Case 1 A 28yearold man manual worker with good past health Presented with intermittent palpitation for 2 to 3 days Vitals at triage Temp 365 o C BP 10786 mmHg HR 167 bpm SpO2 99 on RA RR 22min ID: 1047133
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1. HKCEM JCM 7/2021OSCEPMH
2. Case 1A 28-year-old man, manual worker, with good past health.Presented with intermittent palpitation for 2 to 3 days.Vitals at triageTemp 36.5 oCBP 107/86 mmHg; HR 167 bpmSpO2 99% on RA; RR 22/min
3. Case 1
4. Case 1 – long lead II
5. Case 1Question 1Describe the ECG findings.
6. Case 1Question 1Describe the ECG findingsWide complex tachycardia (QRS 126 ms), HR 207 bpmRBBBRight axis deviationCapture beat
7. Case 1 – Capture Beat
8. Case 1Question 2What is the diagnosis?
9. Case 1Question 2What is the diagnosis?Answer: (Anterior) Fascicular VT
10. Case 1Question 3What treatment would you give if the rhythm persists?(a) haemodynamically stable?(b) haemodynamically unstable?
11. Case 1Question 3What treatment would you give if the rhythm persists?(a) haemodynamically stable?IV calcium channel blocker(Vagal maneuvers, adenosine, and lidocaine are ineffective in suppressing fascicular tachycardia.)(b) haemodynamically unstable?Synchronized D.C. cardioversion
12. Case 1After treatment given in 3(a), the ECG became like this
13. Case 1Question 4Describe the ECG and what is this phenomenon?
14. Case 1Question 4Describe the ECG and what is the T-wave phenomenon?Sinus rhythm 93 bpmT wave inversion over V3-6Cardiac T wave memoryA phenomenon seen after periods of altered ventricular conductionAfter normal ventricular conduction is restored, the T wave ‘remembers’ and mirrors the direction of the wide QRS complex. Therefore, negative T waves are seen in leads that had negative wide QRS complexes.Peck D, Al-Kaisey A. Cardiac memory: an under-recognised cause of deep T wave inversion in a patient presenting with chest pain. Case Reports 2018;2018:bcr-2018-225476.
15. Case 1Question 5What is the definitive treatment for this patient?
16. Case 1Question 5What is the definitive treatment for this patient?Radiofrequency catheter ablation
17. Case 1Progress of the patientAdmitted to CCUNormal echoPatient preferred medical treatmentStarted on isoptin SRCT coro bookedDischarged on D3
18. Case 2
19. Case 241/FGPHc/o abdominal distention for 6/12, and 4 limbs and facial swelling for 1/52BP 207/146 P 108 T 37.2 SpO2 97% (RA)Bed rest provided at triage
20. Case 2Question 1Your house officer took the above history. Name one important history that is missing.
21. Case 2Question 1Your house officer took the above history. Name one important piece of history that is missing.Answer: LMP
22. Case 2Question 2Name one bedside test that can have an immediate implication for diagnosis and treatment.
23. Case 2Question 2Name one bedside test that could be diagnostic.Answer: Urine PT
24. Diagnosis of PreeclampsiaNew onset HT after 20 weeks with proteinuria:BP ≥140/90 mm Hg two times, taken 4 hours apartBP ≥160/110 mm Hg onceProteinuria is defined by:24 hour protein ≥300 mgProtein/creatinine ratio of ≥0.3Proteinuria is NOT required if the patient has new onset HT with specified findingsALSO 2017
25. Diagnosis of PreeclampsiaDiagnosing Preeclampsia Without ProteinuriaPlatelets <100,000/uLCreatinine >1.1 mg/dL or doubled from baselineTransaminases twice the normal levelsPulmonary edemaCerebral or visual symptomsBlood pressure >160/110ALSO 2017
26. Case 2Question 3Name 2 medication options for BP control and the starting dosage
27. Case 2Question 3Name 2 medication options for BP control and the starting dosageLabetalol 20mg IVHydralazine 5mg IV
28. Case 2Question 4The patient develops generalized convulsion, what medication would you give?
29. Case 2Question 4The patient develops generalized convulsion, what medication would you give?MgSO4 solution 4-6 gm IV over 15 minutes as loading dose followed by maintenance IV infusion 2 gm per hourBenzodiazepines can also be used but MgSO4 is the first choice
30. Case 3
31. Case 348/Mslipped and fell 3 weeks before attendancelanded on right shoulderInitially seen bone setter with X ray, commented NADPersistent pain & cannot abduct beyond 90 degreeAn AP view of X ray right shoulder was shown.
32. Case 3
33. Case 3Question 1Describe the X ray finding.
34. Case 3Question 1Describe the X ray finding.An inferior and medial shift of humeral head relative to the glenoid fossa
35. Case 3Question 2Further X ray views have been arranged. What are the views of Fig (a) and Fig (b)? What is the diagnosis?Which view was preferred to delineate the diagnosis?
