right perihepatic region, may represent haemorrhage She complained of left shoulder pain despite the lack of signs
of shoulder injury. What is the cause of the pain? What is the name of the sign? She complained of left shoulder pain despite the lack of signs of shoulder injury. What is the cause of the pain? What is the name of the sign? It is pain referred to the left shoulder due to irritation of the phrenic nerve from blood adjacent to the left hemidiaphragm.
It is known as Kehrs sign. Name a grading system for this injury. What is the grading for this patient? The American Association for the Surgery of Trauma (AAST) splenic injury scale. Grade V Grad e Description of splenic injury
I Subcapsular hematoma <10 percent surface area. Parenchymal laceration <1 cm in depth. Capsular tear. II Subcapsular hematoma 10 to 50 percent surface area; intraparenchymal hematoma <5 cm. Parenchymal laceration 1 to 3 cm in depth. III
Subcapsular hematoma >50 percent of surface area; ruptured subcapsular or intraparenchymal hematoma 5 cm. Parenchymal laceration >3 cm in depth. IV Any injury in the presence of a splenic vascular injury or active bleeding confined within splenic capsule. Parenchymal laceration involving segmental or hilar vessels producing >25 percent of devascularization V Any injury in the presence of splenic vascular injury with active bleeding extending beyond the spleen into the peritoneum. Shattered spleen.
1. How should patients with injury of this organ be managed in general? How should patients with injury of this organ be managed in general? Laparotomy is indicated in haemodynamically unstable patients with a positive FAST scan or generalized peritonitis.
Haemodynamically stable patients with low grade (I to II) blunt or penetrating splenic injuries without any evidence for other intra-abdominal injuries, active contrast extravasation, or a blush on CT, may be initially observed safely. Patients with active contrast extravasation or contrast blush on CT scan , or those with high grade (III, IV) splenic injuries should be considered for embolization.
Grade V injuries are generally unsuitable for embolization due to vascular disruption. Failure of embolization indicates the need for surgery. When and what drugs should be given to this patient to reduce the risk of post-operative sepsis? When and what drugs should be given to this patient to reduce the risk of post-operative sepsis? Vaccination
should be given after the 14th postsplenectomy day. Pneumocccal vaccine Haemophilus influenza type b vaccine Meningococcal groups A, C, W 135, Y vaccine
Meningococcal group B vaccine Seasonal influenza vaccine Daily antibiotic prophylaxis (penicillin or amoxicillin) for at least one year following splenectomy.
Case 4 A 43-year-old lady, good past health, presents with headache for 2 days, with increased severity for 1 hour, associated with vomiting. No history of head injury. Physical examination showed power 1/5 on right side and power 3/5 on left side. GCS E4V1M6, BP 113/70, P 75, Temp 35.3 C, SpO2 97% 2L Describe the CT findings. Describe the CT findings.
Acute subarachnoid haemorrhage in basal cisterns, extending to bilateral Sylvian fissures, left cerebral sulci, anterior interhemispheric fissure, prepontine cistern. Acute blood within the third and fourth ventricles. Flaring
of ventricular temporal horns suggestive of early hydrocephalus What specific physical signs will you look for? What specific physical signs will you look for? Meningism Nuchal rigidity - more pronounced on flexion
Kernigs sign pain in hamstrings following extension of the knee from a flexed position with the hip flexed to 90 Brudzinskis sign involuntary hip flexion on passive flexion of the patients neck while in a supine position Retinal subhyaloid haemorrhage in fundoscopy
What are the risk factors for the above diagnosis? What are the risk factors for the above diagnosis? Modifiable risk factors: Hypertension
Smoking Heavy alcohol consumption Oral contraceptives (OCPs)
Arteriovenous malformations Connective tissue disorders (Ehlers-Danlos syndrome, Marfan syndrome) Name 2 clinical grading systems for the above diagnosis. Hunt and Hess grading
(Grade 4) Grade Clinical condition 1 4 Asymptomatic or mild headache and slight nuchal rigidity Moderate to severe headache, stiff neck, no
neurologic deficit except cranial nerve palsy Drowsy or confused, mild focal neurologic deficit Stupor, moderate or severe hemiparesis 5 Deep coma, decerebrate posturing 2 3 World Federation of Neurological
7 to 12 Present or absent 5 3 to 6 Present or absent What treatment can be given in A&E?
