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JCM OSCE (Answer)

JCM OSCE (Answer). YCH AED Dr. Cheung Chi Kin, Arthur 8 th Oct 2014. Question 1. Question 1. What are the X ray findings? (1.5 marks) Which type of fracture does this girl have? (0.5 mark) What is the specific name for this fracture? (0.5 mark)

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JCM OSCE (Answer)

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  1. JCM OSCE (Answer) YCH AED Dr. Cheung Chi Kin, Arthur 8th Oct 2014

  2. Question 1

  3. Question 1 • What are the X ray findings? (1.5 marks) • Which type of fracture does this girl have? (0.5 mark) • What is the specific name for this fracture? (0.5 mark) • What are the mechanisms of this injury? (1.5 marks) • What is the descriptive name for the fracture also involving metaphysis of distal tibia? (0.5 mark) • What is the treatment of choice? (0.5 mark) • F/12 • Left ankle sprained 2 days ago • Presented with ankle pain • & limping gait • X ray was performed

  4. Question 1 • What are the X ray findings? (1.5 marks) • A radiolucent/ fracture line at left distal tibia • Extending from epiphysis to epiphyseal plate • Soft tissue swelling around ankle • Which type of fracture does this girl have? (0.5 mark) • Salter-Harris type 3 fracture

  5. Question 1 • What is the specific name for this fracture? (0.5 mark) • Tillaux fracture • What are the mechanisms of this injury? (1.5 marks) • In adolescents, the medial part of epiphyseal plate closes first while the anteriolateral part still opens • During forced external rotation of foot • Epiphyseal plate is weaker than ligament, therefore lateral epiphysis is prone to avulsion fracture

  6. Question 1 • What is the descriptive name for the fracture also involving metaphysis of distal tibia? (0.5 mark) • Triplane fracture • What is the treatment of choice? (0.5 mark) • Operative treatment (internal fixation) if joint surface displacement > 2mm

  7. Question 2

  8. Question 2 • F/14 Good past health • Presented with repeated vomiting x 1/52 • Associated with abdominal pain after food • Bowel opening normal • Thin body build, abdomen soft • List four important differential diagnoses in this case. (2 marks)

  9. Question 2 • List four important differential diagnoses in this case. (2 marks, any 4 of below) • GI: peptic ulcer/ pancreatitis/ small bowel obstruction • Gyn: hyperemesis gravidarum/ molar pregnancy/ UTI/ twins • Diabetic ketoacidosis • Increased intracranial pressure/ post head injury (In this case, Urine wbc nit –ve, PT –ve; Hstix 5.6; CT brain NAD)

  10. Question 2 • CT scan of abdomen was performed. Describe the findings and what is the likely diagnosis? (2 marks)

  11. Question 2 • CT scan of abdomen was performed. Describe the findings and what is the likely diagnosis? (2 marks) • There is a very narrow distance between the abdominal aorta and the SMA, • measuring 4.9mm (normally 13-34mm), • where the third part of duodenum passes through • The diagnosis is Superior Mesenteric Artery Syndrome (due to lack of retroperitoneal or mesenteric fat)

  12. Aorta-SMA angle is 10 degrees (normal 28-65)

  13. Question 2 • How do you dispose this patient? (0.5 mark) • What is the another structure which can be entrapped between SMA & aorta? (0.5 mark)

  14. Question 2 • How do you dispose this patient? (0.5 mark) • Admit Surgery • What is the another structure which can be entrapped between SMA & aorta? (0.5 mark) • Left renal vein (Nutcracker Syndrome) - Presented with haematuria, left-sided varicocele

  15. Question 3

  16. Question 3 • M/42 Hx NPC 2007 in remission • Presented with fever & sore throat x 1/7 • BP 139/69 P112 RR18 Temp 39.0 SpO2 98% • No stridor or neck swelling • XR neck was performed

  17. Question 3 • What are the X ray findings? (1 mark) • What is the diagnosis? (0.5 mark) • Name 2 common pathogens. (1 mark) • What is the initial management in AED? (2.5 mark)

