Transcript JCM OSCE

JCM
OSCE
AED UCH
5/9/2012
Case 1
• 11/M
• Fought with classmate
• Right arm pain with tenderness
1. What is the X-ray finding?
2. Name three differential diagnoses from the
X-ray finding.
3. What will be your management?
1. What is the X-ray finding?
•
Rediolucent transverse line at neck of right
humerus
2. Name three differential diagnoses from the
X-ray finding.
3. What will be your management?
1. What is the X-ray finding?
•
Rediolucent transverse line at neck of right
humerus
2. Name three differential diagnoses from the X-ray
finding.
•
Normal variant of epiphyseal line
•
Little League’s syndrome (overuse syndrome)
•
Post-traumatic fracture of NOH
3. What will be your management?
1.
What is the X-ray finding?
•
2.
Rediolucent transverse line at neck of right humerus
Name three differential diagnoses from the X-ray finding.
•
Normal variant of epiphyseal line
•
Little League’s syndrome (overuse syndrome)
•
Post-traumatic fracture of NOH
3.
What will be your management?
•
Immobilization (arm sling) and FU
Case 2
• 13 months/M
• Cough for 3 days
• Noisy breathing for a day
1.
Name 2 CXR findings. Are they pathological?
2.
Name 3 neck X-ray findings.
3.
What is the diagnosis?
4.
Name 2 medications for the disease.
1.
Name 2 CXR findings. Are they pathological?
•
Steeple sign (subglottic tracheal narrowing) - pathological.
•
Right deviation of trachea – normal variant.
2.
Name 3 neck X-ray findings.
3.
What is the diagnosis?
4.
Name 2 medications for the disease.
1.
Name 2 CXR findings. Are they pathological?
•
Steeple sign (subglottic tracheal narrowing) - pathological.
•
Right deviation of trachea – normal variant.
2.
Name 3 neck X-ray findings.
•
Prevertebral soft tissue swelling, subglottic tracheal narrowing, ballooning of
hypopharynx
3.
What is the diagnosis?
4.
Name 2 medications for the disease.
1.
Name 2 CXR findings. Are they pathological?
•
Steeple sign (subglottic tracheal narrowing) - pathological.
•
Right deviation of trachea – normal variant.
2.
Name 3 neck X-ray findings.
•
3.
What is the diagnosis?
•
4.
Prevertebral soft tissue swelling, subglottic tracheal narrowing, ballooning of
hypopharynx
Croup
Name 2 medications for the disease.
1.
Name 2 CXR findings. Are they pathological?
•
Steeple sign (subglottic tracheal narrowing) - pathological.
•
Right deviation of trachea – normal variant.
2.
Name 3 neck X-ray findings.
•
3.
Prevertebral soft tissue swelling, subglottic tracheal narrowing, ballooning of
hypopharynx
What is the diagnosis?
•
4.
Croup
Name 2 medications for the disease.
•
Dexamethasone (po/IM/IV)
•
Nebulized Adrenaline
Case 3
• 90/M
• Known COAD
• Chest pain for a day
1. Besides the emphysematous and fibrotic
changes of the lung, what are the X-ray
findings?
2. What are the two differential diagnoses?
3. What further imaging is helpful?
4. If the patient deteriorates with SOB, what will
be your management?
1. Besides the emphysematous and fibrotic
changes of the lung, what are the X-ray
findings?
•
Pneumomediastinum, pneumothorax, and
subcutaneous emphysema
2. What are the two differential diagnoses?
3. What further imaging is helpful?
4. If the patient deteriorates with SOB, what will
be your management?
1. Besides the emphysematous and fibrotic changes of
the lung, what are the X-ray findings?
•
Pneumomediastinum, pneumothorax, and
subcutaneous emphysema
2. What are the two differential diagnoses?
•
Spontaneous pneumomediastinum and
pneumothorax
•
Ruptured oesophagus
3. What further imaging is helpful?
4. If the patient deteriorates with SOB, what will be your
management?
1.
Besides the emphysematous and fibrotic changes of the
lung, what are the X-ray findings?
•
2.
What are the two differential diagnoses?
•
Spontaneous Pneumomediastinum and pneumothorax
•
Ruptured oesophagus
3.
What further imaging is helpful?
•
4.
Pneumomediastinum, pneumothorax, and subcutaneous
emphysema
Water soluble contrast study
If the patient deteriorates with SOB, what will be your
management?
1.
Besides the emphysematous and fibrotic changes of the lung, what are
the X-ray findings?
•
2.
Pneumomediastinum, pneumothorax, and subcutaneous
emphysema
What are the two differential diagnoses?
•
Spontaneous Pneumomediastinum and pneumothorax
•
Ruptured oesophagus
3.
What further imaging is helpful?
•
4.
Water soluble contrast study
If the patient deteriorates with SOB, what will be your management?
•
Chest drain insertion
Case 4
• A 59 years old lady was recently prescribed
transdermal patch for treatment of her
Alzheimer’s disease because of poor oral drug
compliance.
• The patient was found to have vomiting,
diarrhoea, dizziness and generalized limb
weakness the day after starting the patch.
• The patient was fully conscious, with blood
pressure 137/73 mmHg and pulse rate of 58
bpm.
• Her pupil size were 2 mm, chest clear on
auscultation and bowel sounds were normal.
1. What is the most likely ingredient in the patches?
2. Which drug class does the drug belong to?
3. Which enzyme is inhibited by the drug?
4. What is the most important step in the management
of this patient?
5. Name the antidote(s) for overdose of this drug.
1. What is the most likely ingredient in the patches?
•
Answer: Rivastigmine
2. Which drug class does the drug belong to?
3. Which enzyme is inhibited by the drug?
4. What is the most important step in the management of this
patient?
