Transcript OSCE 26th March, 2014

HKCEM
College monthly meeting
OSCE
August 2015
AED
QEH
Q1
 A 29-year-old lady
sustained 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. Pacemaker
2. 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 ICD
2.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