  18. Question 3 • What are the X ray findings? (1 mark) • Thumbprint sign • ballooning/ air-trapping in hypopharynx • What is the diagnosis? (0.5 mark) • Acute epiglottitis

  19. Question 3 • Name 2 common pathogens (1 mark, any 2 of below) • Haemophilus influenzae type B (less prevalent since introduction of vaccine in 1987) • Grp A beta haemolytic streptococci (most common) • Streptococcus pneumoniae • Staphylococcus aureus

  20. Question 3 • What is the initial management in AED? (2.5 mark, any 5 of below) • Manage in Resuscitation room • Avoid lie flat and vigorous throat examination • Supplemental oxygen via face mask • IV access, blood test, culture • IV antibiotic (e.g. Augmentin 1.2g or Zinacef 1.5g) • Consult ENT & ICU • Prepare Difficult Airway Management (DAM)

  21. Only 15-20% adult patients required an artificial airway......majority of patients without respiratory distress can be managed conservatively under close monitoring

  22. Question 4

  23. Question 4 • F/55 Good past health, non smoker, non drinker • Presented with cough & throat discomfort x2/52 • Throat clear, neck soft, no cervical LN • Chest clear, no added sound • Few high pitched breath sound during expiration • Otherwise systemically well, ambulatory • ENT consulted, normal laryngoscopy to VC • CXR was performed

  24. Question 4 • Name 3 differential diagnoses. (1.5 marks) • What is the positive finding on CXR? (0.5 mark) • Name 3 important negative findings on CXR. (1.5 marks) • Name 3 important investigations. (1.5 marks)

  25. Question 4 • Name 3 differential diagnoses. (1.5 marks, any 3 of below) • Foreign body aspiration • Infection e.g. tracheitis – bacterial, TB • Trachea tumor/ subglottic stenosis • Tracheomalacia • External compression to trachea • What is the positive finding on CXR? (0.5 mark) • A radioopague lesion in lower trachea above carina

  26. Question 4 • Name 3 important negative findings on CXR. (1.5 marks) • No hyperinflated lung field/ collapse • No pneumomediastinum • No tracheal deviation • Name 3 important investigations. (1.5 marks) • Contrast CT thorax • Bronchoscopy +/- biopsy • Sputum for AFB smear, culture & cytology

  27. Bx confirmed CA trachea

  28. Question 5

  29. Question 5 • F/32 Good past health • Presented on day 10 post delivery with sudden onset bi-temporal headache and bilateral blurred vision • Exam: Right homonymous hemianopia • CNs, limb power & sensation normal • No cerebellar sign • CT brain normal

  30. * By the time when MRI was performed, patient had slightly improved visual field From http://radiopaedia.org/articles/posterior-reversible-encephalopathy-syndrome-1 MRI T2 FLAIR (Fluid attenuated inversion recovery) sequence

  31. Question 5 • What are the MRI findings? (1 mark) • What is the most likely diagnosis? (0.5 mark) • What is the alternative important diagnosis? (0.5 mark) • Name 3 predisposing factors for this condition. (1.5 mark) • Name one proposed mechanism for this condition. (1 mark) • What is the prognosis for this patient? (0.5 mark)

  32. Question 5 • What are the MRI findings? (1 mark) • Hyperintense lesions on T2 FLAIR sequence • over bilateral occipital region • What is the most likely diagnosis? (0.5 mark) • Posterior reversible encephalopathy syndrome (PRES) • What is the alternative important diagnosis? (0.5 mark) • Embolic stroke

  33. Question 5 • Name 3 predisposing factors for this condition. (1.5 mark, any 3 of below) • Hypertensive emergency • Eclampsia/ Pre-clampsia • Receiving immunosuppressant/ chemotherapy • Bone marrow or stem cell transplantation • Haemolytic uraemic syndrome • Systemic lupus erythematosus

  34. Question 5 • Name one proposed mechanism for this condition. (1 mark) • Endothelial dysfunction and breakdown of cerebral autoregulation, causing vasogenic edema involving especially the subcortical white matter of parietal and occipital lobe • What is the prognosis for this patient? (0.5 mark) • Usually benign with complete reversal of clinical symptoms within several days

  35. Thank you Good Luck for Exam 2015!

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