Accident and Emergency OSCE Examination

End Posting Assesment

(Answer is provided)

Group 7

Phase III, Year 5

Academic Session 2010/2011

Universiti Sains Malaysia

Accident & Emergency OSCE

Questions

a) Name the instrument (1m)b) Indication of the instrument (2m)c) Contraindication for the usage of the instrument (2m)d) Where to insert the instrument (2m)e) Complication of the procedure (3m)

1

Accident & Emergency OSCE Pediatric Resuscitation

Name the instrument (1m) Indication of the instrument (2m) Contraindication for the usage of the instrument (2m)

insert the instrument (2m) Complication of the procedure (3m)

Accident & Emergency OSCE

This is 12 lead ECG strip belonging to 52 years old Malay man, smoker for 20 years who presented to casualty with the complaint of left associated with giddiness and palpitation.

Question

a) Comment the ECG strip (2m)b) What is your diagnosis based on the history and ECG strip (1m)c) What is the risk factor that you can elicit in the history, relatd) Outline your management in Emergency department for the patient. (5m)

2

Accident & Emergency OSCE Medical Emergency

This is 12 lead ECG strip belonging to 52 years old Malay man, smoker for 20 years who presented to casualty with the complaint of left sided chest tightness for 2 hours which is associated with giddiness and palpitation.

Comment the ECG strip (2m) What is your diagnosis based on the history and ECG strip (1m) What is the risk factor that you can elicit in the history, related to the diagnosis in B (2m)Outline your management in Emergency department for the patient. (5m)

This is 12 lead ECG strip belonging to 52 years old Malay man, smoker for 20 years who sided chest tightness for 2 hours which is

ed to the diagnosis in B (2m) Outline your management in Emergency department for the patient. (5m)

3

Accident & Emergency OSCE Traumatology

24 years Old Malay man was brought in to casualty by EMD after receiving a call from public saying that he was involving in motorbike vs car accident.

Questions

a) Comment the X ray (3m) b) What is your radiological diagnosis (1m) c) Outline your management in ED (6m)

4

Accident & Emergency OSCE Medical emergency

34 years Old Malay lady presented to Emergency department with complaint of high grade fever and palpitation. Vital sign shows high grade fever (temperature 40°C), BP 130/90, heart rate 140 beat per minute, and respiratory rate 16 breath per minutes.

Questions

a) Comment on the picture (2m) b) What is your provisional diagnosis (2m) c) Outline your management to this patient. (6m)

5

Accident & Emergency OSCE Orthopedic emergency

24 years old chinese lady alleged fall from escalator and sustain pain over the right lower limb and was brought to casualty by her partner.

Questions

a) Comment on the above picture (3m) b) What is your provisional diagnosis (2m) c) Outline your management at A&E department (5m)

6

Accident & Emergency OSCE Pediatric Resuscitation

Answer

a) Intraosseous cannula

b) Temporary measure for rapid vascular access in critically ill or injured pediatric patient (3-4 hours only)

c) Contraindication i. Absolute contraindication

- fracture of the tibia or long bones which are potential site for IO insertion ii. Relative contraindication

- cellulutis overlying the insertion site - Inferior vena cava injury - Previous attempt on the same leg bone - Osteogenis imperfecta - Osteopetrosis - children ages more than 6 years

d) where to insert the instrument

i. preferably tibia bone (2-3 cm inferior to proximal tibia tuberosity and 2-3 cm medial to it with needle being advanced inferiorly)

ii. Distal femur (anterior midline, above the external epicondyles, 1-3 cm above the femoral plateau)

iii. Anterior superior iliac spine iv. Sternum v. Ulnar bone

e) Complication

i. Extravasation of fluid ii. Compartment syndrome iii. Necrosis of the muscle due to extravasation of hypertonic or caustic medications

like sodium bicarbonate, dopamine, or calcium chloride iv. Infection and osteomyelitis v. local hematoma, pain, growth plate injuries and fat microemboli

7

Accident & Emergency OSCE Medical Emergency

Answer a) The ECG shows

- ST elevation in lead II, III and aVF - Reciprocal ST depression in lead I, aVL - Reciprocal T inversion in lead V1 and V2 - Normal sinus rhythm

b) Inferior myocardial infarction

c) Risk factor

- Male sex - Age more than 55 years old - Smokers

d) Management in the Emergency department

i. Triage the patient to the red zone with cardiac monitoring ii. Secure the airway, breathing and circulation iii. If ABC is not compromised, give oxygen via nasal prong 3L/min iv. Sublingual GTN 0.3- 0.5 mg (can be repeated every 5 minutes for 3 times if no

