1. JCM OSCE QMH A&E Feb 2014

2. Case 1 • F/32 • LBP for one week • No fever, no neurological deficits • PE unremarkable • Xray LS spine

3. Case 1

4. Question 1 • What is the Xray finding? • What could be the DDx?

5. Question 2 • What could be causative organism?

6. Xray Findings • Loss of L2/L3 disc height. • Erosion with increase sclerosis noted at L2 and L3. Increase left psoas shadow is seen. Pedicle is still preserved.

7. DDx • Infective vs malignancy • Infective more likely in view of increased psoas shadow and patient’s age

8. Infective spondylo-discitis • Infection that involves 1 or more of the extradural components of the spine • Organisms: • Staphylococcus aureus (in 60% of patients) and Enterobacter species • Tuberculosis • Fungal (cryptococcus), in immocomprised patient

9. Progress • Admitted to orthopaedics • CT guided drainage • Pus x C/ST: +ve for AFB • Undergoing Anti- TB treatment

10. Case 2 • M/20 • Complained of R sided chest pain for one day • No SOB • No history of trauma • PE showed decreased breath sound over R lung

12. Questions • What are the findings? • How do you manage him? • What are the indications for surgical treatment?

13. Xray finding • R hydropneumothorax • Trachea and mediastinum is shifted to L side • Absence of pneumomediastinum

14. Management • Haemodynamic support, oxygen • Early CTS consultation, may need early thoracotomy • Insertion of large bore chest drain (>32 Fr) • Blood (include type and screen)

15. Indication for surgical treatment • Signs of hypovolemic shock • Continuous bleeding (>100mL/hr) • Persistent air leak • Persistent pneumothorax • Impaired lung expansion • Pachypleuritis • Different from ATLS guideline for traumatic haemothorax (>1500mL first drain or 200mL/hr for >2hr)

16. Progress • Chest drain inserted, blood drained • Consulted CTSU • emergency VATS clot evaculation, pleurodesis done • Discharge D5

17. Case 3 • F/21 • PMH: Schizophrenia • Sudden onset of colicky generalised abdominal pain again since after lunch • Small amount BO • PE: abd distension

18. AXR

19. Questions • What are the findings? • Name a few differential diagnoses • What is the diagnosis?

20. Findings • Coffee bean sign noted with apex pointing towards LUQ. • Differential: • Other causes of intestinal obstruction, e.g. bezoar formation (hx of schizophrenia), ileosigmoid knot • Ischemic bowel, ureteric colic, ectopic pregnancy… • Diagnosis: sigmoid volvulus

21. Progress • Flexible sigmoidoscopy and flatus tube • decompression performed • Discharged D2

22. Case 4 • F/50 • Found collapsed in hospital canteen • On arrival GCS 14/15 • BP 160/70, P 60 • Tenderness and swelling over right face

26. CT face

27. Questions • Please describe the CT scan finding • What do you need to look for in physical examination? • If CT scan is not available, what Xray view will you order? Any pitfall in this view?

28. CT bone window: • Fracture of lateral wall and floor of Rt orbit • Lateral and medial walls of Rt maxillary sinus. Opacification of Rt maxillary sinus with air-fluid(blood) level

29. Physical Examination • Signs of extra-ocular muscle entrapment, especially diplopia on upward gaze • Signs of ocular injury, including hyphaema, rupture of eyeball, visual acuity • Causes of her collapse… and injuries in other parts of her body

30. If CT scan is not available, what Xray view will you order? • Water’s view • Pitfall: Maxillary fluid level may not be appreciated in supine patient lying on stretcher

31. Progress • seen by EYE • no clinical evidence of muscle entrapment • no globe injury • no indication for ocular intervention • Discharged D4

32. Case 5 • M/77 • Trip and fell with head and neck injury • Brief LOC • PE: GCS 15/15 • Tenderness over R neck • RUL power 4/5, LUL 5/5

33. CT brain + neck

34. CT reconstruction

35. Questions • What are the CT findings? • What do you need to look for in physical examination • What is the classification of this injury? • What are the possible long term complications in this injury? • Name 2 clinical prediction rules for predicting cervical injury requiring Xray

36. CT findings: • Fracture odontoid process with posterior displacement of the upper portion -> Hangman’s fracture • Comminuted fracture of the posterior arch of C1 -> Jefferson fracture

37. Physical examination • Signs of spinal cord compression: • Breathing effort (Diaphragmatic breathing) • Limb numbness/weakness • Anal tone • Distended bladder

38. What is the classification of this injury? Classified by location of fracture (Anderson and D’Alonzo classification) • Type I (<5%) • Tip of dens at insertion of alar ligament which connects dens to occiput • Usually stable but may be associated with atlanto-occipital dislocation • Type II (>60%) • Most common dens fractures • Fracture at base of dens at its attachment to body of C2 • Type III (30%) • Subdentate—through body of C2 • Does not actually involve dens • Unstable fracture as the atlas and occiput can now move together as a unit

39. What are the possible long term complication in this injury? • Non-union • Due to limited vascular supply • May occur in 30-50% of Type II fractures, especially in elderly • Malunion • Pseudarthrosis • Neurological deficit from cord injury

40. Name 2 clinical prediction rules for predicting cervical injury requiring Xray • Canadian C-Spine Rules • NEXUS criteria

41. Progress • MRI C spine: • No significant cord compression at C1/2 level