Transcript 投影片 1 - HKCEM

JCM OSCE (Answer)
YCH AED
Dr. Cheung Chi Kin, Arthur
8th Oct 2014
Question 1
Question 1
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F/12
Left ankle sprained 2 days ago
Presented with ankle pain
& limping gait
X ray was performed
What are the X ray findings? (1.5 marks)
Which type of fracture does this girl have? (0.5 mark)
What is the specific name for this fracture? (0.5 mark)
What are the mechanisms of this injury? (1.5 marks)
What is the descriptive name for the fracture also involving metaphysis
of distal tibia? (0.5 mark)
What is the treatment of choice? (0.5 mark)
Question 1
1. What are the X ray findings? (1.5 marks)
– A radiolucent/ fracture line at left distal tibia
– Extending from epiphysis to epiphyseal plate
– Soft tissue swelling around ankle
2. Which type of fracture does this girl have? (0.5 mark)
– Salter-Harris type 3 fracture
Question 1
3. What is the specific name for this fracture? (0.5 mark)
– Tillaux fracture
4. What are the mechanisms of this injury? (1.5 marks)
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In adolescents, the medial part of epiphyseal plate closes
first while the anteriolateral part still opens
During forced external rotation of foot
Epiphyseal plate is weaker than ligament, therefore
lateral epiphysis is prone to avulsion fracture
Question 1
5. What is the descriptive name for the fracture also
involving metaphysis of distal tibia? (0.5 mark)
– Triplane fracture
6. What is the treatment of choice? (0.5 mark)
– Operative treatment (internal fixation) if joint
surface displacement > 2mm
Question 2
Question 2
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F/14 Good past health
Presented with repeated vomiting x 1/52
Associated with abdominal pain after food
Bowel opening normal
Thin body build, abdomen soft
1.List four important differential diagnoses in
this case. (2 marks)
Question 2
1. List four important differential diagnoses in this case.
(2 marks, any 4 of below)
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GI: peptic ulcer/ pancreatitis/ small bowel obstruction
Gyn: hyperemesis gravidarum/ molar pregnancy/ UTI/ twins
Diabetic ketoacidosis
Increased intracranial pressure/ post head injury
(In this case, Urine wbc nit –ve, PT –ve; Hstix 5.6; CT brain NAD)
Question 2
2. CT scan of abdomen was performed. Describe the
findings and what is the likely diagnosis? (2 marks)
Question 2
2. CT scan of abdomen was performed. Describe the
findings and what is the likely diagnosis? (2 marks)
– There is a very narrow distance between the
abdominal aorta and the SMA,
– measuring 4.9mm (normally 13-34mm),
– where the third part of duodenum passes through
– The diagnosis is Superior Mesenteric Artery
Syndrome (due to lack of retroperitoneal or
mesenteric fat)
Aorta-SMA angle is 10 degrees (normal 28-65)
Question 2
3. How do you dispose this patient? (0.5 mark)
4. What is the another structure which can be
entrapped between SMA & aorta? (0.5 mark)
Question 2
3. How do you dispose this patient? (0.5 mark)
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Admit Surgery
4. What is the another structure
which can be entrapped
between SMA & aorta? (0.5
mark)
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Left renal vein (Nutcracker
Syndrome) - Presented with
haematuria, left-sided
varicocele
Question 3
Question 3
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M/42 Hx NPC 2007 in remission
Presented with fever & sore throat x 1/7
BP 139/69 P112 RR18 Temp 39.0 SpO2 98%
No stridor or neck swelling
XR neck was performed
Question 3
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3.
4.
