TMH Question 1 A 65F with unremarkable past health attended the Accident and Emergency Department for acute onset of palpitation for 1hr She was alert with blood pressure 16390 mmHg pulse 170 beatsmin and SpO2 98 on RA ID: 1036055
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1. JCM 2/9/2020OSCE answersTMH
2. Question 1A 65/F with unremarkable past health attended the Accident and Emergency Department for acute onset of palpitation for ~1hr.She was alert with blood pressure 163/90 mmHg, pulse 170 beats/min, and SpO2 98% on RA.
3. ECG
4. a. What are the ECG findings? (3 marks)
5. a. What are the ECG findings? (3 marks)Monomorphic wide complex tachycardia of ventricular rate 173 bpmInferior axisLeft bundle branch blockAV dissociation
6. b. What is your diagnosis? (1 mark)
7. b. What is your diagnosis? (1 mark)Right ventricular outflow tract tachycardia
8. C. What drug will you give this patient? (1 mark)
9. C. What drug will you give this patient? (1 mark)ATP 10mg IV bolusCCB, BB
10. What is the definitive treatment for this condition? (1 mark)
11. What is the definitive treatment for this condition? (1 mark)EPS + RFA
12. Question 2A 70/F attends the Accident and Emergency Department for left upper quadrant pain for one day. The pain started after a bout of vigorous coughing. She has past medical history of DM, hypertension, atrial fibrillation and chronic rheumatic heart disease with mitral valve replacement and tricuspid valve valvuloplasty.BP128/58 mmHg, pulse 79 beats/min, afebrile.Physical examination found a palpable vague swelling of 15cm over left abdomen.
13. What are your differential diagnoses for a painful abdominal mass? (2 marks)
14. What are your differential diagnoses for a painful abdominal mass? (2 marks)Abdominal wall Abdominal wall abscessRectus sheath hematomaAbdominal wall neoplasmsIntra-abdominalStrangulated herniaSymptomatic abdominal aortic aneurysmIntra-abdominal neoplasms
15. Any specific signs you would look for during physical exam to distinguish intra-abdominal pathology from abdominal wall pathology? (1 marks)
16. Any specific signs you would look for during physical exam to distinguish intra-abdominal pathology from abdominal wall pathology? (1 marks)Movement with respirationFothergill signCarnett sign
17. Fothergill signVoluntary contraction of rectus muscle (lifts head or leg while lying supine)Rectus sheath hematomas become fixed and more tenderIntra-abdominal masses become less distinct and tenderPositive sign: an abdominal mass that does not cross the midline and remains palpable when the rectus muscles are flexed
18. Carnett signTense the abdominal muscles by asking patient to raise head or shoulder off table while lying supinePositive sign for abdominal wall pathology: abdominal tenderness increased or unchangedNegative sign: decreased abdominal tenderness
19. Contrast CT abdomen and pelvis
20. c. Describe the CT findings. (1 marks)
21. c. Describe the CT findings. (1 marks)Left rectus abdominis muscle grossly swollen with heterogeneous densities; no contrast enhancementLinear hyperdensity with the left rectus abdominis muscle swelling, suggestive of active contrast extravasation within the rectus sheath hematoma
22. d. What is the diagnosis? (1 marks)
23. d. What is the diagnosis? (1 marks)Left abdominal rectus sheath hematomaActive hemorrhage from feeding artery
24. e. How would you manage this patient? (3 marks)
25. e. How would you manage this patient? (3 marks)NPOSet 2 large bore IV, IVF +/- blood product resuscitationMonitor Hb levelCorrect any coagulopathy: stop warfarin, give Prothrombin complex concentrate or FFPPain control, bed rest, compression of hematoma
26. What treatment can be offered if conservative treatment failed? (1 marks)
27. What treatment can be offered if conservative treatment failed? (1 marks)Angiography with arterial embolisation of superior/ inferior epigastric arteriesSurgical ligation of superior/ inferior epigastric arteries +/- hematoma evacuation
28. Rectus sheath hematomaAccumulation of blood within rectus sheathRupture of epigastric vessels or torn rectus muscle fibresSpontaneous (anticoagulant), trauma, cirrhosisR>L, lower> upperAbdominal wall ecchymosis, substantial Hb dropGenerally self limiting
29. CT classificationtype I: small and confined within the rectus muscle; does not cross the midline or dissect fascial planestype II: also confined within the rectus muscle but can dissect along the transversalis fascial plane or cross the midlinetype III: large, usually below the arcuate line, and often presents with evidence of hemoperitoneum and/or blood within the prevesical space of Retzius (retropubic space)
30. Question 3A 59 year old female was accidentally hit by the blunt end of a screwdriver over her right eye. She complained of severe right eye pain.Physical examination showed 3mm proptosis over the right eye with limited ability to open the eye. There were severe swelling and tenderness at the right orbital region. VA was 6/12. IOP was 18 mmHg.
