HKCEM College monthly meeting

OSCE August 2015

AEDQEH

Q1 A 29-year-old lady sust

ained a fall at home with right eye injury.

1.1 Describe ONE important x ray finding? (1 mark)1.2 What is the name of the sign? (1 mark)1.3 What is the diagnosis? (1 mark)

orbital emphysema / intra-orbital air

Black eyebrow sign

Orbital fracture

1.4 Name 3 the other radiographic signs that may be found in this condition? (not necessarily in this patient) (3 marks)

1.Maxillary sinus opacification or air/fluid level

2.Tear-drop sign - herniation of orbital contents into the roof of maxillary sinus

3.Trap-door sign - orbital floor is obliterated, widened, displaced downward or fragmented and seen as a bright white line within maxillary sinus

4.Opacification of ethmoid air cells

1.5 Name 3 management principles for this patient? (3 marks)

1.Exclude associated ocular injury (present in 35%) - check visual acuity, intraocular pressure, eye motility

2.Prophylactic antibiotics

3.Analgesics

4.Refer/ consult ophthalmologist

1.6 What is your advice to the patient before discharge? (1 mark)

Instruct patient not to blow the nose

Q2

A 20-year-old man complained of left chest pain after being hit by others during basketball game.

2.1 What are the TWO X-ray findings? (2 mark)

Linear air collection adjacent to the

1.mediastinum and

2.heart border

2.2 Name 4 possible causes of the above condition. (4 marks)

1.Spontaneous pneumomediastinum due to

Use of abusive drugs, e.g. cocaine, ectasy

Asthma

Rapid ascent during scuba diving

2.Blunt trauma to the chest

3.Positive pressure ventilation in noncompliant lungs

4.Boerhaave’s syndrome

2.3 What are the TWO clinical signs that may be present in physical exam? (2 marks)

1.Hamman’s (Hammond) sign - clunching or clicking sound synchronous with heart beat

2.Surgical emphysema over neck or chest wall

2.4 Name 2 other radiographic signs that may be found in this condition? (2 marks)

1.Continuous diaphragm sign

2.Naclero’s V sign

3.Ring around the artery sign

Q3

A 62-year-old gentleman with history of ischemic cardiomyopathy and ICD implantation. He complained of palpitations and shocks delivered by ICD.

3.1 What are the functional capabilities of an ICD? (2 marks)

1. Pacemaker2. Cardioverter Defibrillator

3.2 What is the ECG rhythm? (1 mark)

Paced rhythm

3.3 Name 3 management principles for this patient? (3 marks)

1.IV access 2.blood tests (electrolytes, cardiac enzymes)

3.Cardiac monitoring

4.Admission for evaluation by cardiologist and ICD interrogation

3.4 After you have finished your physical examination, he complained of palpitations and dizziness. BP rechecked 80/42.What is the ECG rhythm? (1 mark)

Wide complex tachycardia / ventricular tachycardia

3.5 What should be the treatment now? (1 mark)

1.Synchronised cardioversion

3.6 Any precautions with your treatment? (2 marks)

1.The sternal paddle should be placed at least 10 cm away from the ICD2.Wear gloves (when touching the patient – not to be shocked by the ICD)

Q4

This 54-year-old woman attended AED after right index finger injury by snake bite a few hours ago. From the patient’s discription, it was a Bamboo snake.

4.1 Name 2 clinical features which may suggest significant envenomation by Bamboo snake in this patient? (2 marks)

1.Significant pain

2.Rapidly progressive swelling beyond area of bite

3.Ecchymosis, petechiae, systemic bleeding

4.Incoaguable blood

4.2 Name 4 investigations, with reasons, that would be useful in monitoring of this patient? (4 marks)

Coagulation study - 20 minute whole blood clotting time, PT, APTT, fibrinogen and FDP

WBC – signs of infection

CK – Rhabdomyolysis

RFT – renal impairment due to Rhabdomyolysis

K – Rhabdomyolysis -> AKI & hyperK

4.3 What 2 anti-venoms are available in HK for this Bamboo snake envenomation ? (2 marks)

Green pit viper antivenom (Thai Red Cross)

Agkistrodon halys (Shanghai Institute of Biological Products)

This patient complained of severe right hand pain despite analgesics.

The Orthopaedic surgeon is worrying about Compartment syndrome and is planning for fasciotomy.

4.4 What precaution need to be taken BEFORE the surgical procedure? (1 mark)

Monitor coagulation profile & give antivenom if deranged

4.5 What is the percentage of patients requiring operation after Bamboo snake bites? (1 mark)

Around 3 % (HKPIC data)

Q5

• A 39-year-old man with unremarkable past health attended AED for seizure.

5.1 Name 4 causes of seizure. (4 marks)

Metabolic - hypoNa, hypoCa, hypoglycemia

Infectious - meningitis, encephalitis, brain abscess

CNS structural lesions - tumor, hemorrhage

Intoxications - TCA, camphor, tetramine

5.2 Describe 2 CT abnormalities? (2 marks)Hyperdense lesion over R frontal region Mild focal oedema with mild Mid-line shift

5.3 What is the likely Dx? (1 mark)

Arterio-venous malformation with calcification in right frontal region

5.4 What is the most important and useful investigation of choice? (1 mark)

Cerebral angiogram

5.5 Name 2 definite treatment options? (2 marks)

1.Surgical resection

2.Endovascular embolization

3.Radiosurgery - gamma knife