What are the X ray findings? (1 mark)
What is the diagnosis? (0.5 mark)
Name 2 common pathogens. (1 mark)
What is the initial management in AED? (2.5 mark)
Question 3
1. What are the X ray findings? (1 mark)
– Thumbprint sign
– ballooning/ air-trapping in hypopharynx
2. What is the diagnosis? (0.5 mark)
– Acute epiglottitis
Question 3
3. Name 2 common pathogens (1 mark, any 2 of below)
– Haemophilus influenzae type B (less prevalent since
introduction of vaccine in 1987)
– Grp A beta haemolytic streptococci (most common)
– Streptococcus pneumoniae
– Staphylococcus aureus
Question 3
4. What is the initial management in AED?
(2.5 mark, any 5 of below)
– Manage in Resuscitation room
– Avoid lie flat and vigorous throat examination
– Supplemental oxygen via face mask
– IV access, blood test, culture
– IV antibiotic (e.g. Augmentin 1.2g or Zinacef 1.5g)
– Consult ENT & ICU
– Prepare Difficult Airway Management (DAM)
Only 15-20% adult patients
required an artificial
airway......majority of
patients without respiratory
distress can be managed
conservatively under close
monitoring
Question 4
Question 4
• F/55 Good past health, non smoker, non drinker
• Presented with cough & throat discomfort x2/52
– Throat clear, neck soft, no cervical LN
– Chest clear, no added sound
– Few high pitched breath sound during expiration
– Otherwise systemically well, ambulatory
• ENT consulted, normal laryngoscopy to VC
• CXR was performed
Question 4
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4.
Name 3 differential diagnoses. (1.5 marks)
What is the positive finding on CXR? (0.5 mark)
Name 3 important negative findings on CXR. (1.5 marks)
Name 3 important investigations. (1.5 marks)
Question 4
1. Name 3 differential diagnoses. (1.5 marks, any 3 of
below)
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Foreign body aspiration
Infection e.g. tracheitis – bacterial, TB
Trachea tumor/ subglottic stenosis
Tracheomalacia
External compression to trachea
2. What is the positive finding on CXR? (0.5 mark)
– A radioopague lesion in lower trachea above carina
Question 4
3. Name 3 important negative findings on CXR. (1.5
marks)
– No hyperinflated lung field/ collapse
– No pneumomediastinum
– No tracheal deviation
4. Name 3 important investigations. (1.5 marks)
– Contrast CT thorax
– Bronchoscopy +/- biopsy
– Sputum for AFB smear, culture & cytology
Bx confirmed CA trachea
Question 5
Question 5
• F/32 Good past health
• Presented on day 10 post delivery with
sudden onset bi-temporal headache and
bilateral blurred vision
• Exam: Right homonymous hemianopia
• CNs, limb power & sensation normal
• No cerebellar sign
• CT brain normal
* By the time when
MRI was performed,
patient had slightly
improved visual
field
From http://radiopaedia.org/articles/posterior-reversible-encephalopathy-syndrome-1
MRI T2 FLAIR (Fluid attenuated inversion recovery) sequence
Question 5
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What are the MRI findings? (1 mark)
What is the most likely diagnosis? (0.5 mark)
What is the alternative important diagnosis? (0.5 mark)
Name 3 predisposing factors for this condition. (1.5 mark)
Name one proposed mechanism for this condition. (1 mark)
What is the prognosis for this patient? (0.5 mark)
Question 5
1. What are the MRI findings? (1 mark)
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Hyperintense lesions on T2 FLAIR sequence
over bilateral occipital region
2. What is the most likely diagnosis? (0.5 mark)
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Posterior reversible encephalopathy syndrome
(PRES)
3. What is the alternative important diagnosis? (0.5
mark)
– Embolic stroke
Question 5
4. Name 3 predisposing factors for this condition.
(1.5 mark, any 3 of below)
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Hypertensive emergency
Eclampsia/ Pre-clampsia
Receiving immunosuppressant/ chemotherapy
Bone marrow or stem cell transplantation
Haemolytic uraemic syndrome
Systemic lupus erythematosus
Question 5
5. Name one proposed mechanism for this condition.
(1 mark)
– Endothelial dysfunction and breakdown of cerebral
autoregulation, causing vasogenic edema involving
especially the subcortical white matter of parietal
and occipital lobe
6. What is the prognosis for this patient? (0.5 mark)
– Usually benign with complete reversal of clinical
symptoms within several days
Thank you
Good Luck for Exam 2015!