20120801 OSCE ANSWER by 7LiH18j

VIEWS: 47 PAGES: 48

									OSCE
JCM


Dr CT Lui
TMH A&E
Aug 2012
Case summary
 Case 1: complete hydatidiform mole
 Case 2: UGIB

 Case 3: PJP pneumonia

 Case 4: addisonian crisis/hypothermia/hyperK

 Case 5: SAH
Case 1
Case 1
 A 38-year-old lady, attended for vaginal
  bleeding with lower abdominal discomfort.
  On and off vomiting for recent 2-3 weeks
 BP 130/85. P100. Temp 37oC

 Urine Preg test +ve
Case 1
   State 3 most common differential diagnoses
     Miscarriage
      (threatened/inevitable/incomplete/missed)
     Ectopic pregnancy

     Molar pregnancy

   What’s the single most useful investigation in
    ED?
       Ultrasound pelvis (transvaginal/transabdominal)
Transabdominal USG – longitudinal view




                         Transabdominal USG pelvis
                         Longitudinal view
Case 1
•   What’s the sonographic feature?
     –   heterogeneous mass with numerous discrete anechoic spaces showing “snowstorm pattern”
     –   ± theca lutein cyst may be found in USG
•   What’s the diagnosis?
     •   Molar pregnancy, likely complete hydatidiform mole
•   What are the associated clinical features/complications for the above named
    condition?
     –   Thyrotoxicosis
     –   Larger than date uterus
     –   Hyperemesis gravidarum
     –   Early onset preeclampsia
     –   Theca lutein cyst and cyst complications
•   Label 2 important risk factors for the above condition
     –   AMA (Advanced maternal age)
     –   Previous GTD
•   What’s the definitive management?
     –   Suction currettage of uterus
Case 1
•   What need to be monitored after treatment and
    how?
    –   ß-hCG
    –   Weekly until 3 consecutive normal
•   If the monitoring showed plateau / risk in the
    marker, what’s the diganosis?
    –   Persistent trophoblastic disease
•   What’s the malignant form of the above named
    condition and what’s the first line of treatment?
    –   Choriocarcinoma
    –   Chemotherapy (e.g. methotrexate)
Case 2
Case 2
•   A 50-year-old gentleman attended for vomiting
    with blood stained vomitus
•   What relevant points in history taking?
    –   Recent use of aspirin / NSAID
    –   History of hepatic disease / portal hypertension /
        known variceal diseases
    –   Vomiting / alcohol binge
    –   History of peptic ulcer diseases
•   Do you know of any validated scoring system for
    risk stratification for the above condition?
GBS
                                   Blood Urea
   Glasgow-Blatchford             ≥6·5 <8·0
                                   ≥8·0 <10·0
                                                                2
                                                                3

    Bleeding Score (GBS)           ≥10·0 <25·0
                                   ≥25
                                                                4
                                                                6

     Low risk = Score of 0        Hemoglobin (g/L) for men
                                   ≥12.0 <13.0                  1
                                   ≥10.0 <12.0                  3
     Any score higher than 0 is   <10.0                        6

      "high risk" for needing a
                                   Hemoglobin (g/L) for women
                                   ≥10.0 <12.0                  1

      medical intervention of      <10.0                        6
                                   Systolic blood pressure (mm Hg)

      transfusion, endoscopy, or   100–109
                                   90–99
                                                                1
                                                                2

