Case 1 An 8 year old boy presents with left eye painful swelling for 1 day His mother also noted mild purulent nasal discharge for 1 week and low grade fever since 3 days ago There was no history of trauma ID: 933408
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Slide1
JCM OSCE
TKOH
4 November 2020
Slide2Case 1
An 8 year old boy presents with left eye painful swelling for 1 day. His mother also noted mild purulent nasal discharge for 1 week and low grade fever since 3 days ago. There was no history of trauma.
Slide3Case 1
https://www.chegg.com/
Slide4Case 1
Q1 What is the diagnosis ?
Slide5Case 1
Q1 What is the diagnosis?
Left orbital cellulitis with subperiosteal abscess
Left ethmoidal sinusitis
Slide6Uptodate
Slide7Case 1
Q2 Name 2 physical exam findings you would look for in this patient
Slide8Case 1
Q2 Name 2 physical exam findings you would look for in this patient
Proptosis
Painful ophthalmoplegia
Chemosis
Diplopia
Relative afferent pupillary defect
Visual impairment
Slide9Case 1
Uptodate
Slide10Case 1
Q3 Name 2 common causative pathogens for this condition
Slide11Case 1
Q3 Name 2 common causative pathogens for this condition
Streptococcus
pyogenes
Streptococcus pneumoniae
staphylococcus aureus
Hemophilus
influenzae
Anaerobes
Slide12Case 1
Q4 Suggest 2 potential complications for this child
Slide13Case 1
Q4 Suggest 2 potential complications for this child
Orbital abscess
Cavernous sinus thrombosis
Optic neuritis
visual loss
Endophthalmitis
Intracranial infection
Slide14Case 2
A 65 years old man with good past health went scuba diving in Sai Kung with friends today
Diving profile according to friend
25m for 30 mins
30m for 45 mins
20m for 30 mins
20m for 30 mins
Not sure if having rapid ascent
He was noted to be amnesic for 40 minutes of the diving event. He denied chest pain / earache / joint pain / head injury.
No other
neurological abnormality on exam. Vitals were stable
Slide15Case 2
Q1 What is the most likely diagnosis
?
Slide16Case 2
Q1 What is the most likely diagnosis?
Type II Decompression sickness with neurologic involvement
Slide17Case 2
Reference: Practice of emergency medicine 2
nd
Edition
Slide18Case 2
Q2 Name 2 risk factors for the above diagnosis
Slide19Case 2
Risk factors for decompression
sickness
Patient factor
Inexperienced
driver, male
Right-to-left shunt/patent foramen
ovale
Alcohol consumption/dehydration
Diving
profile
Rapid and multiple ascent
Prolonged and deep
dive
Others
Immediate air travel after
diving
Slide20Case 2
Q3 Your colleague suggests you contact PYNEH for a therapeutic procedure. What is it?
Slide21Case 2
Q3 Your colleague suggests you contact PYNEH for a therapeutic procedure. What is it?
Hyperbaric oxygen therapy
Slide22Case 2
Q4 What are the mechanisms of this therapeutic procedure for the condition ?
Slide23Case 2
Q4 What are the mechanisms of this therapeutic procedure for the condition ?
Reduction of gas bubble size, based upon Boyle’s Law
Nitrogen bubbles is inversely related to the pressure exerted upon it. At 3 ATM, bubble volume decreases by two thirds
Oxygenation to hypoxic tissues by increasing dissolved O2 content of arterial blood
Accelerating absorption of bubbles by increasing nitrogen gradient from bubble to plasma
Slide24Case 2
Q5 Suggest 4 other indications in which this therapeutic procedure may be useful
Slide25Case 2
Carbon monoxide poisoning
Necrotizing soft tissue infection
Central retinal artery occlusion
Actinomycotic brain abscess
Non-healing wounds
Refractory osteomyelitis
Radiation necrosis of soft tissue and bone
Crush injury / traumatic ischemia
Sensorineural hearing loss
Severe anaemia
Compromised skin grafts / flaps
Q5 Suggest 4 other indications in which this therapeutic procedure may be useful
Slide26Case 3
A 62 years old man, who was known hepatitis B carrier, was referred by GP for progressive weight loss for 1 month.
Exam revealed jaundice, hepatomegaly and distended abdomen with shifting dullness.
Bedside USG noted a space occupying lesion in background of small cirrhotic liver. Ascites was noted.
Private CT was done.
Slide27Case 3
Q1 Name the abnormality labeled with the arrow
Slide28Case 3
Q1 Name the abnormality labeled with the arrow
Esophageal varices
Slide29Case 3
The patient developed fresh hematemesis at A&E. You suspect bleeding from the structure labeled in Q1.
