1. YCH AED Dr. Cheung Chi Kin, Arthur 8th Oct 2014
JCM OSCE (Answer)
YCH AED
Dr. Cheung Chi Kin, Arthur
8th Oct 2014

2. Question 1

3. Question 1 What are the X ray findings? (1.5 marks)
Left ankle sprained 2 days ago
Presented with ankle pain
& limping gait
X ray was performed
What are the X ray findings? (1.5 marks)
Which type of fracture does this girl have? (0.5 mark)
What is the specific name for this fracture? (0.5 mark)
What are the mechanisms of this injury? (1.5 marks)
What is the descriptive name for the fracture also involving metaphysis of distal tibia? (0.5 mark)
What is the treatment of choice? (0.5 mark)

4. Question 1 What are the X ray findings? (1.5 marks)
A radiolucent/ fracture line at left distal tibia
Extending from epiphysis to epiphyseal plate
Soft tissue swelling around ankle
Which type of fracture does this girl have? (0.5 mark)
Salter-Harris type 3 fracture

5. Question 1 What is the specific name for this fracture? (0.5 mark)
Tillaux fracture
What are the mechanisms of this injury? (1.5 marks)
In adolescents, the medial part of epiphyseal plate closes first while the anteriolateral part still opens
During forced external rotation of foot
Epiphyseal plate is weaker than ligament, therefore lateral epiphysis is prone to avulsion fracture

6. Question 1
What is the descriptive name for the fracture also involving metaphysis of distal tibia? (0.5 mark)
Triplane fracture
What is the treatment of choice? (0.5 mark)
Operative treatment (internal fixation) if joint surface displacement > 2mm

7. Question 2

8. Question 2 F/14 Good past health
Presented with repeated vomiting x 1/52
Associated with abdominal pain after food
Bowel opening normal
Thin body build, abdomen soft
List four important differential diagnoses in this case. (2 marks)

9. Question 2 List four important differential diagnoses in this case.
(2 marks, any 4 of below)
GI: peptic ulcer/ pancreatitis/ small bowel obstruction
Gyn: hyperemesis gravidarum/ molar pregnancy/ UTI/ twins
Diabetic ketoacidosis
Increased intracranial pressure/ post head injury
(In this case, Urine wbc nit –ve, PT –ve; Hstix 5.6; CT brain NAD)

10. Question 2
CT scan of abdomen was performed. Describe the findings and what is the likely diagnosis? (2 marks)

11. Question 2
CT scan of abdomen was performed. Describe the findings and what is the likely diagnosis? (2 marks)
There is a very narrow distance between the abdominal aorta and the SMA,
measuring 4.9mm (normally 13-34mm),
where the third part of duodenum passes through
The diagnosis is Superior Mesenteric Artery Syndrome (due to lack of retroperitoneal or mesenteric fat)

12. Aorta-SMA angle is 10 degrees (normal 28-65)

13. Question 2 How do you dispose this patient? (0.5 mark)
What is the another structure which can be entrapped between SMA & aorta? (0.5 mark)

14. Question 2 How do you dispose this patient? (0.5 mark)
Admit Surgery
What is the another structure which can be entrapped between SMA & aorta? (0.5 mark)
Left renal vein (Nutcracker Syndrome) - Presented with haematuria, left-sided varicocele

15. Question 3

16. Question 3 M/42 Hx NPC 2007 in remission
Presented with fever & sore throat x 1/7
BP 139/69 P112 RR18 Temp 39.0 SpO2 98%
No stridor or neck swelling
XR neck was performed

18. Question 3 What are the X ray findings? (1 mark)
What is the diagnosis? (0.5 mark)
Name 2 common pathogens. (1 mark)
What is the initial management in AED? (2.5 mark)

19. Question 3 What are the X ray findings? (1 mark)
Thumbprint sign
ballooning/ air-trapping in hypopharynx
What is the diagnosis? (0.5 mark)
Acute epiglottitis