HPT) v. Aspirin 300 mg stat vi. Clopidogrel 300 mg stat vii. Analgesic 10-15 mg IV slow bolus with IV metoclopromide 10 mg. if patient still

in pain, put patient on IV infusion morphine 1mg/kg in 50 ml water for injection. viii. Blood investigation; Cardiac enzyme (CK, Troponin T), FBC ix. Fluid resuscitation (crucial in inferior MI) x. Consider giving thrombolytic agent, particularly streptokinase (1.5 millions unit

in 100 ml normal saline infused over 60 minutes). Ask further history to the patient to elicit any contraindication to streptokinase.

xi. Right sided ECG to exclude RV involvement. xii. Refer to cardiologist or internal medicine team.

8

Accident & Emergency OSCE Traumatology

Answer

a) X ray finding i. Left thorax radiolucent suggestive of massive pneumothorax ii. Left lung collapsed iii. Trachea shifted to the left.

b) Left lung traumatic pneumothorax

c) Management of this patient

- Triage the patient to the red zone with cardiac and oxygen saturation monitoring - Secure the Airway, breathing and circulation. - Put patient on high flow mask with oxygen 10-15 L/min - This patient may require intubation if unconscious in order to protect the airway or if

O2 fails to reach >95% on high flow mask. - Complete the primary and secondary survey - Insert chest tube to the left thorax at safe triangle. - Repeat the thorax X ray post chest tube insertion. - Blood investigation (FBC, GSH, PT/aPTT, ABG) - Analgesic ( IV morphine 10-15 mg stat) with anti emetic (IV metoclopromide 10 mg

stat) - This patient may require sedation with midazolam if intubated or restless. - Refer the patient to the surgical team.

9

Accident & Emergency OSCE Medical emergency

Answer a) Midline neck swelling

b) Thyroid storm

c) Management to this patient

- Triage the patient to red zone - Oxygen with high flow mask 10-15L/min - ECG to exlude spectrum of Acute coronary syndrome - Monitor ECG, vital sign and pulse oxymetry every 10-15 minutes - Establish peripheral line - Fluid maintenance with dextrose-saline by slow infusion. - Blood investigation (Thyroid function test, FBC, BUSE/Creatinine, LFT) - CXR for evidence of heart failure and chest infection - Urinalysis for evidence of UTI. - Relieve the fever by paracetamol, tepid sponging or other cooling method. AVOID

using ASPIRIN as it will release T4 and free T3 from it protein bound. - Anti thyroid medication

i. Beta blocker (IV propanolol 1-2 mg slowly 4-6 hourly) ii. Thyroid hormone formation inhibitor (propylthiouracil 600 mg stat or

carbimazole 60-120 mg/day in 3 divided dose. iii. Steroids for inhibit release of thyroid hormone and peripheral conversion T4

to T3 (IV dexamethasone 2mg 6 hourly) - Treat underlying heart problem - Refer the patient to endocrinologist or internal medical team.

10

Accident & Emergency OSCE Orthopedic emergency

Answer a) Comment of the picture

i. Partial flex, adducted and internally rotated of the right hip joint ii. Shortening of the right limb iii. Slight flexion of right knee joint.

b) Traumatic right posterior hip dislocation

c) A&E management to this patient i. Triage the patient to the yellow zone ii. Ensure that airway, breathing and circulation has secured iii. X ray of the pelvis, right femur and right tibia-fibular iv. Adequate analgesic v. Closed reduction under general anaesthesia vi. X ray of the pelvis post reduction. vii. Inform the orthopedic team. If reduction fail, or unstable hip dislocation, then may

require admission to the orthopedic ward. Notes; complication of the posterior hip dislocation Major complications that are known to be associated with dislocation of the hips include avascular necrosis of the femoral head leading to premature osteoarthritis, soft tissue interposition and re-dislocation, neurovascular damage, fracture of the neck of the femur and separation of epiphysis. Coxa magna, premature epiphyseal fusion, and heterotopic calcification have also been noted to occur as long-term sequelae to this clinical entity. [Pandanaboyana Sanjay, "Posterior Dislocation Of The Hip In A Child Following Trivial Trauma: A Case Report", The Internet Journal of Emergency Medicine 2003 : Volume 1 Number 2]