      surgery.                     <90
                                   Pulse ≥100 (per min)
                                                                3
                                                                1
                                   Presentation with melaena    1
                                   Presentation with syncope    2
                                   Hepatic disease              2
                                   Cardiac failure              2
Case 2
•   The patient had history of alcoholic cirrhosis
    with previous endoscopic treatment for UGIB.
    What’s the most likely cause for the bleeding?
    –   Variceal bleeding from esophageal varices
•   What are the ED management?
    –   NPO
    –   IV fluid resuscitation
    –   Blood taking for crossmatch
    –   Consult surgeon for endoscopy
Case 2
   If you are in a rural hospital and the shortest
    time to the definitive treatment is 2 hours.
    Patient become hypotensive with BP 70/40,
    P130 despite supportive treatment. State 2
    ED management.
     Insertion of sengstaken-blakemore tube /
      Minnesota tube
     Octreotide / Terlipressin infusion
Case 2
•   List 3 treatment options for the above
    condition
    –   Endoscopic banding or sclerotherapy
    –   PTE (Percutaneous transhepatic embolization) or
        Transjugular intrahepatic portosystemic shunt
        (TIPS)
    –   Surgery
         •   Portosystemic shunt
         •   Esophageal devascularization
         •   Liver transplantation
Case 3
Case 3
•   A 34 year old gentleman presented with fever, dyspnea
    and productive cough for 5 days. Progressive dyspnea
    in recent 1 day.
•   BP 100/70, P120, temp 39.1C, RR30, SpO2 85% on RA
•   State 3 important points in history taking
    –   Past medical history / immunosuppression
    –   TOCC (Travel history, occupation, cluster, contact)
    –   Drug allergy
•   What special aspect during resuscitation?
    –   Infection control (negative pressure resuscitation room,
        Personal protective equipment) and staff protection.
Case 3
 The patient had history of HIV infection on
  treatment.
 CXR was taken
Case 3
   What’s the CXR finding?
   What’s the diagnosis?
   State 2 validated guidelines / scores for managing patients with the above
    diagnosis for risk stratification.
   Is this typical or atypical type for this patient with the above diagnosis? List
    3 common corresponding microbes for both.
   What’s the most important microbe to be considered in this patient?
   What’s the diagnostic modality for definitive diagnosis? What’s the
    treatment?
   If the patient become abruptly dyspneic, list one possible complication
    associated with the above diagnosis.
Case 3
•   What’s the CXR finding?
    –   Bilateral lung field patchy infiltrate
•   What’s the diagnosis?
    –   Bilateral bronchopneumonia
•   Do you know of any validated guidelines /
    scores for managing patients with the above
    diagnosis who could be managed outpatient?
    –   CURB-65
    –   Pneumonia Severity Index (PSI)
Case 3
•   Is this typical or atypical type for this patient with
    the above diagnosis?
    –   Atypical pneumonia
    –   Typical: strep pneumoniae, haemophilus influenzae ,
        moraxella catarrhalis.
    –   Atypical: legionella pneumophila, mycoplasma
        pneumoniae, M TB, chlamydia pneumoniae, chlamydia
        psittaci
•   What’s the most likely microbe to be considered
    in this patient?
    –   pneumocystis jiroveci
Case 3
   What’s the diagnostic modality for definitive
    diagnosis? What’s the treatment?
     Bronchoalveolar lavage (BAL) for PCP
     Septrin

   If the patient become abruptly dyspneic, list
    one possible complication associated with the
    above diagnosis.
       Pneumothoraces (can be bilateral)
CURB-65
           Symptom                          Points
           Confusion                        1
           Urea>7mmol/l                     1
           Respiratory rate>30              1
           SBP<90mmHg,
                                            1
           DBP<60mmHg
           Age>=65                          1


The risk of death at 30 days increases as the
score increases:
0—0.6%                                 0-1 treat as an outpatient
1—3.2%                                 2 consider a short stay in hospital or watch
2—13.0%                                very closely as an outpatient
3—17.0%                                3-5 requires hospitalization
4—41.5%
5—57.0%
Step 1: Stratify to Risk Class I vs. Risk Classes II-V
                       Presence of:

                                              Over 50 years of age      Yes/No


                                              Altered mental status     Yes/No

                                              Pulse ≥125/minute         Yes/No

                                              Respiratory rate
                                              >30/minute                Yes/No


                                              Systolic blood
                                              pressure <90 mm Hg        Yes/No   PSI
                                              Temperature <35°C or
                                              ≥40°C                Yes/No
                       History of:

                                              Neoplastic disease        Yes/No
                                              Congestive heart
                                              failure                   Yes/No
                                              Cerebrovascular
                                              disease                   Yes/No

                                              Renal disease             Yes/No
                                              Liver disease             Yes/No


                                              If any "Yes", then
                                              proceed to Step 2


                                              If all "No" then assign
                                              to Risk Class I
Step 2: Stratify to Risk Class II vs III vs IV vs V
Demographics                                            Points Assigned
          If Male                                       +Age (yr)
              If Female                                 +Age (yr) - 10

