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 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 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)

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 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).

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