Q1 A 45 years old lady was brought in by ambulance for agitation BP 195110 P 105min temp 388 RR 32 SpO2 95 RA ECG was done Q1 Give 4 ddx CNS infection Thyroid storm Heat stroke Toxicology eg sympathomimetic overdose ID: 1032959
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1. JCM OSCE March 2021PWH AED
2. Q1A 45 years old lady was brought in by ambulance for agitation.BP 195/110, P 105/min, temp 38.8, RR 32, SpO2 95% RAECG was done.
3. Q1Give 4 ddx.CNS infectionThyroid stormHeat strokeToxicology e.g. sympathomimetic overdoseNeuroleptic malignant syndrome, serotonin syndrome
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5. Q1 What is the ECG diagnosis?Atrial fibrillation with rapid ventricular response
6. Q1The clinician noted that she had a neck swelling on treatment but defaulted follow up for few weeks.On physical exam, there was basal crepitation over both chest and mild lower limb edema.What is the most important clinical diagnosis?Thyroid storm
7. Q1Suggest 4 medications to give in this condition.Propylthiouracil 150-200mg Q6H POHydrocortisone 200mg stat IV, then 100mg Q6-8HPropranolol 40-80mg Q4-6H PO or 1 mg IVAlternative: diltiazem 60-120mg Q8HLugol’s solution 6-8 drops Q6-8H (use 1 hour later after PTU)Alternative if allergy: Lithium
8. Q1Would you give aspirin to control the temperature? Why?NoAspirin would increase serum free T4 and T3 by decreasing their protein binding
9. Q2A middle-aged man complained of sudden right lower leg pain when playing badminton. There was severe pain and swelling. He could not bear weight.
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11. Q2What clinical test did the examiner perform? (Clinical test showed right leg pathology)Simmond’s Test/ Thompson TestThe absence of foot plantarflexion on calf compression => positiveIndicative of Achilles tendon rupture
12. Q2What is the most likely diagnosis? Give 1 ddx. Right Achilles tendon rupture.Ddx: calf muscle tear/ rupture baker’s cyst
13. Q2Suggest 2 physical signs for the most likely diagnosis that may be present apart from local tenderness, bruise or swelling.Weak plantarflexionPresence of a palpable gapAsymmetrical resting posture (increase ankle dorsiflexion)
14. Q2What are the ultrasound features of this patient’s problem?Hypoechoic defect within the tendonSonographic Thompson test: widening of hypoechoic defect when squeezing the calfHerniation of fat into the gap
15. Q2LeftRight
16. Q2LeftRight
17. Q2The patient was taking an antibiotic for infection recently. What is the likely antibiotic?FluoroquinoloneWhat are the cardiovascular adverse effects of the above antibiotics?QT interval prolongation/ Aortic aneurysm and dissection/ heart valve regurgitation/incompetenceName 1 more drug that can predispose to above condition.Corticosteroid
18. Q2Patient refused surgery. Please state the management plan.Serial castingNWB with long leg cast in position of plantar flexionProgressively decrease plantar flexion and change to short leg castDuration: 6-12 weeksRehabilitationPain control
19. Q3A 78 y.o. man presented with decreased general condition for 2 days. The relative claimed he had no fever or recent head injury.GCS E4V4M6BP 220/110, P 80CTB was done.
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21. Q3Please comment on CT findings Bilateral acute on chronic subdural hemorrhagesAssociated compression onto the cerebral hemispheres with sulcal effacementMild midline shift to leftNo hydrocephalus
22. Q3Suggest one underlying brain pathology for this condition. Cerebral atrophy
23. Q3What is the underlying mechanism of this condition?Tearing of bridging veins draining from surface of brain to dural sinus
24. Q3Suggest a drug for blood pressure control in this condition.IV labetalol
25. Q3If the patient is on warfarin, what should be given?PCC – Prothrombin Complex ConcentrateFFP – Fresh Frozen PlasmaIf he is on dabigatran, what should be given?Idarucizumab, PCCWhat is the reversal agent for heparin?Protamine sulfate
26. Q4A 72 y.o. man, with history of DM, complained of fever and sore throat for 1 day. He had dysphagia and mild SOB.Please give 4 potential life threatening ddx.Acute epiglottitisRetropharyngeal abscessQuinsyLudwig’s angina
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28. Q4On physical examination, there was diffuse swelling over submandibular area and anterior neck with erythema and tenderness. The patient claimed he did not have the swelling yesterday. His voice was muffled. There was no cervical lymphadenopathy. You could hear mild stridor. He could speak full sentences and oxygen saturation was satisfactory. What is the most likely ddx?Ludwig’s angina
29. Q4What are the common organisms for above condition?Polymicrobial infectionMost common organism: viridans streptococciOral anaerobes: Peptostreptococcus species, Fusobacterium nucleatum, pigmented Bacteroides and Actinomyces spp.
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31. Q4Please comment on the Xray.Thumb signSubmandibular swelling, no fluid collection or gas
32. Q4Outline your management plan.Timely assessment and management of the airwayAnticipate difficult airway with backup plansUrgent consult ENT and ICUGive intravenous empirical broad-spectrum antibioticsContrasted CT neck
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34. Q4Please comment on the CT.An ill-defined irregular rim-enhancing collection over left tonsillar region displacing the trachea to the right
35. Q4What is the definitive treatment?Surgical drainage
36. Q5A 38 years old pregnant lady in 36 weeks of gestation, complained of epigastric pain. BP 210/130, P100. Urine dipstix showed abnormality.What would be the most likely ddx?Severe preeclampsiaWhat are the alarming symptoms of above diagnosis?Persistent and/or severe headacheVisual disturbance (blurred vision, photophobia)Epigastric painAltered mental statusNew dyspnea, orthopnea
37. Q5What are the main aspects in management in ED?Seizure prophylaxis and treatmentBlood pressure controlObserve for possible complicationsMonitor fetal well-beingConsult obstetricians for delivery
38. Q5What is first line medication in the above mentioned most likely diagnosis? State with dosage.Magnesium sulphate 4-6 gram IV over 5-10 minutes, followed by 1 gram/hr for 24 hours for maintenance
39. Q5What should be monitored during infusion of the above named medication?Deep tendon reflexRespiration rateConscious levelUrine outputSerum Mg level
40. Q5What is the first sign of toxicity of the above named medication?Loss of deep tendon reflexWhat is the management if toxicity of the above named medication appears?10ml 10% calcium gluconate over 10 minutes
41. Q5What are the drugs to use in lowering blood pressure in this patient? Give 2 with dosage.Labetalol 10-20mg IVHydralazine 5mg IV
42. Q5The patient was on infusion you gave for seizure control. Suddenly, she developed GTC convulsion. What would you give?Another 2gm MgSO4 IV bolusThe convulsion stopped, but patient remained comatose. CT brain was done. What would you look you?Subarachnoid hemorrhage
43. Thank you.