5. Name the antidote(s) for overdose of this drug.
1.
What is the most likely ingredient in the patches?
•
2.
Answer: Rivastigmine
Which drug class does the drug belong to?
•
Answer: Carbamate (1 mark) / Cholinesterase inhibitor
(0.5 mark)
3.
Which enzyme is inhibited by the drug?
4.
What is the most important step in the management of this
patient?
5.
Name the antidote(s) for overdose of this drug.
1.
What is the most likely ingredient in the patches?
•
2.
Answer: Rivastigmine
Which drug class does the drug belong to?
•
3.
Answer: Carbamate (1 mark) / Cholinesterase inhibitor
(0.5 mark)
Which enzyme is inhibited by the drug?
•
Answer: Acetylcholinesterase
4.
What is the most important step in the management of this
patient?
5.
Name the antidote(s) for overdose of this drug.
1.
What is the most likely ingredient in the patches?
•
2.
Which drug class does the drug belong to?
•
3.
Answer: Carbamate (1 mark) / Cholinesterase inhibitor (0.5 mark)
Which enzyme is inhibited by the drug?
•
4.
Answer: Acetylcholinesterase
What is the most important step in the management of this patient?
•
5.
Answer: Rivastigmine
Answer: Search and remove all the patches (N.B. 2 more patches
in the axilla of this patient)
Name the antidote(s) for overdose of this drug.
1.
What is the most likely ingredient in the patches?
•
2.
Answer: Rivastigmine
Which drug class does the drug belong to?
•
3.
Answer: Carbamate (1 mark) / Cholinesterase inhibitor (0.5 mark)
Which enzyme is inhibited by the drug?
•
4.
Answer: Acetylcholinesterase
What is the most important step in the management of this patient?
•
5.
Answer: Search and remove all the patches (N.B. 2 more patches in the axilla
of this patient)
Name the antidote(s) for overdose of this drug.
•
Answer: Atropine (Pralidoxime usually not indicated in carbamate poisoning)
• Note:
• Clinical presentation in overdose: CNS depression,
vomiting, diarrhoea, sweating, bradycardia, miosis,
muscle weakness, muscle fasciculations (DUMBELS +
nicotinic over-stimulation) etc
• A patient died from pre-renal failure from excessive
diarrhoea and vomiting
• Patch resembles colour of skin so may be missed if not
searched carefully
• Pseudocholinesterase level may be low but not
predictive of clinical severity
Case 5
• 47/F
• Hx of Antithrombin III deficiency
• Presented with
• Headache for a few days
• Right side weakness for a day
• BP 130/80, p 90/min
• Afebrile
• GCS 13/15; E3V4M6
• PERL
• Right hemi-paresis with power grade 4/5
1.
What is the CT finding?
2.
What is the diagnosis?
3.
Any laboratory test can help to make the
diagnosis?
4.
Any further imaging can help to confirm
the diagnosis?
5.
Name the mainstay of treatment.
1.
What is the CT finding?
•
Hyperdensity at sagittal and transverse sinuses
2.
What is the diagnosis?
3.
Any laboratory test can help to make the diagnosis?
4.
Any further imaging can help to confirm the diagnosis?
5.
Name the mainstay of treatment.
1.
What is the CT finding?
•
2.
Hyperdensity at sagittal and transverse sinuses
What is the diagnosis?
•
Cerebral sinus thrombosis
3.
Any laboratory test can help to make the diagnosis?
4.
Any further imaging can help to confirm the diagnosis?
5.
Name the mainstay of treatment.
1.
What is the CT finding?
•
2.
Hyperdensity at sagittal and transverse sinuses
What is the diagnosis?
•
3.
Cerebral sinus thrombosis
Any laboratory test can help to make the diagnosis?
•
D-dimer
4.
Any further imaging can help to confirm the diagnosis?
5.
Name the mainstay of treatment.
1.
What is the CT finding?
•
2.
What is the diagnosis?
•
3.
Cerebral sinus thrombosis
Any laboratory test can help to make the diagnosis?
•
4.
D-dimer
Any further imaging can help to confirm the diagnosis?
•
5.
Hyperdensity at sagittal and transverse sinuses
MRI +/-MR venogram, or CT venogram
Name the mainstay of treatment.
Magnetic resonance venogram showing the cerebral venous system and most frequent (%)
location of cerebral venous and sinus thrombosis, as reported in the International Study on
Cerebral Venous and Dural Sinuses Thrombosis (n=624).44.
Saposnik G et al. Stroke 2011;42:1158-1192
Copyright © American Heart Association
CT venogram of our patient
1.
What is the CT finding?
•
2.
What is the diagnosis?
•
3.
Cerebral sinus thrombosis
Any laboratory test can help to make the diagnosis?
•
4.
D-dimer
Any further imaging can help to confirm the diagnosis?
•
5.
Hyperdensity at sagittal and transverse sinuses
MRI +/-MR venogram, or CT venogram
Name the mainstay of treatment.
1.
What is the CT finding?
•
2.
Hyperdensity at sagittal and transverse sinuses
What is the diagnosis?
•
3.
Cerebral sinus thrombosis
Any laboratory test can help to make the diagnosis?
•
4.
D-dimer
Any further imaging can help to confirm the diagnosis?
•
5.
MRI +/-MR venogram, or CT venogram
Name the mainstay of treatment.
•
Anti-coagulation therapy
Proposed algorithm for the management of CVT. The CVT writing group recognize the
challenges facing primary care, emergency physicians and general neurologists in the
diagnosis and management of CVT. The aim of this algorithm is to provide guidance to physi...
Saposnik G et al. Stroke 2011;42:1158-1192
Copyright © American Heart Association