Transcript 投影片 1 - HKCEM

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?
–
–
•
What’s the diagnosis?
•
•
–
–
–
–
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
–
–
•
Molar pregnancy, likely complete hydatidiform mole
What are the associated clinical features/complications for the above named
condition?
–
•
heterogeneous mass with numerous discrete anechoic spaces showing “snowstorm pattern”
± theca lutein cyst may be found in USG
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?
–
–
•
If the monitoring showed plateau / risk in the
marker, what’s the diganosis?
–
•
ß-hCG
Weekly until 3 consecutive normal
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

Glasgow-Blatchford
Bleeding Score (GBS)
Low risk = Score of 0
 Any score higher than 0 is
"high risk" for needing a
medical intervention of
transfusion, endoscopy, or
surgery.

Blood Urea
≥6·5 <8·0
2
≥8·0 <10·0
3
≥10·0 <25·0
4
≥25
6
Hemoglobin (g/L) for men
≥12.0 <13.0
1
≥10.0 <12.0
3
<10.0
6
Hemoglobin (g/L) for women
≥10.0 <12.0
1
<10.0
6
Systolic blood pressure (mm Hg)
100–109
1
90–99
2
<90
3
Pulse ≥100 (per min)
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?
–
•
What’s the diagnosis?
–
•
Bilateral lung field patchy infiltrate
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,
DBP<60mmHg
1
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
Temperature <35°C
or ≥40°C
Yes/No
History of:
Neoplastic disease
Congestive heart
failure
Cerebrovascular
disease
Yes/No
Renal disease
Liver disease
Yes/No
Yes/No
If any "Yes", then
proceed to Step 2
If all "No" then assign
to Risk Class I
Yes/No
Yes/No
PSI
Step 2: Stratify to Risk Class II vs III vs IV vs V
Demographics
If Male
If Female
Nursing home resident
Comorbidity
Points Assigned
+Age (yr)
+Age (yr) - 10
+10
Neoplastic disease
Liver disease
+30
+20
Congestive heart failure
+10
Cerebrovascular disease
+10
Renal disease
Physical Exam Findings
+10
Altered mental status
+20
Pulse ≥125/minute
+20
Respiratory rate >30/minute
+20
Systolic blood pressure <90 mm Hg
+15
Temperature <35°C or ≥40°C
Lab and Radiographic Findings
+10
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
∑ <70 = Risk Class II
∑ 71-90 = Risk Class III
∑ 91-130 = Risk Class IV
∑ >130 = Risk Class V
Typical vs atypical pneumonia
Comparison of Typical and Interstitial (Atypical) Pneumonias
Feature
Typical Pneumonia
Interstitial (Atypical) Pneumonia
Onset
Rigors
Facies
Sudden
Single chill
“Toxic”
Gradual
“Chilliness”
Well
Cough
Productive
Nonproductive: paroxysmal
Purulent (bloody)
103–104°F
Frequent
Frequent
Mucoid
< 103°F
Rare
Rare
Neutrophils
Mononuclear cells
> 15,000/mm3 with left shift
> 15,000/mm3
Defined density, lobar pneumonia
Nondefined infiltrate or interstitial
pneumonia
Streptococcus pneumoniae
Mycoplasma pneumoniae
Sputum
Temperature
Pleurisy
Consolidation
Gram stain (sputum)
White blood cell count and
differential count
Chest radiograph
Most common cause
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
•
–
Active external – rewarming shock and afterdrop
•
–
Blanket
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
1
Asymptomatic or mild headache and slight nuchal
rigidity
2
Severe headache, stiff neck, no neurologic deficit
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
Group Appearance of blood on head
CT scan
1
No blood detected
2
Diffuse deposition or thin layer
with all vertical layers (in
interhemispheric fissure,
insular cistern, ambient cistern)
less than 1 mm thick
3
Localized clot and/or vertical
layers 1 mm or more in
thickness
4
Intracerebral or
intraventricular clot with
diffuse or no subarachnoid
blood
Claassen grading system
Grade
Head CT criteria
1
No SAH or IVH
2
Minimal SAH and no IVH
3
Minimal SAH with bilateral IVH
4
Thick SAH (completely filling one
or more cistern or fissure)
without bilateral IVH
5
Thick SAH (completely filling one
or more cistern or fissure) with
bilateral IVH
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