36. Case 3Fig (a)Fig (b)
37. Case 3Question 2Further X ray views have been arranged. What are the views of Fig (a) and Fig (b)? Fig (a) = Scapular Y viewFig (b) = Axillary viewWhat is the diagnosis?Posterior shoulder dislocationWhich view was preferred to delineate the diagnosis?Axillary viewAP view missed 50% of casesScapular Y view unreliable
38. Case 3Question 3aName one imaging study you would perform before decision on treatment. Question 3bWhat would you like to identify by this study?
39. Case 3Question 3aName one imaging study you would perform before decision on treatment. Answer: CT Question 3bWhat would you like to identify by this study? Answer: 1. to confirm diagnosis; 2. to rule out fracture(s); 3. to rule out reverse Hill-Sachs lesion; 4. to look for other associated injuries.
40. Case 3Question 4Describe the closed reduction method.
41. Case 3Question 4Describe the closed reduction method.axial traction on the adducted arm with the elbow flexedWhile traction is applied, the arm is internally rotated and adducted.Direct pressure on the posterior aspect of the dislocated humeral head, directing it anteriorly, may assist reduction.UpToDate
42. Case 4
43. Case 486/M with Parkinson’s Disease, WC outdoorUnwitnessed Fall at home while walking to toiletLeft eye bruises+
44. Case 4
45. Case 4
46. Case 4Question 1Describe the X ray findings.
47. Case 4Question 1Describe the X ray findings.AP filmTear-drop sign over left orbital floorWhitening of left maxillary sinusLateral filmFracture anterior wall of maxillary sinus
48. Case 4CT brain was also performed with some bone window films as shown below.
49. Case 4
50. Case 4
51. Case 4
52. Case 4
53. Case 4
54. Case 4Question 2Describe the CT findings.
55. Case 4Question 2Describe the CT findings.Fracture left anterior and lateral maxillary antrumFluid present over bilateral maxillary sinus, Left > RightFracture left lateral orbital wall and orbital floor
56. Case 4Question 3What is the diagnosis?
57. Case 4Question 3What is the diagnosis?Left Tripod fracture / Zygomaticomaxillary complex fracture
58. Case 4Question 4What is your treatment at A&E?
59. Case 4Question 4What is your treatment at A&E?Look for any associated injuriesCheck EOM and any enophthalmosCheck visual acuityCheck any paraesthesia over distribution of infraorbital nerveAvoid nasal blowingOral antibiotic and adequate analgesiaMaxillofacial surgery and eye referral
60. Case 5
61. Case 559/Mc/o right eye pain, redness and poor vision x 2 daysP/EPupil 3mm at left, 6mm dilated at right Right cornea hazziness+VA: Left 20/25 Right NLP
62. Case 5Question 1What is the most worrisome diagnosis at this stage?
63. Case 5Question 1What is the most worrisome diagnosis at this stage?Acute glaucoma
64. Case 5Further history revealed On and off subjective fever for 2 weeksMalaise and decrease appetite for 1 weekChills and rigor, accompanied with palpitation Seen GP 10 days ago, given meds without improvementFurther physical exam noted loss of red reflex over right eyeTemperature 36.6 oC, R/C 38 oCH’stix 25.8
65. Case 5Question 2What other diagnosis would you suspect?
66. Case 5Question 2What is the diagnosis would you suspect?Endophthalmitis
67. Case 5Question 3How would you classify the diagnosis of Question 2?
68. Case 5Question 3How would you classify the diagnosis of Question 2?Exogenous endophthalmitis (more common)Post-operative e.g. cataract surgeryafter intravitreal injectionFollowing ocular traumaEndogenous endophthalmitis
69. Case 5Question 4Further history revealed patient also complained of dysuria and urinary urgency. What is the culprit micro-organism?
70. Case 5Question 4Further history revealed patient also complained of dysuria and urinary urgency. What is the culprit micro-organism?Klebsiella pneumoniae
71. Case 5Question 5Do you known which antibiotics have better ocular penetration?
72. Case 5Question 5Which antibiotics have better ocular penetration?Fluoroquinolone
73. Case 5Question 6What would be your management plan?
74. Case 5Question 6What would be your management plan?Consult Ophthalmology x vitreous tapping + intravitreal antibiotics
75. Case 5ProgressTransfer to Eye UnitIV ciprofloxacin RE AC tapping, vitreous tapping and intravitreal antibiotics (Vancomycin + Fortum)Admitted Medical, then to ICU due to sepsisCTBilateral acute pyelonephritis with left renal vein thrombosis septic pulmonary emboli and infarcts prostate abscess Blood culture – Klebsiella pneumoniaeRepeated drainage of right prostatic abscessRight eye enucleation doneProlonged hospital stay, sepsis eventually controlled
76. The endThanks!