Q2 Name 1 pharmacological agent that could be used to reduce bleeding
Slide30Case 3
Q2 Name 1 pharmacological agent that could be used to reduce bleeding
Terlipressin
(vasopressin analog)
Octreotide (somatostatin analog)
Slide31Case 3
Patient continued massive hematemesis and soon went into hypovolemic shock despite fluid resuscitation and blood products transfusion. Surgeon advised temporary stabilization with a device.
Q3 What is the procedure?
Slide32Case 3
Patient continued massive hematemesis and soon went into hypovolemic shock despite fluid resuscitation and blood products transfusion. Surgeon advised temporary stabilization with a device.
Q3 What is the procedure?
Balloon tamponade
Slide33Case 3
Q4 Name 2 choices of the device
Slide34Case 3
Q4 Name 2 choices of the device
Sengstaken
-Blakemore tube (3 lumens)
Minnesota tube (4 lumens)
Linton-
Nachlas
tube (single lumen)
Slide35Case 3
Q5 Suggest a class of drug that prevents re-bleeding for this condition
Slide36Case 3
Q5 Suggest a class of drug that prevents re-bleeding for this condition
Non-selective beta-blocker e.g. propranolol,
nadolol
, carvedilol
Slide37Case 4
A 30-year-old man was sent to A&E in the evening unconscious. His vital signs are as follows:
GCS E2V2M5
BP 85/55 Pulse 105/min, SpO2 100% RA, temp 35 °C, flushing
Pupils 3 mm sluggish, normal tone and jerks, no clonus
Found a brown bottle with clear liquid beside him
Slide38Case 4
Q1 What 2 clinical features suggest that the patient has used a vasodilator?
Slide39Case 4
Q1 What 2 clinical features suggest that the patient has used a vasodilator?
Hypotension
Tachycardia
Flushing
Slide40Case 4
Q2 His male partner says he inhaled the contents of the bottle. Name 1 reason for the patient to use the substance.
Slide41Case 4
Q2 His male partner says he inhaled the contents of the bottle. Name 1 reason for the patient to use the substance.
Relaxation of throat and anal involuntary smooth muscles through vasodilatation (popularized to facilitate anal [and sometimes vaginal] sex in penetration)
For euphoria/ “rush” as recreational drug
Slide42Case 4
Q3 Name 2 possible substances that the brown bottle may contain
.
Slide43Case 4
Q3 Name 2 possible substances that the brown bottle may contain.
Alkyl nitrites (“Poppers”)
Gamma hydroxybutyrate (GHB)
Slide44Case 4
Q4 If the patient develops cyanosis, name one investigation you are going to do.
Slide45Case 4
Q4 If the patient develops cyanosis, name one investigation you are going to do.
Methaemoglobin
level
Slide46Case 4
Q5 How would you manage this patient?
Slide47Case 4
Q5 How would you manage this patient?
Close monitoring of airway patency, ventilation and conscious level
IV crystalloid for hypotension
N.B. Beware of concomitant phosphodiesterase inhibitor use
profound
hypotenison
Naloxone if severe GHB-associated respiratory/CNS depression is suspected
Urine toxicology +/- bottle contents for toxicology
Slide48Case 4 – Poppers
“Popper” is a slang term given broadly to drugs of the chemical class called alkyl nitrites that are inhaled.
Includes amyl nitrite, isobutyl nitrite, isopentyl nitrite, isopropyl nitrite etc.
Packaged as leather cleaner, room
deordorizers
etc. (in the US/UK)
Alkyl nitrites have very low vapor points
Called “poppers” in the 1970s as they were packaged in glassed ampoules wrapped in cloth, to be “popped” with fingers to inhale the contents
Illegal in Canada, EU as drugs
Slide49Case 4 - Poppers Uses and effects
Reduction to nitric oxide --> relaxion of throat and anal involuntary smooth muscles through vasodilatation
Popularized to facilitate anal (and sometimes vaginal) sex in penetration
Recreational use: for the “high” or “rush”
Effects: vasodilatation --> flushing, headache, palpitations
Disinhibition, euphoria
Slide50Case 4 – Poppers Toxicity
Vasodilatation: Tachycardia ,Sudden hypotension
Methemoglobinemia if oral ingestion (can be fatal)
Inhalation use rarely overdosed as vaporized rapidly
Interaction with sildenafil, tadalafil, TNG etc. [also vasodilators]
fatal hypotension
Maculopathy with isopropyl nitrite
Slide51Case 4 -
Gamma-hydroxybutyrate (GHB)
Endogenous metabolite of g-aminobutyric acid (GABA)
Acute intoxication: rapid onset of CNS depression, coma, bradycardia, hypotension
"Date rape drug"
Rapid elimination: plasma t1/2 20-45 min, all eliminated by 12 hours
Rapid recovery
Cannot be detected on urine immunoassay
Early specimen collection if GHB intoxication is suspected
Slide52Case 5
A 5 year old girl is brought to the ED by parents for difficulty in breathing today. Her parents noted she has reduced appetite in the past two week and has become unusually tired over the past few days.
