OSCE

KWH AED

5th Nov 2014

Question 1

• A 40-year-old man

• good past health

• complained of sudden onset of palpitation, with chest discomfort, no syncope

• BP 154/78

Initial ECG on presentation

5 mins into the resuscitation room, after treatment given

Final ECG after 2mins

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]

• 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.

3)What is the likely cause for the second ECG?

-idiopathic

4)What is the recommended treatment for second ECG?

-verapamil

Question 2

• 48 yrs old man

• complained of left upper chest pain after lifting a heavy object.

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

Question 3

• 60-year-old lady • fell with right hip pain

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

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

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

Question 41)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)

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 an initiating 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

Question 5•50-year-old lady,

•Complained of right thumb pain after contusion against the wall

Question 51)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).

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