OSCE
26th March, 2014
Case 1
 67 years old gentleman attended AED
after a fall at escalator. He complained
of neck pain afterwards. He did not
have any limb weakness or sphincter
disturbance
 What are the abnormalities?
 Fracture dens of C2
 Degenerative changes with post nipping of the
osteophytes in C4/C5, C5/C6
 How to classify the pathology?
 Dens fractures are classified as type I, II, or III.
 Which ligamental injury is associated with this condition.
 Transvere alantal ligament
 Transverse atlantal ligament disruption occurs in
approximately 10% of cases. Injuries of this ligament
can result in atlantoaxial instability after odontoid
fracture osseous healing, and the chance of odontoid
fracture non-union is increased with its disruption.
 Give 2 complication of this condition
 nonunion
 malunion
 pseudoarthrosis formation
 infection
 neurovascular injury
 acute airway compromise
 Treatment modalities:
 externally immobilized by a halo vest
 fused surgically.
Case 2
 73 years old gentlemen had history of hypertension and
diabetes. He presented to our department with
dizziness, sweating and urinary incontinence. He had
fever and coryzal symptoms few days ago and had
consulted private doctor
 Describe the ECG
 SR 90/min
 ST elevation V1-V2
 Negative T V1-V2
 On further asking, this patient had history of recurrent
syncope few years ago. By that time investigation was
normal. What will be your diagnosis?
 Brugada syndrome
Type1
Type 2
Type 3
 What test will you order to confirm your diagnosis?
 Flecainide stress test/ Stress test with Class 1a, 1c or
Class III drugs
 What will be the treatment?
 Implantable cardioverter defibrillator (ICD)
Case 3
 61 years old gentleman presented with acute dysphagia.
He had history of foreign body (fishbone) ingestion 2
days ago
 Describe the findings
Rim enhancing collection noted along the left
oropharyngeal space
 What is your diagnosis?
Left retropharyngeal abscess
Relations of the retropharyngeal space:
* Superior: Base of the skull
* Inferior: Superior mediastinum
* Lateral: Carotid sheath
* Anterior: Buccopharyngeal fascia
* Posterior: Alar fascia
 What is the common causative organism?
 Aerobic organisms, such as beta-hemolytic streptococci
and Staphylococcus aureus
 Anaerobic organisms, such as species of Bacteroides and
Veillonella
 Gram-negative organisms, such as Haemophilus
parainfluenzae and Bartonella henselae
 Name 2 complications of this disease
 Airway obstruction.
 Mediastinitis.
 Pericarditis.
 Aspiration pneumonia.
 Epidural abscess.
 Septicaemia.
 Adult respiratory distress syndrome(ARDS).
Case 4
 70 years old gentleman had history of malignancy, just
put on chemotherapy few days ago. He presented to
AED with poor oral feeding, repeated vomiting and
dizziness. BP was 92/62, pulse 130/min at triage.
 What is your differential diagnosis?
 Hypovolaemic shock (GI loss)
 Distributive shock (septic shock)
 Obstructive shock ( Cardiac tamponade, pulmonary
embolism)
 Cardiogenic shock (ACS)
 What is your diagnosis?
 Cardiac tamponade
 What will the likely cause and the treatment?
 Malignancy
 Pericardiocentesis
 What is the bedside investigation to confirm your
diagnosis?
 Cardiac ultrasound/ Echocardiogarm
 What will be the diagnostic finding in that investigation?
 Pericardial effusion with RA/RV diastolic collapse
Case 5
 62 years old gentleman presented to AED with repeated
vomiting and diarrhoea. He had returned from Saban 2
days ago and had taken seafood there. The serum Na on
admission is 118. He was put on normal saline and
admitted EMW. On next day Na dropped to 108. Urea
2.9, Cr 64. Blood pressure was normal. Hydration was
good and there was no edema.
 Name 3 possible causes of the hyponatraemia.
 SIADH
 Hypothyroidism
 Addision’s disease
 Pseudohypontraemia
 Fluid loss
Hyponatraemia
 Isovolemic: SIADH, hypothyroidism, Addison’s disease,
water intoxification
 Hypovolemia: Fluid loss, dehydration, diuretics,
adrenal insufficiency
 Hypervolemic: CHF, cirrhosis, CRF
 Name 3 laboratory investigations you will perform.
Urine Na
Serum/ urine osmolality
TFT
Spot cortisol
Synathen test
 The serum osmolality is 240mOsmol/kg and urine
Osmolality is 567mOsmol/kg.
What is your diagnosis?
 SIADH
What will be your treatment?
 Fluid restriction
 Sodium supplement
 In symptomatic hyponatraemia, what kind of fluid
should be given and what will be the maximal rate of
increase of sodium per hour?
 Hypertonic saline (3% or 5.85% NaCl solution)
 Maximal rate 0.5mM/hr elevation
 What is the risk of rapid rise of sodium level?
 Central pontine myelinolysis
Case 6
 A 20 year-old lady with known history of asthma on
regular puffs presented to your ED for acute dyspnea in
the middle of the night. Here are her vital signs
 Conscious, however apprehensive
 BP 130/80, pulse 130/min
 SpO2 98% on 4L/min O2 via nasal cannula
 Talk in phases
 Temperature 38 degree Celsius
 What investigations would you do/order in ED?
 ABG (i-stat or point of care test)
 Peak expiratory flow rate, PEFR
 CXR
 ECG
 CBP D/C, R/LFT, Clotting profile
 Here is her blood gas, please interpret
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pH 7.28
pCO2 41.25mmHg
pO2 80mmHg
HCO3 20
BE -4
Na 128
K 4.0
Chloride 85
 High anion gap metabolic acidosis, respiratory acidosis
together with metabolic alkalosis
 pH 7.28 --> Acidosis
 HCO3 20, BE -4, --> metabolic acidosis
 Expected PaCO2 28mmHg +/- 2, however now is
41.25mmHg --> respiratory acidosis
 Anion gap 27 --> High anion gap metabolic acidosis
 Delta anion gap 15, delta HCO3 4, Delta anion gap/Delta
HCO3 ( Delta ratio ) = 3.75 >2 therefore metabolic
alkalosis
 What is your initial management in ED?
 Oxygen supplement with continuous SpO2 monitoring
 Puff bronchodilator including Ventolin/Atrovent, no ceiling
dose
 IV steroid, hydrocortisone 100mg-200mg stat
 MgSO4, 10mmol loading within 10-30minutes
 Prepare for intubation with mechanical ventilation, in
selected case, may have a trial of non-invasive ventilation
 Consult ICU
 She deteriorates further and you decide to intubate her,
what medications will you give for your RSI?
 Induction agent: Ketamine / Propofol
 Muscle relaxant: Suxamethonium
 Avoid giving histamine releasing medications including
morphine
 After your intubation, your portable ventilator alarms
and there is essentially no tidal volume achieved. Why?
 Bronchospasm with high airway pressure as a result of
high airway resistance that exceed the upper pressure
limit
 Pneumothorax
 Your ICU colleague agree to admit the patient but has to wait for 30
minutes in your resuscitation room, they can borrow a conventional
ventilator for you, what is your initial setting of the ventilator?
 Sedate and paralyze the patient
 SIMV(VC) + PS
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TV 6ml/kg predicted body weight
Zero PEEP
FiO2 1.0
RR 8-10/min, adjusted according to the flow-time or volume-time curve
Prolonged IE ratio e.g. 1:3.3 to 1:10
Increase the peak airway pressure limit to for example 100
Measure iPEEP and Plateau pressure
Thank you