OSCEJCM Dr CT Lui TMH A&E Aug 2012
Case summary • Case 1: complete hydatidiform mole • Case 2: UGIB • Case 3: PJP pneumonia • Case 4: addisonian crisis/hypothermia/hyperK • Case 5: SAH
Case 1 • A 38-year-old lady, attended for vaginal bleeding with lower abdominal discomfort. On and off vomiting for recent 2-3 weeks • BP 130/85. P100. Temp 37oC • Urine Preg test +ve
Case 1 • State 3 most common differential diagnoses • Miscarriage (threatened/inevitable/incomplete/missed) • Ectopic pregnancy • Molar pregnancy • What’s the single most useful investigation in ED? • Ultrasound pelvis (transvaginal/transabdominal)
Transabdominal USG – longitudinal view Transabdominal USG pelvis Longitudinal view
Case 1 • What’s the sonographic feature? • heterogeneous mass with numerous discrete anechoic spaces showing “snowstorm pattern” • ± theca lutein cyst may be found in USG • What’s the diagnosis? • Molar pregnancy, likely complete hydatidiform mole • What are the associated clinical features/complications for the above named condition? • Thyrotoxicosis • Larger than date uterus • Hyperemesis gravidarum • Early onset preeclampsia • Theca lutein cyst and cyst complications • Label 2 important risk factors for the above condition • AMA (Advanced maternal age) • Previous GTD • What’s the definitive management? • Suction currettage of uterus
Case 1 • What need to be monitored after treatment and how? • ß-hCG • Weekly until 3 consecutive normal • If the monitoring showed plateau / risk in the marker, what’s the diganosis? • Persistent trophoblastic disease • What’s the malignant form of the above named condition and what’s the first line of treatment? • Choriocarcinoma • Chemotherapy (e.g. methotrexate)
Case 2 • A 50-year-old gentleman attended for vomiting with blood stained vomitus • What relevant points in history taking? • Recent use of aspirin / NSAID • History of hepatic disease / portal hypertension / known variceal diseases • Vomiting / alcohol binge • History of peptic ulcer diseases • Do you know of any validated scoring system for risk stratification for the above condition?
GBS • Glasgow-Blatchford Bleeding Score (GBS) • Low risk = Score of 0 • Any score higher than 0 is "high risk" for needing a medical intervention of transfusion, endoscopy, or surgery.
Case 2 • The patient had history of alcoholic cirrhosis with previous endoscopic treatment for UGIB. What’s the most likely cause for the bleeding? • Variceal bleeding from esophageal varices • What are the ED management? • NPO • IV fluid resuscitation • Blood taking for crossmatch • Consult surgeon for endoscopy
Case 2 • If you are in a rural hospital and the shortest time to the definitive treatment is 2 hours. Patient become hypotensive with BP 70/40, P130 despite supportive treatment. State 2 ED management. • Insertion of sengstaken-blakemore tube / Minnesota tube • Octreotide / Terlipressin infusion
Case 2 • List 3 treatment options for the above condition • Endoscopic banding or sclerotherapy • PTE (Percutaneous transhepatic embolization) or Transjugular intrahepatic portosystemic shunt (TIPS) • Surgery • Portosystemic shunt • Esophageal devascularization • Liver transplantation
Case 3 • A 34 year old gentleman presented with fever, dyspnea and productive cough for 5 days. Progressive dyspnea in recent 1 day. • BP 100/70, P120, temp 39.1C, RR30, SpO2 85% on RA • State 3 important points in history taking • Past medical history / immunosuppression • TOCC (Travel history, occupation, cluster, contact) • Drug allergy • What special aspect during resuscitation? • Infection control (negative pressure resuscitation room, Personal protective equipment) and staff protection.
Case 3 • The patient had history of HIV infection on treatment. • CXR was taken
Case 3 • What’s the CXR finding? • What’s the diagnosis? • State 2 validated guidelines / scores for managing patients with the above diagnosis for risk stratification. • Is this typical or atypical type for this patient with the above diagnosis? List 3 common corresponding microbes for both. • What’s the most important microbe to be considered in this patient? • What’s the diagnostic modality for definitive diagnosis? What’s the treatment? • If the patient become abruptly dyspneic, list one possible complication associated with the above diagnosis.
