Transcript OSCE Question 02/2015

OSCE Answer 02/2015
TMH AED
1
Question 1
•
•
•
•
•
M/69
Known history of HT, IHD, PVD
Sudden onset of constant low back pain
BP 162/85mmHg
P 78/min
2
Question 1
• Suggest 5 differential diagnosis of acute low
back pain
– Mechanical spinal disease
– Non-mechanical spinal disease
– Visceral disease
3
Mechanical Spinal Disease
•
•
•
•
•
•
•
Lumbar strain
Degenerative spine
Spondylolisthesis
Spinal stenosis
Prolapsed intervertebral disc
Osteoporosis
Fracture or facet joint dislocation
4
Non-Mechanical Spinal Disease
• Neoplasia
– Multiple myeloma
– Bone metastasis
– Lymphoma and
leukemia
– Spinal cord tumour
• Infection
– Septic discitis
– Epidural abscess
• Inflammatory arthritis
– Ankylosing spondylitis
– Psoriatic spondylitis
– Reiter disease
• Paget disease
– Osteomyelitis
5
Visceral Disease
• Pelvic
• Gastrointestinal
– Chronic pelvic
– Acute pancreatitis
inflammatory disease
– Acute cholecystitis
– endometriosis
• Abdominal aortic
• Renal
– Nephrolithiasis
– Pyelonephritis
– Perinephric abscess
aneurysm
• Psoas abscess
6
Red Flag Symptoms
7
Question 1
• Bedside abdominal USG was performed
8
Question 1
• What’s the sonographic diagnosis?
– 7cm in diameter abdominal aortic aneurysm with
concentric hyperechoic lesion signifying thrombus
9
Question 1
• How to measure the
size of the lesion?
– Outer to Outer wall
– Longitudinal view
– Perpendicular to the
long axis of aorta
10
Question 1
• How to classify the type of the lesion using
ultrasound?
– Identify the origin of the SMA, 2cm below should be
the origin of renal arteries
– Classify according to the location of the aortic
aneurysm
• Suprarenal
• Juxtarenal
• Infrarenal
(Ultrasound Clin 2 (2007) 437–453)
11
Question 1
• State the microbe that is most commonly
associated with this condition?
– A study in southern Taiwan from 1996 to 2006 on
mycotic aneurysm
• Salmonella (34.6%)
• Klebsiella (11.5%)
• Staphylococcus aureus (11.5%)
(J Microbiol Immunol Infect 2008;41(4): 318-324)
12
Question 2
• F/40
• Good past health
• Sudden onset of right sided weakness 1 hour
before
• BP 180/93 mmHg
• P 104/min
• GCS 15/15
13
Question 2
• Urgent CT brain was performed
14
Question 2
• Described the CT
finding
– Loss of insular ribbon
sign
– A loss of definition of the
gray-white interface in
the lateral margin of the
insular cortex
(Radiology. 1990;176(3):801)
15
Question 2
• Suggest 3 more
hyperacute stroke
CT signs
– Hypodensity of basal
ganglia
16
Question 2
• Dense MCA sign
17
Question 2
• Cortical Sulcal
Effacement
18
Question 2
• Outline subsequent management plan for this
patient
– Stabilization, history taking and physical
examination
– Baseline investigations like blood tests, ECG, CXR
– Consult neurologist for assessment
– Stroke management
– Reperfusion therapy and anti-platelet agent
Emerg Med Clin North Am. 2012 Aug;30(3):713-44
19
Stroke Management
• Fluid
– Hypovolemia reduce cerebral perfusion
– Hypervolemia cerebral edema
– Look for SIADH with hyponatremia
• Glucose
– Hypoglycemia stroke mimics
– Hyperglycemiapoor functional outcome
– (Stroke. 2001;32(10):2426)
20
Stroke Management
• Head position
– Lying flat would increase mean flow velocity of
cerebral artery by 20% in one study
(Neurology. 2005;64(8):1354)
– Prop up 30° in patients with
• Raised intracranial pressure
• Risk of aspirations
• Cardiopulmonary disease or oxygen desaturation
21
Stroke Management
• Blood pressure control
– Blood pressure control within 7 – 10 days post
stroke leads to increase 30 days mortality
(The Lancet. 22/10/2014 open access)
(http://dx.doi.org/10.1016/S0140-6736(14)61121-1)
– Goals of blood pressure control
• Thrombolytic therapy: SBP < 185mmHg, DBP <
110mmHg
• No thrombolytic therapy: SBP <220mmHg, DBP <
120mmHg
22
Reperfusion Therapy
• Intravenous alteplase (tPA) within 4.5 hours
from onset
• Intra-arterial alteplase (tPA) within 6 hours
from onset
• Mechanical thrombolysis
23
Antiplatelet treatment
• Aspirin 160 to 320mg daily within 48 hours
would decrease recurrent of stroke within 14
days and death within 28 days (International
Stroke Trial (IST) and Chinese Acute Stroke
Trial (CAST))
• ?Dual antiplatelet treatment with aspirin and
clopidogrel (300mg loading, then 75mg daily)
for high risk patient (ABCD2 score ≥ 4)
(CHANCE trial)
24
Question 2
• State 3 etiologies for young onset stroke
– Cardiac
• Congenital heart disease
• Endocarditis, cardiomyopathy, prosthetic valve
replacement
– Haematologic
• sickle cell disease
• Prothrombolic conditions like antiphospholipid
syndrome, protein C deficiency, protein S deficiency etc
25
Question 2
• State 3 etiologies for young onset stroke
– Vasculopathy
• Moyamoya disease (primary or secondary)
• Dissection
• Vasculitis
– Substance abuse
26
Question 2
• Cerebral angiogram was performed after
stabilization
27
Question 2
• Describe the finding
– Puff of smoke appearance
– Due to collateral vasculature
• What is the diagnosis?