What treatment can be given in A&E? Nimodipine 60 mg every four hours Intravenous fluid (usually normal saline) (To keep patient hydrated to minimize the effects of vasospasm and cerebral salt wasting.) Discontinue antithrombotic. (Reverse any anticoagulant effect with
appropriate agents, such as Vitamin K1, FFP, PCC) Control blood pressure. (According to 2012 American Stroke Association guidelines, keep systolic blood pressure < 160mm Hg, preferably with labetalol, nicardipine or enalapril.) May consider antiepileptic drugs in higher risk patients with poor neurologic grade, unsecured aneurysm, and associated intracerebral hemorrhage. Avoid phenytoin due to its association with worse neurologic and cognitive outcome after SAH.
May consider tranexamic acid when definitive treatment of the aneurysm is unavoidably delayed and there are no other contraindications. What further investigations may be requested? What further investigations may be requested? CT angiogram Transcranial Digital
of brain Doppler ultrasonography subtraction angiogram (if high clinical suspicion of aneurysm and aneurysm not detected on CTA) What are the definitive and operative treatments? What are the definitive and operative treatments?
Endovascular Surgical coiling clipping Ventricular catheter insertion for drainage of cerebrospinal fluid What are the potential complications?
What are the potential complications? Vasospasm Rebleeding Hydrocephalus Seizure Delayed cerebral ischemia (DCI) / delayed ischemic neurological deficit (DIND) Hyponatremia
( SIADH/ cerebral salt wasting) Case 5 A 70-year-old had history of loss of consciousness twice in 2010. Holter exam done in 2010 was unremarkable. He first attended GOPC because his wife noticed he was snoring and having difficulty breathing during his sleep. He is then referred from GOPC for abnormal ECG. He does not have chest pain, dyspnea or palpitation recently. Physical
examination : Dual heart sounds, no murmur, chest clear, no ankle edema Vital RA signs: BP 175/95, P 93, Temp 37.5 C, SpO2 99% Describe the ECG. What is the likely diagnosis and which type? Describe the ECG. What is the likely
diagnosis and which type? Sinus rhythm Coved type ST elevation >2mm that descends with an upward convexity to an inverted T wave in leads V1 to V2 Type
1 Brugada ECG pattern What is the pathogenesis of the above diagnosis? What is the pathogenesis of the above diagnosis? Autosomal dominant inheritance with variable expression Mutations Defective
in the SCN genes SCN5A and SCN10A myocardial sodium channels reduce sodium inflow currents, thereby reducing the duration of normal action potentials What are the provoking factors? What are the provoking factors? Fever
Cocaine Hyperkalemia What is the definitive treatment? What is the definitive treatment? Implantable cardioverter-defibrillator
Case 6 A 21-year-old medical student presents with mild bloating sensation in throat after eating noodles this afternoon. No odynophagia. No vomiting. No chest pain. No fever. No dyspnea. Physical examination: chest clear, abdomen soft, throat clear
Vital signs: BP 116/75, P 84, Temp 36.8 C, SpO2 97% RA Describe the x-ray findings. What is the diagnosis? Describe the x-ray findings. What is the diagnosis? Rims of radiolucency outlining mediastinum and tracking up soft tissues of the neck
Pneumomediastinum What specific physical signs will you look for? What specific physical signs will you look for? Subcutaneous (30 to 90 percent of patients) This is typically detected in the neck or precordial area and is moderately sensitive and highly specific for SPM. Hamman's
emphysema sign (12 to 50 percent of patients) This is a crunching, rasping sound, synchronous with the heartbeat, heard over the precordium mainly during systole and particularly in the left lateral decubitus position, and in many occasions associated with muffling of heart sounds What are the causes of the above diagnosis?
What are the causes of the above diagnosis? Vigorous vomiting, coughing, crying, screaming Valsalva maneuver (lifting heavy objects, blowing balloons, labour) Scuba diving
Respiratory diseases (COPD, asthma, Infections (Upper and lower respiratory tract infection, deep neck infection) Inhalation of helium, irritant gases, drugs (eg. cocaine)
How will you treat this patient? How will you treat this patient? Treat conservatively as this is a case of uncomplicated spontaneous pneumomediastinum. Analgesic Rest Avoid maneuver that increase pulmonary pressure
(Valsalva or forced expiration) CT thorax Treat and neck underlying cause
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