31. a. What are the possible injuries? (2 marks)
32. a. What are the possible injuries? (2 marks)Anterior segmentCorneal abrasion Hyphema Lens dislocationGlobe rupturePosterior segmentVitreous haemorrhageRetinal detachment Extra-ocularOrbital bone fractureRetro-bulbar hemorrhageTraumatic ICH
33. Plain CT orbit
34. b. Describe the CT findings. (1.5 marks)c. What is the diagnosis? (0.5 mark)
35. b. Describe the CT findings. (1.5 marks)Hyperdensity over right orbital apex posterior to the right globeContour of right globe is preservedNo lens dislocationNo periorbital fracturec. What is the diagnosis? (0.5 mark)Right acute traumatic retro-bulbar hemorrhage(ddx: posterior globe rupture)
36. d. Is operative treatment indicated for this condition? (0.5 mark)
37. d. Is operative treatment indicated for this condition? (0.5 mark)No, conservative treatment if IOP is normal
38. e. The patient complains of worsening pain, swelling and vision over her right eye. IOP is now 44 mmHg. What is the complication she developed? (0.5 mark) What is the treatment for this complication? (0.5 mark)
39. e. The patient complains of worsening pain, swelling and vision over her right eye. IOP is now 44 mmHg. What is the complication she developed? (0.5 mark) Right orbital compartment syndromeWhat is the treatment for this complication? (0.5 mark)Surgical decompression of the right orbit by lateral canthotomy and inferior cantholysis
40. Retrobulbar hematomaan uncommon, rapidly progressive, sight threatening emergency that result from accumulation of blood in the retrobulbar spaceClinical featuresPainful ProptosisIncreased orbital tissue tension, increased intraocular pressureEcchymosis of eyelidsChemosisDecreased Visual FieldDecreased Visual Acuity/Loss of VisionAfferent Pupillary Defect (APD in swinging flash light test)
41. Ocular compartment syndromeRigid orbital bone limits expansion of accumulated bloodOptic nerve limits anterior displacement of orbital contentsThe raised intraorbital is transmitted to optic nerve, retinal artery and vasculature of the optic nerve resulting in ischemiaTrue eye emergency: permanent visual loss if untreatedSurgical decompression of the orbit by lateral canthotomy and inferior cantholysis
42. Question 4A 56 year old man attended AED for left eye ptosis for 3 months. He also complained of recent weight loss.Physical exam showed left pupil miosis and left eye partial ptosis.