20. Question 3 Name 2 common pathogens (1 mark, any 2 of below)
Haemophilus influenzae type B (less prevalent since introduction of vaccine in 1987)
Grp A beta haemolytic streptococci (most common)
Streptococcus pneumoniae
Staphylococcus aureus

21. Question 3 What is the initial management in AED?
(2.5 mark, any 5 of below)
Manage in Resuscitation room
Avoid lie flat and vigorous throat examination
Supplemental oxygen via face mask
IV access, blood test, culture
IV antibiotic (e.g. Augmentin 1.2g or Zinacef 1.5g)
Consult ENT & ICU
Prepare Difficult Airway Management (DAM)

22. Only 15-20% adult patients required an artificial airway
Only 15-20% adult patients required an artificial airway......majority of patients without respiratory distress can be managed conservatively under close monitoring

24. Question 4

25. Question 4 F/55 Good past health, non smoker, non drinker
Presented with cough & throat discomfort x2/52
Throat clear, neck soft, no cervical LN
Chest clear, no added sound
Few high pitched breath sound during expiration
Otherwise systemically well, ambulatory
ENT consulted, normal laryngoscopy to VC
CXR was performed

27. Question 4 Name 3 differential diagnoses. (1.5 marks)
What is the positive finding on CXR? (0.5 mark)
Name 3 important negative findings on CXR. (1.5 marks)
Name 3 important investigations. (1.5 marks)

28. Question 4 Name 3 differential diagnoses. (1.5 marks, any 3 of below)
Foreign body aspiration
Infection e.g. tracheitis – bacterial, TB
Trachea tumor/ subglottic stenosis
Tracheomalacia
External compression to trachea
What is the positive finding on CXR? (0.5 mark)
A radioopague lesion in lower trachea above carina

29. Question 4 Name 3 important negative findings on CXR. (1.5 marks)
No hyperinflated lung field/ collapse
No pneumomediastinum
No tracheal deviation
Name 3 important investigations. (1.5 marks)
Contrast CT thorax
Bronchoscopy +/- biopsy
Sputum for AFB smear, culture & cytology

30. Bx confirmed CA trachea

31. Question 5

32. Question 5 F/32 Good past health
Presented on day 10 post delivery with sudden onset bi-temporal headache and bilateral blurred vision
Exam: Right homonymous hemianopia
CNs, limb power & sensation normal
No cerebellar sign
CT brain normal

33. MRI T2 FLAIR (Fluid attenuated inversion recovery) sequence
* By the time when MRI was performed, patient had slightly improved visual field
From
MRI T2 FLAIR (Fluid attenuated inversion recovery) sequence

34. Question 5 What are the MRI findings? (1 mark)
What is the most likely diagnosis? (0.5 mark)
What is the alternative important diagnosis? (0.5 mark)
Name 3 predisposing factors for this condition. (1.5 mark)
Name one proposed mechanism for this condition. (1 mark)
What is the prognosis for this patient? (0.5 mark)

35. Question 5 What are the MRI findings? (1 mark)
Hyperintense lesions on T2 FLAIR sequence
over bilateral occipital region
What is the most likely diagnosis? (0.5 mark)
Posterior reversible encephalopathy syndrome (PRES)
What is the alternative important diagnosis? (0.5 mark)
Embolic stroke

36. Question 5
Name 3 predisposing factors for this condition. (1.5 mark, any 3 of below)
Hypertensive emergency
Eclampsia/ Pre-clampsia
Receiving immunosuppressant/ chemotherapy
Bone marrow or stem cell transplantation
Haemolytic uraemic syndrome
Systemic lupus erythematosus

37. Question 5 Name one proposed mechanism for this condition. (1 mark)
Endothelial dysfunction and breakdown of cerebral autoregulation, causing vasogenic edema involving especially the subcortical white matter of parietal and occipital lobe
What is the prognosis for this patient? (0.5 mark)
Usually benign with complete reversal of clinical symptoms within several days

38. Thank you
Good Luck for Exam 2015!