EEEM OSCE 2008 Past Paper PDF

EEEM OSCE 2008 Sep Total 20Q. 8 min. each station. No rest station. (drafted by Ralph) 1. Photo 1: stone fish Photo 2: hand with patch of necrosis and blister, swelling A man was stung by photo 1 on hand. Q: What is in photo 1? Stonefish Q: Mention one out-patien...

EEEM OSCE 2008 Sep Total 20Q. 8 min. each station. No rest station. (drafted by Ralph) 1. Photo 1: stone fish Photo 2: hand with patch of necrosis and blister, swelling A man was stung by photo 1 on hand. Q: What is in photo 1? Stonefish Q: Mention one out-patient management Hot water immersion He was treated with amoxil and cloxacillin. He returned 3 days later with hand of photo 2 Q: What most important diagnosis to consider? necrotizing fasciitis Q: If need to add on one more antibiotic, what to add? fluoroquinolone, e.g. iv levofloxacin 2. Middle age man suffered knee injury. Some pain, knee effusion, reduced movement Xray of knee showing tibial plateau fracture Q: Name the classification Schatzker classification Q: Name the bimodal distribution of the problem and give reason for each males in 40s (high-energy trauma) & females in 70s (falls) Q: What to pay attention besides local knee exam in this patient? compartment syndrome, neurovascular injury (popliteal a. & peroneal n.) 3. Patient has diminished radial pulse after injury Xray of left wrist showing distal radius fracture with dorsal angulation & displacement, disrupted DRUJ. ? distal ulna cause some disruption of carpal arch Q: Description of Xray Q: Give the common name of the condition Galeazzi # Q: Immediate important complication compartment syndrome Q: Commonest long-term complication besides chronic pain DRUJ instability/ subluxation 1 4. Matching Q. Blood groups A, B, AB, O and respective no. of people nominal data Q. Very satisfactory, mild satisfactory, not satisfactory and respective no. of people ordinal data Q. Pain score 0,1,2, ….10 ordinal data Q. 2 groups non-numerical data, one group number 10d or cannot tolerate fluid intake - watch out for S/S of Cx (e.g. severe headache/ confusion/ seizure)!" 2 8. A man sudden onset of right upper limb weakness weakness at C6, C7) and pain. Low grade fever. Normal conscious state. Rash over right forearm. Plain CT brain shown Q: Any abnormality in CT brain? No Q: Likely diagnosis herpes zoster Q: Clinical course of the rash MP rash to cluster of vesicles that ulcerate and crust over the corse of 7-10d, then healing by 2-4 wk Q: Explain why there is weakness Infection spread from dorsal root ganglia to anterior horn cell, causing focal motor weakness (Segmental zoster paresis) Q: Treatment Acyclovir + po steroid Q: Name the syndrome when face involved Ramsay Hunt syndrome 9. Young man has palpitation for 2 days. Attended A&E symptom subsided. DAMA. Had sex with girl friend. Mild right loin pain. Semi-coma, BP: 200/120. died despite resuscitation. ECG: wide complex tachy + ?LVH. CT abdomen photo: soft tissue shadow near right side kidney. (copycat from JCM) Q: Describe ECG. Describe CT Q: Likely Dx pheochromocytoma Q: A common name for this disease 10% tumor Malignant – 10% Bilateral – 10% Pediatric – 10% Extra-Adrenal – 10% Familial – 10% Q: Prevalence of the disease in hypertensive patient? 0.1% 10. MG patient. Fell with fracture wrist. Regular medication mestinon, prednisolone, cyclosporin. ABG shown: respiratory acidosis & partial ??respiratory compensation Q: Interpretation of ABG Q: 3 conditions leading to this situation myasthenia crisis, cholinergic crisis (respiratory muscle weakness due to depolarisation block), steroid-induced crisis (dramatic decrease in muscle strength with corticotrophin) Q: 2 analgesic medication contraindicated and reason opioid - central respiratory depression; gabapentin - may aggravate MG; ??TCA ??BZD 3  Q: RSI. What muscle relaxant to use and dose - avoid NMBA if possible - depolarising agents C/I; due to decreased number of acetylcholine receptors and hence resistance - If NMBAs are necessary, use of rocuronium or vecuronium (in incremental, small doses of 0.1 to 0.2 times the 95% effective dose (ED95)), and then reversal with sugammadex; If sugammadex is unavailable, we avoid the use of NMBAs if at all possible. 11. 