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OSCE Feb 2012

OSCE Feb 2012. Dr. Wong Kim Chiu Associate Consultant North District Hospital. Case 1. 2/3/2011 M/67 Chronic smoker GERD. Case 1. c/o: found collapsed at home at 10:15 a.m. Last seen well at 10 a.m Arrived A&E at 10:51 a.m. ? Preceded by headache and neck pain. Case 1. On arrival :

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OSCE Feb 2012

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  1. OSCE Feb 2012 Dr. Wong Kim Chiu Associate Consultant North District Hospital

  2. Case 1 • 2/3/2011 • M/67 • Chronic smoker • GERD

  3. Case 1 • c/o: found collapsed at home at 10:15 a.m. • Last seen well at 10 a.m • Arrived A&E at 10:51 a.m. • ? Preceded by headache and neck pain

  4. Case 1 • On arrival : • P/E: GCS E3, V2, M6 • PERL, 3mm • Left hemiparesis • (Rt. side power 4/5, Lt. side power 2/5)

  5. Case 1 • ECG : SR, no acute ischemic changes

  6. Case 1 • CT brain : • Evidence of right MCA infarct with dense MCA sign and effacement of sulci.

  7. Case 1 • rt PA was given at 11:55 a.m. • Transferred to ICU for close monitoring

  8. Case 1 • Developed hypotension at 3:30 p.m. • PR  no tarry stool • H’cue 11.2 • No evidence of acute hemorrhage

  9. Case 1 • ECG : new onset ST depression over inferior leads • Bedside Echo: • no free fluid in abdomen • no pericardial effusion / pleural effusion • RWMA +ve • RV no dilated • Dx: NSTEMI

  10. Case 1 • Neurologist consulted: • Not for aspirin in view of recent adminstration of rt PA

  11. Case 1 • Rapid deterioration with shock and bradycardia • Intubation • Adrenaline and noradrenaline were given • BP on low side despite inotropes support

  12. Case 1 • Succumbed at 6:44 p.m. on the same day.

  13. Case 2 • M/59 • Good past health • c/o: constricting chest pain after running on the day of attention • P/E: unremarkable • 1st ECG showed SR with V.E. x 1

  14. Case 2 • Proceed chest pain protocol in O Ward. • Smart M.O. dug out history of right calf pain for 20 days. • ? Right calf swelling • Feeling SOB just after jogging • Still pending 1st TnI

  15. Case 2 • USG doppler was booked. • It showed right superficial femoral vein and popliteal vein thrombosis. • 1st TnI came back 0.26 • ECG repeated : sinus tachy 139/min., • No RAD or RBBB • No S1Q3T3

  16. Case 2 • CT thorax showed: • Extensive intra-arterial tubular filling defects suggestive of bilateral pulmonary thromboembolism involving the main pulmonary trunk and all of its branches, the right pulmonary lobar arteries and their branches. • Both lungs are clear, no pleural effusion • Dx: acute massive pulmonary thromboembolism

  17. Diagnosis of PE • The decision to do medical imaging is usually based on clinical grounds, i.e. the medical history, symptoms and findings on physical examination, followed by an assessment of clinical probability.

  18. Diagnosis of PE • The most commonly used method to predict clinical probability, the Wells score, is a clinical prediction rule.

  19. Diagnosis of PE • The Wells score: • clinically suspected DVT - 3.0 points • alternative diagnosis is less likely than PE - 3.0 points • tachycardia - 1.5 points • immobilization/surgery in previous four weeks - 1.5 points • history of DVT or PE - 1.5 points • hemoptysis - 1.0 points • malignancy (treatment for within 6 months, palliative) - 1.0 points

  20. Diagnosis of PE • Traditional interpretation • Score >6.0 - High (probability 59% based on pooled data) • Score 2.0 to 6.0 - Moderate (probability 29% based on pooled data) • Score <2.0 - Low (probability 15% based on pooled data)

  21. Diagnosis of PE • Alternate interpretation • Score > 4 - PE likely. Consider diagnostic imaging. • Score 4 or less - PE unlikely. Consider D-dimer to rule out PE.

  22. Diagnosis of PE • The gold standard for diagnosing pulmonary embolism (PE) is pulmonary angiography. Pulmonary angiography is used less often due to wider acceptance of CT scans, which are non-invasive.

  23. Treatment of PE • Anticoagulation • In most cases, anticoagulant therapy is the mainstay of treatment. Acutely, supportive treatments, such as oxygen or analgesia, are often required.

  24. Treatment of PE • Thrombolysis • Massive PE causing hemodynamic instability (shock and/or hypotension, defined as a systolic blood pressure <90 mmHg or a pressure drop of 40 mmHg for>15 min if not caused by new-onset arrhythmia, hypovolemia or sepsis) is an indication for thrombolysis.

  25. Treatment of PE • Surgery • Surgical management of acute pulmonary embolism (pulmonary thrombectomy) is uncommon and has largely been abandoned because of poor long-term outcomes.

  26. Treatment of PE • Inferior vena cava filter • If anticoagulant therapy is contraindicated and/or ineffective, or to prevent new emboli from entering the pulmonary artery.

  27. Case 3 • M/33 • Chronic smoker • Good past health • c/o: sudden onset of chest pain after repeated vomiting because of drunk

  28. Case 3 • GCS 15/15 • BP 167/67, P 67/min • Temp 36.9 C • SaO2 100% • Surgical emphysema +ve

  29. Case 3 • CXR showed pneumomediastinum & diffuse subcutaneous emphysema

  30. Case 3 • ECG showed normal sinus rhythm

  31. Case 3 • CT thorax: • Pneumomediastinum & surgical emphysema. • Diffuse increase in mediastinal fat density and patch of oral contrast of irregular outline over the lower thoracic region (at level of T10), suspicious of acute mediastinitis due to leaking from the lower oesophagus.

  32. Case 3 • EOT was done: • 1.5 cm x 0.5 cm perforation at left side of lower oesophagus at T10 level • Loculation of ~ 6 ml pus surrounding the perforation

  33. Case 3 • Esophageal rupture (also known as Boerhaave's syndrome) is rupture of the esophageal wall due to vomiting.

  34. Case 3 • 56% of esophageal perforations are iatrogenic, usually due to medical instrumentation such as an endoscopy. • Boerhaave's syndrome is reserved for the 10% of esophageal perforations which occur due to vomiting.

  35. Case 3 • Boerhaave's syndrome is the result of a sudden rise in internal esophageal pressure produced during vomiting, as a result of neuromuscular incoordination causing failure of the cricopharyngeus muscle to relax.

  36. Case 3 • In most cases of Boerhaave's syndrome, the tear occurs at the left postero-lateral aspect of the distal esophagus and extends for several centimeters. • It is associated with high morbidity and mortality. • The mortality of untreated Boerhaave syndrome is nearly 100%.

  37. Case 3 • The diagnosis of Boerhaave's syndrome is suggested on the plain chest radiography and confirmed by chest CT scan.

  38. Case 3 • Its treatment includes immediate antibiotics therapy to prevent mediatinits and sepsis, surgical repair of the perforation.

  39. Case 4 • M/79 • PMHx: DM, HT, Gout

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