OPSE-suggested answer

Prepared by: Dr. HK NganPMH AED

Case 1

• M/65• PH:DM, HT• Attended AED because of abdominal

distension and constipation for two days

Case 1

Case 1

• 1) Describe the x-ray findings?• 2) What is the diagnosis?• 3) What are the main complications of this

condition?• 4) Name three predisposing factors for this

condition?• 5) What is the treatment?

Case 1-suggested answer• 1) a loop of dilated(1) large(1) bowel pointing toward the

diaphragm with demonstration of “coffee bean” (2)sign or “bent inner tube”(2) sign (4 mark)

• 2) Sigmoid volvulus (2) (2 mark)• 3) bowel obstruction(1),perforation(1),bowel ischaemia(1)• (3 mark)• 4) Redundant sigmoid colon with narrow mesentery,

chronic constipation, Chacas disease(trypanosomiasis), Parkisonism, spinal cord disease, mental illness, high fiber diet, high altitude (3 mark)

• 5) Sigmoidoscopy(1) and insertion of rectal tube(1) for decompression; operative (1)management and resection

• (3 mark)

Case 2

• Nigerian tourist• F/42• Brought in by police from airport for

abdominal pain

Case 2

Case 2

• 1) Describe the x-ray findings?• 2) What is the diagnosis?• 3) What will be the complication of this

condition?• 4) What is your management?

Case 2-suggested answer• 1) Bowel is not dilated; no air-fluid level; multiple oval soft

tissue(packet)homogenous shadows (2)inside the bowel with rim of halo(1) “double condom sign”(2) (4 mark)

• 2) Body packing, body stuffing, internal carrier, balloon swallower (any one) (2 mark))

• 3) bowel obstruction(1); toxicity (1)due to rupture of contained drug (2 mark)

• 4) Asymptomatic: Whole bowel irrigation(1) and laxative(1) (2 mark) Symptomatic: i)Operative intervention(1) in case of obstruction(1), retention(1)

of packet and sign of leakage/rupture(1) of packet ii) Antidote administration(1) (5 mark)

Case 3

• PH: Good• M/50• Presented to AED for chest pain on and off for

3 weeks. Now symptoms free. • Serial Troponin I<0.03 (not rasied)

Case 3

Case 3

• 1) What is the ECG findings ?• 2) What is the diagnosis?• 3) What is the significance of this condition

and what will be the complication?• 4) What is the best treatment for this

condition and why?

Case 3-suggested answer• 1) NSR; HR 60/min;PR interval normal; QRS not widen ; Axis

normal ; TWI at V3,V4 (either one 1 mark); biphasic T wave inversion at V3 V4(2) (3 mark)

• 2) Wellens syndrome (2 mark)• 3)Critical proximal LAD stenosis and preinfarction stage of coronary

artery disease; left untreated may proceed to anterior wall infarction of resulting in serious ventricular dysfunction, CHF and death (7 mark)

• 4) Urgent coronary angiography and revascularization(2) as 75 % of this patient will proceed to AMI(1) even with medical treatment (aspirin, beta-blocker therapy, nitroglycerin, morphine, heparin, clopidogrel, and glycoprotein (GP) IIb/IIa inhibitors) (1)

(3 mark)

Case 4

• F/40• Brought in by mother with abnormal behavior

and delusional idea for one month. No history of head injury.

Case 4

Case 4

Case 4

• 1) What is the CT findings?• 2)Give 3 differential diagnosis from the CT

finding?• 3)Give the cistern/fissure name of A,B, C, D • 4)What physical examination you would

emphasis with this CT findings?• 5)What other investigation you would like to

do to confirm your suspicion?

Case4- suggested answer• 1) A mass leision over the suprasellar region (2);

( 2mark)

• 2) Pituitary adenoma(macroadenoma); aneurysm; craniopharyngioma; meningioma; Rathke’s cyst ;chiasmatic glioma ; dermoid; epidermoid,schewannoma;geminoma; metastasis (any three) (3 mark)

• 3)A-Suprasellar cistern ; • B-Circummesencephalic (ambient) cistern• C-Sylvian cistern/fissure• D- Quadrigeminal cistern (4 mark)• 4)Visual field & acuity exam; fundi; neurological exam (3 mark)• 5) CT brain with contrast; MRI; Angiogram (3 mark)

Case 4

Case 4-suggested answer

Case 5

• 63/M• Construction site worker• Right eye being splashed by liquid concrete

(cement)• Used tap water to rinse it briefly• C/O pain, tearing, blurring of vision

Case 5

Case 5

1. Describe the clinical findings from the photo.2. What is the likely culprit chemical causing

such injury?3. Name one essential bedside test.4. Which will have more serious injury, acid or

alkali? Give your explanation5. How would you grade the severity of this

injury?

Case 5 –suggested answers1. Injected conjunctiva/ hazy cornea/ FS +ve with epithelial defect at cornea

(3 mark)2. Lime or calcium hydroxide ( CaOH2) causing alkali burn

(3 mark)3. pH in the conjunctival sac (1 mark)4. Alkali.(1) Alkali will have more damage because alkaline penetrates faster

and deeper than acid through the cornea. The fatty acids in cell membranes are broken down into soap and glycerol by the process of saponification. While acids result in coagulative necrosis at surface and form a protective barrier to prevent further penetration ( 4 mark)

5. Determined by severity of cornea injury, extensiveness of limbal involvement and percentage of conjunctival involvement

The Roper-Hall(1) classification on the degree of corneal involvement(1`) and limbal ischemia(1). The Dua(1) classification on an estimate of limbal involvement (in clock hours)(1) and the percentage of conjunctival involvement(1). (4 mark)