osce 26 th march, 2014. case 1 67 years old gentleman attended aed after a fall at escalator. he...

OSCE 26th March, 2014

Case 1

67 years old gentleman attended AED after a fall at escalator. He complained of neck pain afterwards. He did not have any limb weakness or sphincter disturbance

What are the abnormalities?

Fracture dens of C2

Degenerative changes with post nipping of the osteophytes in C4/C5, C5/C6

How to classify the pathology?

Dens fractures are classified as type I, II, or III.

Which ligamental injury is associated with this condition.

Transvere alantal ligament

Transverse atlantal ligament disruption occurs in approximately 10% of cases. Injuries of this ligament can result in atlantoaxial instability after odontoid fracture osseous healing, and the chance of odontoid fracture non-union is increased with its disruption.

Give 2 complication of this condition

nonunion

malunion

pseudoarthrosis formation

infection

neurovascular injury

acute airway compromise

Treatment modalities:

externally immobilized by a halo vest

fused surgically.

Case 2

73 years old gentlemen had history of hypertension and diabetes. He presented to our department with dizziness, sweating and urinary incontinence. He had fever and coryzal symptoms few days ago and had consulted private doctor

Describe the ECG

SR 90/min

ST elevation V1-V2

Negative T V1-V2

On further asking, this patient had history of recurrent syncope few years ago. By that time investigation was normal. What will be your diagnosis?

Brugada syndrome

Type1 Type 2 Type 3

What test will you order to confirm your diagnosis?

Flecainide stress test/ Stress test with Class 1a, 1c or Class III drugs

What will be the treatment?

Implantable cardioverter defibrillator (ICD)

Case 3

61 years old gentleman presented with acute dysphagia. He had history of foreign body (fishbone) ingestion 2 days ago

Describe the findings

Rim enhancing collection noted along the left oropharyngeal space

What is your diagnosis?

Left retropharyngeal abscess

Relations of the retropharyngeal space:

* Superior: Base of the skull * Inferior: Superior mediastinum * Lateral: Carotid sheath * Anterior: Buccopharyngeal fascia * Posterior: Alar fascia

What is the common causative organism?

Aerobic organisms, such as beta-hemolytic streptococci and Staphylococcus aureus

Anaerobic organisms, such as species of Bacteroides and Veillonella

Gram-negative organisms, such as Haemophilus parainfluenzae and Bartonella henselae

Name 2 complications of this disease

Airway obstruction.

Mediastinitis.

Pericarditis.

Aspiration pneumonia.

Epidural abscess.

Septicaemia.

Adult respiratory distress syndrome(ARDS).

Case 4

70 years old gentleman had history of malignancy, just put on chemotherapy few days ago. He presented to AED with poor oral feeding, repeated vomiting and dizziness. BP was 92/62, pulse 130/min at triage.

What is your differential diagnosis?

Hypovolaemic shock (GI loss)

Distributive shock (septic shock)

Obstructive shock ( Cardiac tamponade, pulmonary embolism)

Cardiogenic shock (ACS)

What is your diagnosis?

Cardiac tamponade

What will the likely cause and the treatment?

Malignancy

Pericardiocentesis

What is the bedside investigation to confirm your diagnosis?

Cardiac ultrasound/ Echocardiogarm

What will be the diagnostic finding in that investigation?

Pericardial effusion with RA/RV diastolic collapse

Case 5

62 years old gentleman presented to AED with repeated vomiting and diarrhoea. He had returned from Saban 2 days ago and had taken seafood there. The serum Na on admission is 118. He was put on normal saline and admitted EMW. On next day Na dropped to 108. Urea 2.9, Cr 64. Blood pressure was normal. Hydration was good and there was no edema.

Name 3 possible causes of the hyponatraemia.

 SIADH

Hypothyroidism

Addision’s disease

Pseudohypontraemia

Fluid loss

Hyponatraemia

Isovolemic: SIADH, hypothyroidism, Addison’s disease, water intoxification

Hypovolemia: Fluid loss, dehydration, diuretics, adrenal insufficiency

Hypervolemic: CHF, cirrhosis, CRF

Name 3 laboratory investigations you will perform.

Urine Na

Serum/ urine osmolality

TFT

Spot cortisol

Synathen test

The serum osmolality is 240mOsmol/kg and urine Osmolality is 567mOsmol/kg.

What is your diagnosis?

SIADH 

What will be your treatment?

Fluid restriction

Sodium supplement

In symptomatic hyponatraemia, what kind of fluid should be given and what will be the maximal rate of increase of sodium per hour?

 Hypertonic saline (3% or 5.85% NaCl solution)

Maximal rate 0.5mM/hr elevation

What is the risk of rapid rise of sodium level?

Central pontine myelinolysis

Case 6

A 20 year-old lady with known history of asthma on regular puffs presented to your ED for acute dyspnea in the middle of the night. Here are her vital signs

Conscious, however apprehensive

BP 130/80, pulse 130/min

SpO2 98% on 4L/min O2 via nasal cannula

Talk in phases

Temperature 38 degree Celsius

What investigations would you do/order in ED?

ABG (i-stat or point of care test)

Peak expiratory flow rate, PEFR

CXR

ECG

CBP D/C, R/LFT, Clotting profile

Here is her blood gas, please interpret pH 7.28 pCO2 41.25mmHg pO2 80mmHg HCO3 20 BE -4 Na 128 K 4.0 Chloride 85

High anion gap metabolic acidosis, respiratory acidosis together with metabolic alkalosis

pH 7.28 --> Acidosis

HCO3 20, BE -4, --> metabolic acidosis

Expected PaCO2 28mmHg +/- 2, however now is 41.25mmHg --> respiratory acidosis

Anion gap 27 --> High anion gap metabolic acidosis

Delta anion gap 15, delta HCO3 4, Delta anion gap/Delta HCO3 ( Delta ratio ) = 3.75 >2 therefore metabolic alkalosis

What is your initial management in ED?

Oxygen supplement with continuous SpO2 monitoring

Puff bronchodilator including Ventolin/Atrovent, no ceiling dose

IV steroid, hydrocortisone 100mg-200mg stat

MgSO4, 10mmol loading within 10-30minutes

Prepare for intubation with mechanical ventilation, in selected case, may have a trial of non-invasive ventilation

Consult ICU

She deteriorates further and you decide to intubate her, what medications will you give for your RSI?

Induction agent: Ketamine / Propofol

Muscle relaxant: Suxamethonium

Avoid giving histamine releasing medications including morphine

After your intubation, your portable ventilator alarms and there is essentially no tidal volume achieved. Why?

Bronchospasm with high airway pressure as a result of high airway resistance that exceed the upper pressure limit

Pneumothorax

Your ICU colleague agree to admit the patient but has to wait for 30 minutes in your resuscitation room, they can borrow a conventional ventilator for you, what is your initial setting of the ventilator?

Sedate and paralyze the patient

SIMV(VC) + PS TV 6ml/kg predicted body weight Zero PEEP FiO2 1.0 RR 8-10/min, adjusted according to the flow-time or volume-time

curve Prolonged IE ratio e.g. 1:3.3 to 1:10 Increase the peak airway pressure limit to for example 100 Measure iPEEP and Plateau pressure

Thank you