– Moyamoya disease
28
Moyamoya Disease
• Bilateral stenosis or occlusion of vessels
around circle of Willis with prominent
collateral circulation
• Moyamoya is Japanese, meaning hazy like a
puff of smoke in the air
• Can lead to both ischemic and haemorrhagic
stroke
29
Question 3
• F/56
• Good past health
• Vehicle-pedestrian collision with left knee
injury
• BP 153/79mmHg
• P 95/min
30
Question 3
• Left knee X-ray was
taken
31
Question 3
• Describe the X-ray finding
– Fracture over lateral tibial plateau of the left knee
– No depression
• What is the classification of the above
condition?
– Schatzker classification
• Which type this patient belonged to?
– Type I
32
Schatzker Classification
33
Question 3
• What is the mechanism of the injury?
– Valgus force with axial loading
34
Question 3
• Name 4 potential complications
– Early complications
•
•
•
•
•
Compartment syndrome
Vascular injury (popliteal artery)
Nerve injury (peroneal nerve)
Infection
Deep vein thrombosis
35
Question 3
• Name 4 potential complications
– Late complications
•
•
•
•
•
•
Knee stiffness
Knee instability
Osteoarthritis
Malunion, nonunion
Angular deformity
Late collapse
36
Question 4
• M/72
• History of DM, HT, SSS on pacemaker
• Sudden onset of severe chest pain for 3 hours,
only partially relieved by TNG
• BP 164/88 mmHg
• P 62/min
37
Question 4
• ECG was performed
38
Question 4
• Describe the ECG findings
– Widen QRS complex with heart rate 60/min
(pacemaker beat)
– ST elevation in I, aVL, V4-V6
– Reciprocal ST depression in III, aVF
39
Question 4
• State an ECG criteria for assistance of
diagnosis
– Sgarbossa criteria
• What is the diagnosis?
– Acute anteriolateral ST elevation myocardial
infarction
40
Sgarbossa Criteria
41
Modified Sgarbossa Criteria
42
Sgarbossa Criteria
• ST elevation ≥1 mm in a lead with a positive
QRS complex (ie: concordance) - 5 points
• ST depression ≥1 mm in lead V1, V2, or V3 - 3
points
• ST elevation ≥5 mm in a lead with a negative
(discordant) QRS complex - 2 points
• ≥3 points, sensitivity 36%, specificity 90%
(NEJM 334(8):481-487)
43
Modified Sgarbossa Criteria
• at least one lead with concordant STE (Sgarbossa
criterion 1) or
• at least one lead of V1-V3 with concordant ST
depression (Sgarbossa criterion 2) or
• proportionally excessively discordant ST elevation
in V1-V4, as defined by an ST/S ratio of equal to
or more than 0.20 and at least 2 mm of STE. (this
replaces Sgarbossa criterion 3 which uses an
absolute of 5mm)
• Sensitivity 91%, Specificity 90%
(Annals of Emergency Medicine 60 (6): 766–776.)