           Nursing home resident                        +10
Comorbidity
              Neoplastic disease                        +30
              Liver disease                             +20
              Congestive heart failure                  +10
              Cerebrovascular disease                   +10
            Renal disease                               +10
Physical Exam Findings

              Altered mental status                     +20
              Pulse ≥125/minute                         +20

              Respiratory rate >30/minute               +20
                                                                         ∑ <70 = Risk Class II
              Systolic blood pressure <90 mm Hg         +15              ∑ 71-90 = Risk Class III
           Temperature <35°C or ≥40°C                   +10              ∑ 91-130 = Risk Class IV
Lab and Radiographic Findings
                                                                         ∑ >130 = Risk Class V
              Arterial pH <7.35                         +30
              Blood urea nitrogen ≥30 mg/dl (9
              mmol/liter)                               +20
              Sodium <130 mmol/liter                    +20

              Glucose ≥250 mg/dl (14 mmol/liter)        +10
              Hematocrit <30%                           +10

              Partial pressure of arterial O2 <60mmHg   +10
              Pleural effusion                          +10
Typical vs atypical pneumonia
                      Comparison of Typical and Interstitial (Atypical) Pneumonias


  Feature                            Typical Pneumonia             Interstitial (Atypical) Pneumonia

  Onset                                      Sudden                              Gradual
  Rigors                                   Single chill                         “Chilliness”
  Facies                                     “Toxic”                               Well
  Cough                                   Productive                   Nonproductive: paroxysmal
  Sputum                               Purulent (bloody)                          Mucoid
  Temperature                             103–104°F                               < 103°F
  Pleurisy                                 Frequent                                Rare
  Consolidation                            Frequent                                Rare
  Gram stain (sputum)                     Neutrophils                       Mononuclear cells


  White blood cell count and
                                  > 15,000/mm3 with left shift                > 15,000/mm3
  differential count


                                                                    Nondefined infiltrate or interstitial
  Chest radiograph              Defined density, lobar pneumonia
                                                                              pneumonia

  Most common cause                 Streptococcus pneumoniae             Mycoplasma pneumoniae
PCP / PJP
   Opportunistic pneumonia in HIV/AIDS or
    immunocompromised
   Dx by induced sputum / BAL for immunofluorescent
    stain
   PCP prophylaxis by septrin in susceptible host
   Tx
       Septrin
       Pentamidine
       Trimethoprim-dapsone
       Clindamycin-primaquine
Case 4
Case 4
 A 70-year-old gentleman was brought in by
  ambulance for “decreased general condition”
  for 2 days and noted hypothermia
 BP 70/40. P45. Rectal temp 32C. RR 14. SpO2
  96% on O2.
 On examination, patient was cachexic,
  bradycardic and drowsy.
Case 4
•   State 3 relevant investigations in ED
    –   Bedside glucose
    –   ECG
    –   CXR
    –   POCT blood gas
•   Bedside glucose was 2.5 mmol/l.
•   State 3 important aspects of treatment at this
    moment
    –   Fluid resuscitation for hypotension / shock
    –   Glucose / dextrose replacement for hypoglycemia
    –   Rewarming for hypothermia
ECG was performed
Case 4
•   What are the ECG findings?
    –   Regular bradycardia
    –   Wide complex
    –   Tall T wave
    –   No J wave
•   What was the likely ECG diagnosis? What
    further investigation to confirm your diagnosis?
    –   Hyperkalemia
    –   POCT for blood gas and Na/K
Case 4
   If the investigation confirmed your ECG diagnosis, state 5 treatments.
       Calcium gluconate

       Dextrose-insulin infusion

       NaHCO3

       Nebulised ventolin

       K resins

       Dialysis

   If the patient developed respiratory distress and he need to be intubated.
    What’s the major precaution?
       Avoid succinylcholine/suxamethonium (contraindicated in

         hyperkalemia)
Case 4
•   What’s the methods of rewarming? State one
    example for each method
    –   Passive
         •   Blanket
    –   Active external – rewarming shock and afterdrop
         •   bair hugger (active rewarming blanket)
    –   Active internal
         •   Warm saline infusion
         •   Bladder lavage with warm saline
         •   Esophageal, pleural, peritoneal
Case 4
   With the whole clinical picture, what is the
    provisional diagnosis? What investigation could
    be done to confirm the diagnosis?
     Addisonian crisis
     Spot corticol (Critical sample under stress)
Case 5
Case 5
 A 50 year old gentlemen presented for
  headache for 2 hours after coitus, with neck
  pain and vomiting for 5 times. Now become
  confused and drowsy.
 BP 170/100. P60. Temp 37oC

