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

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

3. 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

4. Case 1
“Trifascicular” block

5. 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

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

9. 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

10. 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

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

12. 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

13. 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

14. 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.

15. Case 4

16. 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

19. 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

20. 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

21. 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.

22. Case 5

23. 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

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

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

26. 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.

27. 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

28. Any Questions ?
Thank you !