JCM OSCE Answers PMH A&E Dr. Tse Choi Fung Dr. Lung Ka Yan Ashley Dr. Chan Chi Ming (4/1/2017)

Case 1 An 80-year-old man presented with syncope in the restaurant. This is the ECG:

Case 1 What are the ECG abnormalities? (3 marks) First degree AV block with prolongation of PR interval (224 ms) Right bundle branch block Left axis deviation What is the diagnosis? (1 mark) Trifascicular block What is the definite treatment? (1 mark) Insertion of permanent pacemaker in a symptomatic (syncope) patient

Case 1 “Trifascicular” block

Case 1 Trifascicular block A misnomer term since the AV node itself is not a fascicle A precursor to complete heart block Does not require any treatment by itself, high doses of AV blocking agents should be avoided

Case 2 A 70-year-old man presented with back pain for 6 months. This is the x-ray:

Case 2 What are the x-ray findings? (4 marks) Multiple calcifications over pancreatic region at around L2 level Surgical clips over RUQ which may suggest previous laparoscopic cholecystectomy Degenerative changes over lumbar spine Intact pedicles with no fracture over lumbar spine What is the provisional diagnosis? (1 mark) Chronic pancreatitis

Case 2 What are the common causes for the diagnosis? (3 marks out of 5) Chronic alcoholism Gallstones with intra-ductal obstruction Pancreatic tumour Autoimmune diseases Idiopathic What other symptoms may this patient present? (2 marks out of 3) Chronic diarrhoea Steatorrhoea Weight loss

Case 2 What are the complications that this patient may suffer from? (2 marks) Malabsorption Insulin dependent diabetes mellitus

Case 3 A 50-year-old man presented with confusion. H’stix was 2.0 mmol/L. He did not have history of diabetes mellitus. What is the likely diagnosis & how can you confirm your diagnosis? (4 marks) Hypoglycaemia Whipple’s triad Symptoms of hypoglycaemia Save blood for spot glucose test (usual < 3.6 mmol/L) Treatment with glucose (dextrose infusion) to revert the symptoms & see the response

Case 3 EXogenous Pituitary Liver failure Adrenal insufficiency Insulinoma Non-pancreatic neoplasm What laboratory investigations would you like to do to find out the underlying causes? (4 marks out of 7) EXPLAIN Urine for toxicology to look for exogenous sulphonylurea C-peptide during episodes of hypoglycaemia Liver function test to look for liver failure Adrenal function tests to look for adrenal insufficiency (e.g. cortisol level, ACTH stimulation test) Thyroid function test to look for hypothyroidism Alcohol intake / ethanol level Sepsis work up if clinically suggested

Case 4 A 35-year-old lady presented with fever for 2 weeks with epigastric pain. T 40.1 ⁰C BP 128/99 P 138/min ECG was performed in triage because of tachycardia.

Case 4

Case 4 What are the ECG abnormalities? (5 marks) Sinus tachycardia with a rate of 142 bpm Low voltage Right axis deviation Poor R wave progression Absence of electrical alternan

Case 4 What are the x-ray findings? (3 marks out of 4) Gross cardiomegaly with globular heart No free gas under diaphragm No dilated bowel shadow or stones in AXR No pneumobilia What is the provisional diagnosis? (1 mark) Pericardial effusion

Case 4 What are the possible causes of her diagnosis? (2 marks out of 3) Autoimmune disease e.g. SLE Infection e.g. pericarditis Tumor e.g. CA lung

Case 5 A 42-year-old man sustained crush injury over left middle finger at work. A 2.5 cm long laceration was seen over dorsum of left middle finger near DIPJ. X-ray was performed.

Case 5

Case 5 What are the x-ray findings? (3 marks) Hyperextension of PIPJ & flexion of DIPJ of left middle finger No fracture No foreign body seen What is the diagnosis? (1 mark) Swan neck deformity of left middle finger

Case 5 What is the underlying pathology of his condition? (2 marks) PIPJ palmer side volar plate injury causing loosening

Case 5 Swan neck deformity vs Mallet deformity Injury to the extensor tendon / bony fragment that extends the DIPJ

Case 5 In the PIP joint, the strongest ligament is the volar plate. Swan neck deformity In the PIP joint, the strongest ligament is the volar plate. This ligament connects the proximal phalanx to the middle phalanx on the palmar side of the joint. The ligament tightens as the joint is straightened and keeps the PIP joint from hyperextending. Swan neck deformity can occur when the volar plate loosens from disease or injury. http://www.houstonmethodist.org/orthopedics/where-does-it-hurt/hand/swan-neck-deformity/

Case 5 In our patient, he had previous history of swan neck deformity Laceration over dorsum of left middle finger near DIPJ is not related to his swan neck deformity Suturing of wound was performed & discharged

Any Questions ? Thank you !