43. a. What condition is this patient suffering from? (0.5mark)
44. a. What condition is this patient suffering from? (0.5mark)Left Horner’s syndrome
45. b. What other physical signs may be present? (1.5 marks)
46. b. What other physical signs may be present? (1.5 marks)Ipsilateral facial anhidrosisIpsilateral impaired facial flushing (Harlequin sign)Apparent enophthalmosEnhanced accommodation
47. c. What pharmacological test to confirm the presence of this condition? (0.5 mark)
48. c. What pharmacological test to confirm the presence of this condition? (0.5 mark)Cocaine eye drop testBlocks reuptake of norepinephrine at the sympathetic nerve synapsePupil dilatation in eyes with intact sympathetic innervationNo effect on Horner pupil: 1mm increase in anisocoriaApraclonidine eye drop test
49. d. What are the possible causes? (2 marks)
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51. d. Describe the CXR findings. (1.5 marks)Left apical opacityTracheal deviation to right
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53. Malignant looking mass lesion in left lung apical regionEroded left 2nd and 3rd ribsEroded T1-3 vertebral bodies
54. e. What is the patient’s diagnosis? (1 mark)
55. f. What is the patient’s diagnosis? (1 mark)Left Pancoast tumourBony invasion
56. Question 5A 29 year old man of good past health presented to AED with sudden onset of neck pain this morning, followed by right sided weakness and vertigo. There was no prior trauma or manipulation.PE: BP 141/95 P72 SpO2 99% on RA. GCS 15, PERL.There was nystagmus, right upper motor neuron facial nerve palsy, right side dysmetria. Limb power was 5-/5 over right side and 5/5 over left side.Plain CT brain was normal.
57. a. What are the causes of young stroke? (1.5 marks)
58. a. What are the causes of young stroke? (1.5 marks)vasculitis (moya-moya disease, behcets syndrome)Carotid or vertebral artery dissection (traumatic, fibromuscular dysplasia)thrombophilia/ hypercoagulable state (antiphospholipid syndrome, protein C/S deficiency, leukemia/ thrombocythemia, pregnancy, OCP)embolic (prosthetic heart valve, infective endocarditis)drugs (cocaine, heroin, amphetamines)cerebral venous sinus thrombosis
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65. c. State the name of this neuroimaging. (0.5 mark)d. Describe the abnormal findings in this neuroimaging. (1 mark)
66. c. State the name of this neuroimaging. (0.5 mark)CT angiogram of braind. Describe the abnormal findings in this neuroimaging. (1 mark)Marked loss in calibre of right vertebral artery V3 and V4 segments
67. e. What is the patient’s diagnosis? (0.5 mark)
68. e. What is the patient’s diagnosis? (0.5 mark)Right vertebral artery dissectionRight lateral medullary syndrome
69. Lateral medullary syndromeClinical featuresIpsilateral Horner syndromeIpsilateral ataxiaContralateral hypalgesiaImpairment of pain and thermal sensation over the contralateral side of the trunk and limbsImpairment of pain and thermal sensation over the ipsilateral faceVertigo, dysphagia, nystagmus, facial weakness, hiccups
70. f. What are the treatment options for this diagnosis? (2 marks)
71. f. What are the treatment options for this diagnosis? (2 marks)Thrombolytic therapy (tPA)Endovascular interventionsMechanical thrombectomyIntra-arterial thrombolysisStentingAntithrombotic therapy AntiplateletAnticoagulation Surgical repair
72. Vertebral artery dissectionV3 most commonly affectedCause40% minor trauma or other triggersConnective tissue or vascular disorder e.g. fibromuscular dysplasiaSpontaneousClinical featuresLocal: neck pain, headache, horner syndromeIschemia: lateral medullary infarction, spinal cord ischemia
73. CTAString signTapered stenosisFlame-shaped occlusionIntimal flapDissecting aneurysmMRI/ MRAAngiography
74. Referencehttps://surgeryreference.aofoundation.org/cmf/trauma/midface/further-reading/retrobulbar-hemmorage#retrobulbar-hemorrhage-compartment-syndrome-in-the-orbithttps://www.semanticscholar.org/paper/Imaging-of-Horner's-syndrome.-George-Haydar/fa9803c09573cee844296d997c353271e2715cd1https://www.google.com/url?sa=i&url=https%3A%2F%2Fwww.researchgate.net%2Ffigure%2FThe-four-parts-of-the-vertebral-artery_fig1_10966117&psig=AOvVaw3_E9bKj8UbfBVu7bKpZfMH&ust=1598243530714000&source=images&cd=vfe&ved=0CAIQjRxqFwoTCKisv66_sOsCFQAAAAAdAAAAABAD