Osce_05feb14 (1).ppt

JCM OSCE QMH A&E Feb 2014

Case 1 • • • • •

F/32 LBP for one week No fever, no neurological deficits PE unremarkable Xray LS spine

Case 1

Question 1 • What is the Xray finding? • What could be the DDx?

Question 2 • What could be causative organism?

Xray Findings • Loss of L2/L3 disc height. • Erosion with increase sclerosis noted at L2 and L3. Increase left psoas shadow is seen. Pedicle is still preserved.

DDx • Infective vs malignancy • Infective more likely in view of increased psoas shadow and patient’s age

Infective spondylo-discitis • Infection that involves 1 or more of the extradural components of the spine • Organisms: • Staphylococcus aureus (in 60% of patients) and Enterobacter species • Tuberculosis • Fungal (cryptococcus), in immocomprised patient

Progress • Admitted to orthopaedics • CT guided drainage • Pus x C/ST: +ve for AFB • Undergoing Anti- TB treatment

Case 2 • • • • •

M/20 Complained of R sided chest pain for one day No SOB No history of trauma PE showed decreased breath sound over R lung

Questions • What are the findings? • How do you manage him? • What are the indications for surgical treatment?

Xray finding • R hydropneumothorax • Trachea and mediastinum is shifted to L side • Absence of pneumomediastinum

Management • Haemodynamic support, oxygen • Early CTS consultation, may need early thoracotomy • Insertion of large bore chest drain (>32 Fr) • Blood (include type and screen)

Indication for surgical treatment • • • • • • •

Signs of hypovolemic shock Continuous bleeding (>100mL/hr) Persistent air leak Persistent pneumothorax Impaired lung expansion Pachypleuritis Different from ATLS guideline for traumatic haemothorax (>1500mL first drain or 200mL/hr for >2hr)

Progress • Chest drain inserted, blood drained • Consulted CTSU • emergency VATS clot evaculation, pleurodesis done • Discharge D5

Case 3 • F/21 • PMH: Schizophrenia • Sudden onset of colicky generalised abdominal pain again since after lunch • Small amount BO • PE: abd distension

AXR

Questions • What are the findings? • Name a few differential diagnoses • What is the diagnosis?

Findings • Coffee bean sign noted with apex pointing towards LUQ. • Differential: – Other causes of intestinal obstruction, e.g. bezoar formation (hx of schizophrenia), ileosigmoid knot – Ischemic bowel, ureteric colic, ectopic pregnancy…

• Diagnosis: sigmoid volvulus

Progress • Flexible sigmoidoscopy and flatus tube • decompression performed

• Discharged D2

Case 4 • • • • •

F/50 Found collapsed in hospital canteen On arrival GCS 14/15 BP 160/70, P 60 Tenderness and swelling over right face

CT face

Questions • Please describe the CT scan finding • What do you need to look for in physical examination? • If CT scan is not available, what Xray view will you order? Any pitfall in this view?

CT bone window: • Fracture of lateral wall and floor of Rt orbit • Lateral and medial walls of Rt maxillary sinus. Opacification of Rt maxillary sinus with airfluid(blood) level

Physical Examination • Signs of extra-ocular muscle entrapment, especially diplopia on upward gaze • Signs of ocular injury, including hyphaema, rupture of eyeball, visual acuity • Causes of her collapse… and injuries in other parts of her body

If CT scan is not available, what Xray view will you order? • Water’s view • Pitfall: Maxillary fluid level may not be appreciated in supine patient lying on stretcher

Progress • -

seen by EYE no clinical evidence of muscle entrapment no globe injury no indication for ocular intervention

• Discharged D4

Case 5 • • • • • •

M/77 Trip and fell with head and neck injury Brief LOC PE: GCS 15/15 Tenderness over R neck RUL power 4/5, LUL 5/5

CT brain + neck

CT reconstruction

Questions • What are the CT findings? • What do you need to look for in physical examination • What is the classification of this injury? • What are the possible long term complications in this injury? • Name 2 clinical prediction rules for predicting cervical injury requiring Xray

CT findings: • Fracture odontoid process with posterior displacement of the upper portion -> Hangman’s fracture • Comminuted fracture of the posterior arch of C1 -> Jefferson fracture

Physical examination • -

Signs of spinal cord compression: Breathing effort (Diaphragmatic breathing) Limb numbness/weakness Anal tone Distended bladder

What is the classification of this injury? Classified by location of fracture (Anderson and D’Alonzo classification) o Type I (<5%) • Tip of dens at insertion of alar ligament which connects dens to occiput • Usually stable but may be associated with atlanto-occipital dislocation o Type II (>60%) • Most common dens fractures • Fracture at base of dens at its attachment to body of C2 o Type III (30%) • Subdentate—through body of C2 • Does not actually involve dens • Unstable fracture as the atlas and occiput can now move together as a unit

What are the possible long term complication in this injury? o Non-union o Due to limited vascular supply o May occur in 30-50% of Type II fractures, especially in elderly

o Malunion o Pseudarthrosis o Neurological deficit from cord injury

Name 2 clinical prediction rules for predicting cervical injury requiring Xray • Canadian C-Spine Rules • NEXUS criteria

Progress • MRI C spine: • No significant cord compression at C1/2 level