Case 3 • What’s the CXR finding? • Bilateral lung field patchy infiltrate • What’s the diagnosis? • Bilateral bronchopneumonia • Do you know of any validated guidelines / scores for managing patients with the above diagnosis who could be managed outpatient? • CURB-65 • Pneumonia Severity Index (PSI)
Case 3 • Is this typical or atypical type for this patient with the above diagnosis? • Atypical pneumonia • Typical: strep pneumoniae, haemophilusinfluenzae , moraxellacatarrhalis. • Atypical: legionellapneumophila, mycoplasmapneumoniae, M TB, chlamydiapneumoniae, chlamydiapsittaci • What’s the most likely microbe to be considered in this patient? • pneumocystisjiroveci
Case 3 • What’s the diagnostic modality for definitive diagnosis? What’s the treatment? • Bronchoalveolar lavage (BAL) for PCP • Septrin • If the patient become abruptly dyspneic, list one possible complication associated with the above diagnosis. • Pneumothoraces (can be bilateral)
CURB-65 The risk of death at 30 days increases as the score increases: 0—0.6% 1—3.2% 2—13.0% 3—17.0% 4—41.5% 5—57.0% 0-1 treat as an outpatient 2 consider a short stay in hospital or watch very closely as an outpatient 3-5 requires hospitalization
PCP / PJP • Opportunistic pneumonia in HIV/AIDS or immunocompromised • Dx by induced sputum / BAL for immunofluorescent stain • PCP prophylaxis by septrin in susceptible host • Tx • Septrin • Pentamidine • Trimethoprim-dapsone • Clindamycin-primaquine
Case 4 • A 70-year-old gentleman was brought in by ambulance for “decreased general condition” for 2 days and noted hypothermia • BP 70/40. P45. Rectal temp 32C. RR 14. SpO2 96% on O2. • On examination, patient was cachexic, bradycardic and drowsy.
Case 4 • State 3 relevant investigations in ED • Bedside glucose • ECG • CXR • POCT blood gas • Bedside glucose was 2.5 mmol/l. • State 3 important aspects of treatment at this moment • Fluid resuscitation for hypotension / shock • Glucose / dextrose replacement for hypoglycemia • Rewarming for hypothermia
Case 4 • What are the ECG findings? • Regular bradycardia • Wide complex • Tall T wave • No J wave • What was the likely ECG diagnosis? What further investigation to confirm your diagnosis? • Hyperkalemia • POCT for blood gas and Na/K
Case 4 • If the investigation confirmed your ECG diagnosis, state 5 treatments. • Calcium gluconate • Dextrose-insulin infusion • NaHCO3 • Nebulised ventolin • K resins • Dialysis • If the patient developed respiratory distress and he need to be intubated. What’s the major precaution? • Avoid succinylcholine/suxamethonium (contraindicated in hyperkalemia)
Case 4 • What’s the methods of rewarming? State one example for each method • Passive • Blanket • Active external – rewarming shock and afterdrop • bair hugger (active rewarming blanket) • Active internal • Warm saline infusion • Bladder lavage with warm saline • Esophageal, pleural, peritoneal
Case 4 • With the whole clinical picture, what is the provisional diagnosis? What investigation could be done to confirm the diagnosis? • Addisonian crisis • Spot corticol (Critical sample under stress)
Case 5 • A 50 year old gentlemen presented for headache for 2 hours after coitus, with neck pain and vomiting for 5 times. Now become confused and drowsy. • BP 170/100. P60. Temp 37oC • GCS E3V4M5 • On neurological examination, noted left lower limb paresis
Case 5 • What are the CT findings? • Hyperdensity at bilateral sylvian fissure • Hyperdensity at interhemispheric fissure • Hyperdensity at bilateral cerebral sulci • No dilated temporal horn / significant hydrocephalus / IVH • What’s the diagnosis? • Subarachnoid hemorrhage
Case 5 • If the initial CT was negative, state one investigation that can assist for diagnosis • Lumbar puncture for CSF xanthochromia by spectrophotometry • Name 2 possible specific physical examination findings • Meningismus • Retinal subhyaloid hemorrhage on fundoscopy
Case 5 • State 3 common underlying cause for the above condition. What further investigation could delineate the etiology? • Ruptured saccular aneurysm of cerebral arteries • Ruptured arteriovenous malformation of cerebral vessels • Perimesencephalic non-aneurysmal hemorrhage • Others: traumatic, intracranial arterial dissection, cocaine abuse, cerebral venous thrombosis, bleeding tendency/coagulopathy • Digital subtraction angiography (DSA) / CTA / MRA for the cerebral arteries
Case 5 • Name a clinical severity grading for the above diagnosis. What’s the implication with high clinical grading? What’s the grading for this patient? • Hunt and Hess grading (3) • World Federation of Neurological Surgeons (WFNS) Grading (4) • Clinical outcome • Name a CT grading for the above diagnosis. What’s the implication with high CT grading? What’s the grading for this patient? • Fisher Scale (3) • Claassen grading system (4) • Symptomatic cerebral vasospasm
Clinical grading Hunt and Hess grading of SAH The grade is advanced one level for the presence of serious systemic disease (hypertension, diabetes, severe arteriosclerosis, chronic pulmonary disease) or vasospasm on angiography
Clinical grading World Federation of Neurological Surgeons (WFNS) Grading of SAH
CT grading – Vasospasm risk The Fisher Scale Claassen grading system
Case 5 • What specific treatment could be considered for this patient with evidence of improved outcome? • Nimodipine 60mg q4h PO/NG
Case 5 • State 5 possible acute complications • Vasospasm and cerebral ischemia • Rebleeding • Obstructive hydrocephalus and increased intracranial pressure • Seizures • Non-cardiogenic pulmonary edema • Hyponatremia – hypothalamic injury: SIADH and cerebral salt wasting • Myocardial injuries