OSCE by TSWH HKCEM Question 1 A middle aged man presented with sudden onset crushing chest pain since 1 hour before AampE attendance Where is the likely culprit lesion 1 mark Right coronary artery RCA ID: 1048537
Download Presentation The PPT/PDF document "Joint clinical meeting Feb 2021" is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
1. Joint clinical meetingFeb 2021OSCE (by TSWH)HKCEM
2. Question 1A middle aged man presented with sudden onset crushing chest pain since 1 hour before A&E attendance.
3. Where is the likely culprit lesion? (1 mark)Right coronary artery (RCA).ST elevation ratio in lead II/III less than 1ST depression in lead IAbsent ST elevation in lead V5, V6What is the ECG diagnosis? (1 mark)Inferior ST elevation myocardial infarction.ST elevation in leads II, III, aVF with reciprocal changes most obviously seen in leads I, aVL, V2
4. Right coronary artery (RCA)Left circumflex artery (LCX)ST elevation leads II/III < 1ST elevation leads II/III > or = 1ST elevation in V4RST elevation in lateral leads (I, aVL, V5, V6)ST depression or T wave inversion in lead IIsoelectric and/or no T wave inversion in lead IName one ECG feature that can help differentiate the location of different culprit lesion in this patient. (1 mark)Name 1 additional POC investigation in A&E for this specific ECG diagnosis. (1 mark)Right-sided and posterior ECG.RV infarct – nitrates is contraindicatedPosterior extension of inferior MI – worse prognosisWhat is the definitive treatment? (1 mark)Coronary revascularization with primary percutaneous intervention (PCI) or intravenous thrombolytics administration.
5. Question 1 (cont.)Another patient presented to ED with chest pain.
6. What is the ECG diagnosis? (1 mark)Isolated lateral wall ST elevation myocardial infarction.ST elevation in aVLReciprocal ST depression in inferior leads
7. Name a specific site of lesion that can specifically lead to this ECG diagnosis. (1 mark)1st diagonal branch of LAD. Obtuse marginal branch of LCx.Ramus intermedius.Name 2 mechanical complications of such ECG diagnoses. (2 mark)Ventricular free wall ruptureAcute mitral regurgitation due to ruptured chordae or papillary muscle infarctionVentricular aneurysmVentricular septal defectIntraventricular thrombus
8. If a patient presents with chest pain and such ECG diagnosis soon after bee sting, name the clinical condition.Kounis syndromeKounis syndrome (KS) is defined as the occurrence of an acute coronary syndrome (ACS) concomitantly with hypersensitivity reactions triggered by an allergenic event first described by Kounis and Zavrasin in 1991 as an allergic angina syndrome
9. Question 250-year-old, good past health, presented with sudden severe dizziness, vomiting then collapsed 30 minutes ago. GCS 3 on arrival. CT brain was performed.
10. Name the diagnostic radiological sign in the CT images. (1 mark)Dense basilar artery sign.What is the diagnosis based on the clinical and radiological findings? (2 marks)Posterior circulation stroke due to acute basilar artery occlusion.
11. Suggest 2 relevant POC investigations in ED. (1 mark)ECG. POC glucose. POC blood gas.What would you suspect if the patient has neck pain preceding to collapse? (1 mark)Vertebral artery dissection.Name 3 risk factors that cause stroke in young patients. (3 marks) Inherited or acquired thrombophilia. Vasculitis.Cardioembolism. Moyamoya disease. Cerebral venous sinus thrombosis. What is the definitive treatment? (1 mark)Intravenous thrombolysis followed by endovascular thrombectomy.
12. Question 3A manual worker accidentally fell from a 2-metre high platform and sustained right knee injury. X-ray of the right knee was performed.
13. What is the radiological diagnosis? (1 mark) Anterior right knee dislocation.Which is the most common type of this condition? (1 mark)Anterior type. Defined by the direction of translation of tibiaAnterior (30-50%, most common)Posterior (30-40%)Lateral, medial rotatory (10-20%)
14. Suggest one most important clinical assessment that should be done in ED. (1 mark)Check neurovascular status in the injured limb.What should be performed in ED? (1 mark)Closed reduction of knee dislocation. What is the clinical sign that suggests possible failure of intervention in ED? (1 mark)Pucker sign.