BP 108/66 P 140 RR 40 SpO2 99% on RA Temp 37
°
C
She appears alert but tired-looking. Her mucous membranes appears dry. Skin turgor reduced. CRT 3s
Slide53Case 5
A 5 years old girl is brought to the ED by parents for difficulty in breathing today. Her parents noted she has reduced appetite in the past two week and has become unusually tired over the past few days.
BP 108/66 P 140 RR 40 SpO2 99% on RA Temp 37
°
C
She appears alert but tired-looking. Her mucous membranes appears dry. Skin turgor reduced. CRT 3s
Slide54Case 5
Q1a What is your diagnosis?
Q1b What is the biochemical criteria for the diagnosis of this condition?
Q1c
How would you classify the severity of the condition?
What is the severity of the condition in this child?
Slide55Case 5
Q1a What is your diagnosis?
Diabetic ketoacidosis
Slide56Case 5
Q1b What is the biochemical criteria for diagnosis of this condition?
Slide57Case 5
Q1b
What is the biochemical criteria for diagnosis of this condition?
Biochemical criteria for the diagnosis of diabetic ketoacidosis (DKA)
Hyperglycaemia
Blood glucose 11 mmol/L (>200 mg/dL)
Metabolic acidosis
Venous pH <7.3 or serum bicarbonate <15 mmol/L (15
mEq
/L)
Ketosis
Presence of ketones in the blood (
ß-hydroxybuyrate
≥3
mmol/L ) or urine ("moderate or large" urine ketones)
Slide58Case 5
Q1c How would you classify the severity of the condition?
What is the severity of the condition in this child?
Slide59Case 5
Q1c How would you classify the severity of the condition?
What is the severity of the condition in this child?
Severe DKA
Severity of DKA
Assessed based on the more severe of these parameters:
Venous pH
Bicarbonate (mmol/L)
Mild
<7.3
<15
Moderate
<7.2
<10
Severe
<7.1
<5
Slide60Case 5
Q2 List 4 risk factors associated with DKA as initial presentation of newly diagnosed type 1 diabetes in children
Slide61Case 5
Q2 List 4 risk factors associated with DKA as initial presentation of newly diagnosed type 1 diabetes in children
Young age (<5 years of age)
Low socioeconomic status
Ethnic minority
Delayed diagnosis
Children living in countries with low prevalence of type 1 diabetes
Slide62Case 5
Her parents recalled her body weight was 17.4kg two weeks ago
Her current body weight is 16 kg is at triage
You have given her 160ml NS (10ml/kg) over 1 hour for volume expansion
Q3 How are you going to replace her fluid deficit?
Slide63Case 5
Q3 How are you going to replace her fluid deficit?
Weight loss = pre-morbid body weight – current body weight = 17.4 – 16 = 1.4
kg
Fluid deficit = weight loss = 1400 ml (i.e. 8% dehydration)
Bolus given during resuscitation = 16 x 10ml/kg = 160 ml
Maintenance fluid = 10 x 100ml/kg + 6 x 50ml/kg = 1000 + 300 = 1300ml daily
Replacement over 48 hours = (deficit – bolus given) + maintenance = (1400 - 160) + 1300 x 2 = 1240 + 2600 = 4040 ml = 80ml/hr
Use NS as initial replacement fluid i.e. NS 80ml/hr
Slide64Case 5
Q4 List 4 risks factors associated with cerebral oedema in DKA in children
Slide65Case 5
Q4 List 4 risks factors associated with cerebral oedema in DKA in children
Young age (< 5 years)
New onset diabetes
Severe acidosis (pH < 7.1) at presentation
High blood urea nitrogen at presentation
Low initial partial
pressure of carbon dioxide (pCO2 > 20 mmHg)
Failure of the measured serum sodium to rise during DKA treatment
U
se of bicarbonate therapy for correction of acidosis in DKA
Insulin administration during first hour of resuscitation
Slide66Case 5
Q5 List 4 signs and symptoms for cerebral oedema in DKA in children
Slide67Case 5
Headache
Agitation or Irritability
Lethargy
Vomiting
Deterioration or fluctuating in level of consciousness
Inappropriate slowing of heart rate
Increased blood pressure
Incontinence inappropriate for age
Abnormalities of breathing pattern (e.g. respiratory pauses)
Focal neurological signs (e.g. oculomotor palsies, abnormal pupillary response)
Decerebrise or decorticate posturing
Q5 List 4 signs and symptoms for cerebral oedema in DKA in children