1. OSCE 3 Sep 2014 PYNEH

2. Q1: This is a 46 female with ankle injury Her X-ray ankle is shown below:

3. Q1: Questions 1.What are the pathology noted on ankle x-ray 2. What is the likely mechanism of injury 3. Is this a stable injury? 4. What associated injury one should look out for?

4. Q1 Answer-1/2 1.What are the pathology noted on ankle x-ray # medial malleolus; with soft tissue swelling 2. What is the likely mechanism of injury Eversion + ext rotation 3. Is this a stable injury? Unstable (widening of joint space of ankle mortise  severe ligamentous disruption)

5. Q1 Answer-2/2 4. What associated injury one should look out for? # fibular neck: Maissoneuve#

6. Q2: M/50 back seat passenger involved in RTA, X-ray L-spine taken for backache:

7. Q2: Besides X-ray, CT spine has also been down

8. Q2: Questions 1. What is the abnormality shown in plain LS spine X-ray? 2. What is the name of this condition? 3. What is the mechanism of this injury? 4. Name TWO possible associated injuries:

9. Q2: answer 1.What is the abnormality shown in plain LS spine X-ray and CT? Transverse # of L3 body and posterior colume 2. What is the name of this condition? Chance # 3. What is the mechanism of this injury? -- flexion distraction 4. Name TWO possible associated injuries: -- mesenteric tear --duodenum rupture --pancreas injury

10. Q3: A 81 yo male is presenting to A&E with bradycardia. His ECG is shown below

11. Q3 Questions 1.What is the ECG findings? 2.The patient is edematous all over his body. What is the most suspected underlying cause of this condition? 3.If the BP is 76/45mmHg, give your emergency treatment before you confirm your suspicion? 4.What are the specific treatment to initiate in A&E after quickly confirm your suspicion?

12. Q3 Answer -1/3 1.What is the ECG findings? Junctional bradycardia (about 22/min) Tall T wave and widen QRS 2. The patient is edematous all over his body. What is the most suspected underlying cause of this condition? Hyper K (9.3 in this patient)

13. Q3 Answer -2/3 3. If the BP is 76/45mmHg, give your emergency treatment before you confirm your suspicion? -CaCl2 or Ca gluconate -Atropine -Transcutaneous pacing with sedation (Do not give fluid bolus)

14. Q3 Answer -3/3 4. What are the specific treatment to initiate in A&E after quickly confirm your suspicion? -Insulin glucose infusion -Resonium C ( PO or rectal)

15. Q4: A 67yo female present with SOB in the middle of the night. The patient experienced rapidly onset of SOB while in bed with no chest pain She had cough and sputum for 3 days with chills Her BP: 166/62mmHg; p=88/min SaO2=88% with 100% O2; no fever Physical exam: labored breathing with bilateral lung crepitations and dilated neck veins ECG: sinus, LVH, no ST changes CXR is shown

16. Q4 CXR

17. Q4 Questions 1.Describe the CXR finding: 2.What is your clinical diagnosis? 3.What drug(s) would you offer for her condition? 4.After drug treatment, the patient deteriorated with BP 89/57mmHg and she need intubation. What induction agent would you choose in considering her hemodynamic status? 5.What imaging study would you suggest at this moment?

18. Q4 Answers -1/2 1.Describe the CXR finding: Cardiomegaly, congested lung 2. What is your clinical diagnosis? CHF, APO 3. What drug(s) would you offer for her condition? nitrate infusion, lasix IV

19. Q4 Answers -2/2 4. After drug treatment, the patient deteriorate with BP 89/57mmHg and she need intubation. What induction agent would you choose in considering her hemodynamic status? Ketamine 5. Imaging Study: echo/USG for possible pericardial effusion (that account for rapid development of tamponade with venodilator drugs)

20. Q5: A 3 yo child swallowed a $2 coin 1 days ago. His parents expected 1 day and did not find the coin from his stool.

21. Q5 question 1.Could this location be managed expectantly? 2.What location will be more concern for this coin? 3.What other clinical and X-ray parameters will lead to operative management?

22. Q5 Answer 1.Could this location be managed expectantly? Yes 2. What location will be more concern for this coin? If it is still above diaphragm 3. What other clinical and X-ray parameter will lead to operative management? -Increasing abdominal pain -Sign of Perforated visera (free gas on XR) -Dilated bowel (IO)

23. END