15. ‘Pucker Sign’ an indicator of irreducible knee dislocationSantosh Somayya Jeevannavar, Chidendra Manohar Shettar. BMJ Case Rep. 2013; 2013: bcr2013201279.Pucker signResulted from entrapment of skin and medial subcutaneous tissue between the medial femoral condyleThe medial femoral condyle has button holed through the medial capsuloligamentous complex and sit subcutaneously
16. Some patients may have spontaneous recovery after injury. Suggest one radiological sign that may hint a prior injury. (1 mark) Asymmetrical or irregular joint space. Segond fracture.Osteochondral defect.Segond fracture (Radiopedia.org)
17. Name 4 conditions in which emergency operative intervention is indicated. (4 marks)Irreducible dislocation. Open dislocation. Acute compartment syndrome. Evidence of vascular compromise.
18. Question 4A 80-year-old male presented to the ED with severe abdominal pain and repeated vomiting. Blood was taken including POC arterial blood gas and electrolytes. The results are as follows. pHpCO2PO2HCO3Base excessO2 saturationNaKCl7.0510.1 kPa13.9 kPa21.0 mmol/L-11.0 mmol/L95%1464.898
19. Describe the abnormalities in the POC blood gas and electrolytes result. (2 marks)Mixed respiratory and metabolic acidosis with high anion gap.Anion gap = Na - Cl - HCO3 = 146 - 98 - 21 = 27pHpCO2PO2HCO3Base excessO2 saturationNaKCl7.0510.1 kPa13.9 kPa21.0 mmol/L-11.0 mmol/L95%1464.898Suggest 3 useful ED investigations that could be performed. (3 marks)POC lactate.POC glucose. Abdominal X-ray.
20. In view of the abnormalities in the blood results, an urgent CT abdomen and pelvis with contrast was performed. The following are some of the CT images.
21.
22.
23. Name 2 important findings from the CT images. (2 marks)Portal venous gas.Pneumatosis intestinalis.
24.
25.
26. Suggest 2 differential causes that could result in such imaging findings. (2 marks)Portal venous gas + pneumatosis intestinalis:Post endoscopy. COPD. Diverticulitis. Necrotic bowel tumour. It was noted that the patient has a medical record of history of atrial fibrillation. Suggest one relevant clinical diagnosis of his presentation. (1 marks)Acute mesenteric infarction due to cardioembolism resulting in bowel ischaemia.
27. Question 5A 25-year-old male motorcyclist was sent to the ED after he was thrown away from a motor vehicle crash. He appeared dyspnoeic on arrival.Chest X-ray was taken.
28. Describe the most important finding in this CXR. (1 marks) Multi-segment fractures in left 8th, 9th and 10th ribs.
29. What classical clinical sign would you look for in this patient? (1 mark) Paradoxical respiratory movement. If the patient presents with further respiratory distress, what complication would you consider in the patient? Name one relevant radiological sign you would look on a supine CXR. (2 marks)Pneumothorax.Deep sulcus sign. Double diaphragm sign. Hyperlucency of lung field. Increased sharpness of border of mediastinal structures or cardiac border or diaphragm.
30. Deep sulcus sign (Radiopedia.org)Double diaphragm sign (Learningradiology.com)
31. CT was performed and it showed left haemopneumothorax.What is considered massive haemothorax? (1 mark)> 1500ml blood drained immediately with chest drain insertion.Name 4 conditions that can cause shock in such a polytrauma patient. (4 marks) Hypovolemic shock due to exsanguinating bleeding.Neurogenic shock due to acute cervical cord injury.Cardiogenic shock due to cardiac contusion.Obstructive shock due to tension pneumothorax or cardiac tamponade secondary to hemopericardium.Name a method of pain control in this patient. (1 mark) Intravenous analgesia. Intercostal nerve block.