 GCS E3V4M5

 On neurological examination, noted left lower
  limb paresis
CT brain
Case 5
   What are the CT findings?
     Hyperdensity at bilateral sylvian fissure
     Hyperdensity at interhemispheric fissure

     Hyperdensity at bilateral cerebral sulci

     No dilated temporal horn / significant

      hydrocephalus / IVH
   What’s the diagnosis?
       Subarachnoid hemorrhage
Case 5
   If the initial CT was negative, state one
    investigation that can assist for diagnosis
       Lumbar puncture for CSF xanthochromia by
        spectrophotometry
   Name 2 possible specific physical examination
    findings
     Meningismus
     Retinal subhyaloid hemorrhage on fundoscopy
Case 5
   State 3 common underlying cause for the above
    condition. What further investigation could delineate
    the etiology?
            Ruptured saccular aneurysm of cerebral arteries
            Ruptured arteriovenous malformation of cerebral vessels
            Perimesencephalic non-aneurysmal hemorrhage
            Others: traumatic, intracranial arterial dissection, cocaine abuse,
             cerebral venous thrombosis, bleeding tendency/coagulopathy
       Digital subtraction angiography (DSA) / CTA / MRA for the
        cerebral arteries
Case 5
   Name a clinical severity grading for the above diagnosis.
    What’s the implication with high clinical grading? What’s the
    grading for this patient?
       Hunt and Hess grading (3)
       World Federation of Neurological Surgeons (WFNS) Grading (4)
       Clinical outcome
   Name a CT grading for the above diagnosis. What’s the
    implication with high CT grading? What’s the grading for this
    patient?
       Fisher Scale (3)
       Claassen grading system (4)
       Symptomatic cerebral vasospasm
Clinical grading
  Hunt and Hess grading of SAH


        Grade      Neurologic status
                   Asymptomatic or mild headache and slight nuchal
        1
                   rigidity
                   Severe headache, stiff neck, no neurologic deficit
        2
                   except cranial nerve palsy
        3          Drowsy or confused, mild focal neurologic deficit
        4          Stuporous, moderate or severe hemiparesis
        5          Coma, decerebrate posturing

The grade is advanced one level for the presence of serious systemic disease
(hypertension, diabetes, severe arteriosclerosis, chronic pulmonary disease) or
vasospasm on angiography
Clinical grading

  World Federation of Neurological Surgeons (WFNS) Grading of SAH



      Grade              GCS score         Motor deficit
      1                  15                Absent
      2                  13 to 14          Absent
      3                  13 to 14          Present
      4                  7 to 12           Present or absent
      5                  3 to 6            Present or absent
CT grading – Vasospasm risk
The Fisher Scale                            Claassen grading system

 Group Appearance of blood on head          Grade   Head CT criteria
       CT scan
                                            1       No SAH or IVH
 1      No blood detected
                                            2       Minimal SAH and no IVH
 2      Diffuse deposition or thin layer
        with all vertical layers (in        3       Minimal SAH with bilateral IVH
        interhemispheric fissure,           4       Thick SAH (completely filling one
        insular cistern, ambient cistern)           or more cistern or fissure)
        less than 1 mm thick                        without bilateral IVH
 3      Localized clot and/or vertical      5       Thick SAH (completely filling one
        layers 1 mm or more in                      or more cistern or fissure) with
        thickness                                   bilateral IVH
 4      Intracerebral or
        intraventricular clot with
        diffuse or no subarachnoid
        blood
Case 5
   What specific treatment could be considered
    for this patient with evidence of improved
    outcome?
       Nimodipine 60mg q4h PO/NG
Case 5
   State 5 possible acute complications
       Vasospasm and cerebral ischemia
       Rebleeding
       Obstructive hydrocephalus and increased intracranial
        pressure
       Seizures
       Non-cardiogenic pulmonary edema
       Hyponatremia – hypothalamic injury: SIADH and cerebral
        salt wasting
       Myocardial injuries

								
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