OSCE

1. OSCE KWH AED 5th Nov 2014

2. Question 1 • A 40-year-old man • good past health • complained of sudden onset of palpitation, with chest discomfort, no syncope • BP 154/78

3. Initial ECG on presentation

4. 5 mins into the resuscitation room, after treatment given

7. Final ECG after 2mins

8. Question 1 1)what does the initial ECG show -SVT: narrow complex tachycardia, no P wave, incomplete RBBB, LAFB 2)Can you describe the second ECG? -VT: most likely fascicular VT, [wide complex tachycardia, complete RBBB and LAFB, no P wave, presence of capture beat, AV dissociation]

9. Only 10% of cases of VT occur in the absence of structural heart disease, termed idiopathic VT. • The majority of idiopathic VTs (75-90%) arise from the right ventricle • Fascicular VT is the most common type of idiopathic VT arising from the left ventricle (10-25% of all idiopathic VTs). • ECG features of fascicular VT: -Monomorphic ventricular tachycardia; fusion complexes, AV dissociation, capture beats. -RBBB Pattern. -QRS duration 100 – 140 ms — narrower than other forms of VT. -Short RS interval (onset of R to nadir of S wave) of 60-80 ms — the RS interval is usually > 100 ms in other types of VT. -Axis deviation depending on anatomical site of re-entry circuit (see classification). • Fascicular tachycardia can be classified based on ECG morphology corresponding to the anatomical location of the re-entry circuit: 1)Posterior fascicular VT (90-95% of cases): RBBB morphology + left axis deviation; arises close to the left posterior fascicle. 2)Anterior fascicular VT (5-10% of cases): RBBB morphology + right axis deviation; arises close to the left anterior fascicle. 3)Upper septal fascicular VT (rare): atypical morphology – usually RBBB but may resemble LBBB instead; cases with narrow QRS and normal axis have also been reported. Arises from the region of the upper septum.

10. 3)What is the likely cause for the second ECG? -idiopathic 4)What is the recommended treatment for second ECG? -verapamil

11. Question 2 • 48 yrs old man • complained of left upper chest pain after lifting a heavy object.

15. Question2 1)Please comment on the chest x-ray. - osteolyitc lesion at proximal 1/3 left clavicle with fracture, old fibrosis at both lung field 2)what are your differential diagnoses ? -pathological fracture arising from a)primary bone lesion -benign(eg bone cyst, giant cell tumor) -malignant(osteosarcoma, multiple myeloma) b)secondary bone lesion(metastatic bone lesion) eg Ca lung, Ca thyroid 3)Can you give three investigations ? -CBC, LFT, RFT, Ca, ESR, serum/urine protein electrophoresis - CXR, skeletal survey -Bone biopsy -CT scan 4)What does the final x-ray show? -multiple osteolytic lesion over the skull

16. Question 3 • 60-year-old lady • fell with right hip pain

19. Question 3 1)Please describe the x-ray finding. Sclerosity at right acetabulum 2)What other views will you request to better delineate the lesion? -Judet’s view(obturator oblique, iliac oblique) 3)Which parts of pelvis/hip do the views suggested by you show ? a)obturator oblique -show anterior column and posterior wall b)iliac oblique -show posterior column and anterior wall

23. 4) Name the investigation required before we can decide on the type of treatment. -CT pelvis 5)what are the treatment options? -surgical treatment (ORIF) for displaced fracture(>2mm) or involvement of >40-50% posterior wall -conservative(protected weight bearing) for minimally displaced fracture (<2mm) and involvement of <20% of posterior wall

24. Question 4 • 60-year-old lady • History of CA Left breast with mastectomy done 10 years ago • c/o progressive pain and swelling of left hand for 4 months

27. Question 4 1)what are the physical findings? -erythematous with mild swelling over left hand 2)What does the x-ray show? -marked osteopenia with associated diffuse soft tissue swelling 3)Name 3 differential diagnoses. Which is the most likely? -osteoporosis -disuse osteopenia due to persistent stiffness from eg. lymphoedema -infection: osteomyelitis -neurological: reflex sympathetic dystrophy(complex regional pain syndrome)

28. 4)Name the two types of this syndrome and their underlying pathophysiology. • There are two types of complex regional pain syndrome: type 1 and type 2 • CRPS type I is caused by aninitiating noxious event, such as a crush or soft tissue injury; or by immobilization, such as a tight cast or frozen shoulder. There is no definite nerve injury. • CRPS type II is characterized by the presence of a defined nerve injury. Both types demonstrate continuing pain, allodynia, or hyperalgesia that is usually disproportionate to the inciting event. 5)Name 3 important investigations to find out the underlying cause • nerve conduction test • CXR/x-ray Left shoulder • CT scan thoracic outlet/chest

29. Question 5 • 50-year-old lady, • Complained of right thumb pain after contusion against the wall

31. Question 5 1)Can you describe the physical finding? -failure of extension of distal phalanx of thumb 2)Can you name the part of the thumb that is injured? -extensor pollicis longus 3)What is the most common cause for this injury? Can you explain the pathophysiological mechanism leading to this injury? • fracture distal radius. • The extensor pollicis longus is prone to rupture from synovitis(eg RA) and increased friction at Lister's tubercle(eg undisplaced fracture distal radius).

34. 4)What are the treatment options? • direct repair: rare, only when there is acute injury when there is no tendon retraction or atrophy • tendon transfer /tendon grafting: indicated for most cases because of atrophy of ruptured tendon