44
Question 4
• Outline the management in AED
– Recognize emergency condition and manage in
resuscitation room with resuscitation equipments
standby
– Monitoring devices
– Set up large bore IV access, blood tests, CXR
– Consult cardiologist for assessment
– MONA
– Reperfusion therapy
– Antithrombotic therapy and antiplatelet therapy
45
Primary PCI
• Door to balloon time
– 90 minutes in PCI capable hospital
– 120 minutes in non-PCI capable hospital
• Patients presented more than 12 hours, with
cardiogenic shock, electrical instability or
persistent ischemic symptoms
(2013 ACCF/AHA guideline for the management of
ST-elevation myocardial infarction)
46
Thrombolytic therapy
• Symptoms within 12 hours with primary PCI not
available within 120 minutes
• Door to needle time less than 30 minutes
• Facilitated PCI is not recommended
• Rescue PCI if failed fibrinolysis
(2013 ACCF/AHA guideline for the management of
ST-elevation myocardial infarction)
47
Thrombolytic therapy
• First generation fibrinolytic agents (eg
streptokinase) indiscriminately induce activation
of circulating plasminogen and clot-associated
plasminogen
• Second generation fibrinolytic agents (eg t-PA)
preferentially activate plasminogen in the fibrin
domain
• Second generation fibrinolytic agents improve 24
hours, 30 days and 1 year mortality rate in GUSTO
trial
(Circulation. Oct 10 2000;102(15):1761-5.)
48
Antithrombotic therapy
• Enoxaparin 0.5mg/kg significant reduced
clinical ischemic outcome compared with
unfractionated heparin in STEMI patient
undergoing primary PCI
(ATOLL trial. Lancet. Aug 20
2011;378(9792):693-703.)
49
Antiplatelet agents
• Aspirin should be given immediately
• Adding clopidogrel 300mg (CLARITY-TIMI 28)
is safe and effective
• Increase clopidogrel to 600mg in patient with
STEMI prior to primary PCI was associated
with a smaller infarct size (ARMYDA-6 MI)
(J Am Coll Cardiol. Oct 4 2011;58(15):1592-9.)
50
Question 5
• M/62
• Repeated vomiting for 1 day, with mild
epigastric pain after an alcohol binge
• First vomited out undigested
food and then mild blood streak
51
Question 5
• BP 123/59 mmHg
• P 84/min
• Abdominal examination was unremarkable.
Per rectal examination noted brownish stool.
• CXR was normal
52
Question 5
• Name 3 clinical prediction rules/scores in
upper gastrointestinal bleeding to risk
stratification
– Glasgow-Blatchford bleeding score
– Rockall score
– AIMS65
53
Question 5
• He asked if his condition could be managed
without hospital admission
• State which score is the most relevant in this
scenario? What cut-off and associated clinical
implication for the score?
– Glasgow Blatchford bleeding score
– Score 6 or more has more than 50% risk of
needing an intervention
54
Glasgow Blatchford
Bleeding Score
Lancet. 2000;356(9238):1318.
55
Rockall Score
Lancet. 1996;347(9009):1138.
56
AIMS65
(Gastrointest Endosc. 2011;74(6):1215.)
57
Question 5
• More history was taken and he had known
alcoholic with alcoholic liver cirrhosis
• Blood tests result:
– Hb 13.4 g/dL
– Urea 7.8 mmol/L
58
Question 5
• How would you management this patient?
– GBS 4
– Admit to EMW for observation
• NPO
• IV fluid
• Type and screen, clotting profile
59
Question 5
• He developed gross haematemesis during his
stay in AED
• BP 96/49 mmHg
• P 106/min
60
Question 5
• How would you manage this patient in addition
to the management you ordered before?
– Manage in resuscitation room
– Nasogastric tube insertion, suction with airway
protection
– IV fluid resuscitation and hemodynamic resuscitation
– Consult surgeon for urgent OGD
– IV somatostatin analog, vasopressin
– Balloon tamponade
61
Question 6
• M/69
• History of HT, DM, old CVA
• Decrease general condition for 1 month
62
Question 6
63
Question 6
• Describe the CT finding
– Hydrocephalus
64
Ventriculomegaly vs hydrocephalus
• Enlargement of the recesses of the third
ventricle
• Dilation of the temporal horns of the lateral
ventricle
• Interstitial edema of the periventricular
tissues (seen on MRI)
• Effacement of the cortical sulci
65
Ventriculomegaly vs hydrocephalus
66
Question 6
• What further investigations would you
proceed?
– MRI
– Lumbar puncture
67
Question 6
• If the opening pressure of the lumbar
puncture is 12 cm H2O
• What is the condition called?
– Normal Pressure Hydrocephalus
• What is the classic triad of this condition?
– Gait instability (magnetic gait)
– Cognitive impairment
– Urinary incontinence
68
Question 6
• What is the definitive treatment?
– VP shunt
69
70