2-year-old. High fever and SOB. CXR showed right lower zone haziness. Q: 3 abnormal findings in CXR Q: 2 common organisms Streptococcus pneumoniae, Hemophilus influenzae Q: Global intervention changing the bacteriology Hib vaccine Q: Adult with the infection rapid downhill course with hemopneumothorax. What’s the organism CA-MRSA (necrotizing pneumonia) 12. USG abdomen showing liver abscess Q: bacteriology E coli, Klebiella pneumoniae, Strep milleri Q: investigations - blood c/st + CBC, LRFT, INR - USG/ contrast CT abd - abscess fluid x c/st Q: treatment - fluid resuscitation - IV ABx (rocephin + flagyl) x 4-6/62 - percutaneous CT/USG guided drainage (or open surgical drainage) 13. USG showing adnexal mass and IPFF Q: ddx ectopic pregnancy, bleeding ov cyst, ov cancer Q: further investigation urine PT Q: medical treatment regime for the disease (not necessarily in this question) fluid resuscitation if required; if stable with small unruptured ectopic, can consider single-dose IM methotrexate; if unstable or signs of rupture, for surgical salpingectomy 14. Patient entrapped by large object to right LL for half hour. You’re E-team doctor. BP, pulse good. Q: 1 management before extrication with reason aggressive resuscitation with crystalloid to prevent crush syndrome/ rhabdomyolysis Q: Extricated. Fall in BP. Right lower limb no wound. On the way to hospital. 1 Mx with reason pelvic binder for possible pelvic fracture Q: Arrive at hospital, 2 Ix 4  istat electrolytes/ ECG/ (pelvis Xray) 15. Trauma score Q: components of RTS GCS, RR, SBP Q: maximum mark for AIS (Abbreviated Injury Scale) AIS 1 - Minor; AIS 2 - Moderate; AIS 3 - Serious; AIS 4 - Severe; AIS 5 - Critical; AIS 6 - Maximal (= currently untreatable) Q: max mark for ISS 75 ISS = Summation of squares of highest AIS codes in each of the 3 most severely injured body regions Q: max mark for probability of survival 1 Q: What’s NovoSeven® recombinant factor VIIa Q: Advantage of using NovoSeven® for trauma adjunct for treatment of massive haemorrhage with resistant coagulopathy Q: When is optimal time for using NovoSeven®? before developing severe MA 16. Young man sudden onset right side weakness, neck pain and headache. He had massage in mainland China before. BP: 190/100. CT brain done. Q: describe CT brain dot of hyperdensity at right vertebro-basillar region Q: Dx left (extracranial) internal carotid artery dissection (VA dissection -> no limb weakness!) Q: Cause of the problem inappropriate neck massage Q: 2 Ix CT/ MR angiogram Q: 2 Mx anti-coagulant, endovascular stenting Q: describe sensory finding reduced light touch sensation over R side 17. ECG 1 showing CHB HR 40. Mx in hospital. Second ECG showing ventricular paced rhythm. Patient came later for palpitation with third ECG Q: description of ECG 1 and Mx atropine +/- TCP if unstable; consult CCU Q: description of third ECG and Mx -> failure to pace -> ??magnet 5 18. ECG showing pericarditis Q: ECG description. 2 auscultation findings ECG: Widespread concave ST elevation and PR depression throughout most of the limb leads (I, II, III, aVL, aVF) and precordial leads (V2-6); Reciprocal ST depression and PR elevation in lead aVR (± V1); Spodick's sign (downsloping TP segment, best visualized in lead II and lateral leads) auscultation: muffled HS, pericardial friction rub Q: 1 way to differentiate this condition with BER (benign early repolarisation) - ST/T wave ratio: > 0.25 -> pericarditis; BER - presence of “fish-hook” appearance in V4 -> BER Q: shock, what’s the cause and 2 Mx cause: cardiac tampanade Mx: peri-cardiocentesis & IVF 19. Q: 3 types of radiations alpha, beta, gamma, xray Q: 3 determinants of radiation dose distance, duration, shielding from source Q: Priority of decontamination wound -> mucosa -> intact skin 20. Elderly man with history of heart disease presented with severe abdominal pain and vomiting. CXR showing dilated small bowel and round radio-opaque shadow at right pelvic cavity. CT showing gas in bowel wall and branching hypodense shadow at periphery of liver capsule. Q: 3 life threatening ddx ruptured AAA, perforated hollow viscus, ischemic bowel Q: 2 CT findings pneumatosis intestinalis, portal venous gas Q: Immediate A&E tx - vigorous IVF resuscitation - adequate pain control with strong IV analgesics - (IV broad spectrum ABx/ PPI) - urgent consult surgical + ICU Q: One further Ix that can be diagnostic, locate site of pathology and may be therapeutic mesenteric angiogram +/- embolectomy 6