Clinical Case Studies: Cardiac Emergencies and Abdominal Pain

JCM 2/9/2020 OSCE answers TMH

Question 1 A 65/F with unremarkable past health attended the Accident and Emergency Department for acute onset of palpitation for ~1hr. She was alert with blood pressure 163/90 mmHg, pulse 170 beats/min, and SpO2 98% on RA.

ECG

a. What are the ECG findings? (3 marks)

a. What are the ECG findings? (3 marks) Monomorphic wide complex tachycardia of ventricular rate 173 bpm Inferior axis Left bundle branch block AV dissociation

b. What is your diagnosis? (1 mark)

b. What is your diagnosis? (1 mark) Right ventricular outflow tract tachycardia

C. What drug will you give this patient? (1 mark)

C. What drug will you give this patient? (1 mark) ATP 10mg IV bolus CCB, BB

What is the definitive treatment for this condition? (1 mark)

What is the definitive treatment for this condition? (1 mark) EPS + RFA

Question 2 A 70/F attends the Accident and Emergency Department for left upper quadrant pain for one day. The pain started after a bout of vigorous coughing. She has past medical history of DM, hypertension, atrial fibrillation and chronic rheumatic heart disease with mitral valve replacement and tricuspid valve valvuloplasty. BP128/58 mmHg, pulse 79 beats/min, afebrile. Physical examination found a palpable vague swelling of 15cm over left abdomen.

What are your differential diagnoses for a painful abdominal mass? (2 marks)

What are your differential diagnoses for a painful abdominal mass? (2 marks) Abdominal wall Abdominal wall abscess Rectus sheath hematoma Abdominal wall neoplasms Intra-abdominal Strangulated hernia Symptomatic abdominal aortic aneurysm Intra-abdominal neoplasms

Any specific signs you would look for during physical exam to distinguish intra-abdominal pathology from abdominal wall pathology? (1 marks)

Any specific signs you would look for during physical exam to distinguish intra-abdominal pathology from abdominal wall pathology? (1 marks) Movement with respiration Fothergill sign Carnett sign

Fothergill sign Voluntary contraction of rectus muscle (lifts head or leg while lying supine) Rectus sheath hematomas become fixed and more tender Intra-abdominal masses become less distinct and tender Positive sign: an abdominal mass that does not cross the midline and remains palpable when the rectus muscles are flexed

Carnett sign Tense the abdominal muscles by asking patient to raise head or shoulder off table while lying supine Positive sign for abdominal wall pathology: abdominal tenderness increased or unchanged Negative sign: decreased abdominal tenderness

Contrast CT abdomen and pelvis

c. Describe the CT findings. (1 marks)

c. Describe the CT findings. (1 marks) Left rectus abdominis muscle grossly swollen with heterogeneous densities; no contrast enhancement Linear hyperdensity with the left rectus abdominis muscle swelling, suggestive of active contrast extravasation within the rectus sheath hematoma

d. What is the diagnosis? (1 marks)

d. What is the diagnosis? (1 marks) Left abdominal rectus sheath hematoma Active hemorrhage from feeding artery

e. How would you manage this patient? (3 marks)

e. How would you manage this patient? (3 marks) NPO Set 2 large bore IV, IVF +/- blood product resuscitation Monitor Hb level Correct any coagulopathy: stop warfarin, give Prothrombin complex concentrate or FFP Pain control, bed rest, compression of hematoma

What treatment can be offered if conservative treatment failed? (1 marks)

What treatment can be offered if conservative treatment failed? (1 marks) Angiography with arterial embolisation of superior/ inferior epigastric arteries Surgical ligation of superior/ inferior epigastric arteries +/- hematoma evacuation

Rectus sheath hematoma Accumulation of blood within rectus sheath Rupture of epigastric vessels or torn rectus muscle fibres Spontaneous (anticoagulant), trauma, cirrhosis R>L, lower> upper Abdominal wall ecchymosis, substantial Hb drop Generally self limiting

CT classification type I: small and confined within the rectus muscle; does not cross the midline or dissect fascial planes type II: also confined within the rectus muscle but can dissect along the transversalis fascial plane or cross the midline type III: large, usually below the arcuate line, and often presents with evidence of hemoperitoneum and/or blood within the prevesical space of Retzius (retropubic space)

Question 3 A 59 year old female was accidentally hit by the blunt end of a screwdriver over her right eye. She complained of severe right eye pain. Physical examination showed 3mm proptosis over the right eye with limited ability to open the eye. There were severe swelling and tenderness at the right orbital region. VA was 6/12. IOP was 18 mmHg.

a. What are the possible injuries? (2 marks)

a. What are the possible injuries? (2 marks) Anterior segment Corneal abrasion Hyphema Lens dislocation Globe rupture Posterior segment Vitreous haemorrhage Retinal detachment Extra-ocular Orbital bone fracture Retro-bulbar hemorrhage Traumatic ICH

Plain CT orbit

b. Describe the CT findings. (1.5 marks) c. What is the diagnosis? (0.5 mark)

b. Describe the CT findings. (1.5 marks) Hyperdensity over right orbital apex posterior to the right globe Contour of right globe is preserved No lens dislocation No periorbital fracture c. What is the diagnosis? (0.5 mark) Right acute traumatic retro-bulbar hemorrhage (ddx: posterior globe rupture)

d. Is operative treatment indicated for this condition? (0.5 mark)

d. Is operative treatment indicated for this condition? (0.5 mark) No, conservative treatment if IOP is normal

e. The patient complains of worsening pain, swelling and vision over her right eye. IOP is now 44 mmHg. What is the complication she developed? (0.5 mark) What is the treatment for this complication? (0.5 mark)

e. The patient complains of worsening pain, swelling and vision over her right eye. IOP is now 44 mmHg. What is the complication she developed? (0.5 mark) Right orbital compartment syndrome What is the treatment for this complication? (0.5 mark) Surgical decompression of the right orbit by lateral canthotomy and inferior cantholysis

Retrobulbar hematoma an uncommon, rapidly progressive, sight threatening emergency that result from accumulation of blood in the retrobulbar space Clinical features Painful Proptosis Increased orbital tissue tension, increased intraocular pressure Ecchymosis of eyelids Chemosis Decreased Visual Field Decreased Visual Acuity/Loss of Vision Afferent Pupillary Defect (APD in swinging flash light test)

Ocular compartment syndrome Rigid orbital bone limits expansion of accumulated blood Optic nerve limits anterior displacement of orbital contents The raised intraorbital is transmitted to optic nerve, retinal artery and vasculature of the optic nerve resulting in ischemia True eye emergency: permanent visual loss if untreated Surgical decompression of the orbit by lateral canthotomy and inferior cantholysis

Question 4 A 56 year old man attended AED for left eye ptosis for 3 months. He also complained of recent weight loss. Physical exam showed left pupil miosis and left eye partial ptosis.

a. What condition is this patient suffering from? (0.5mark)

a. What condition is this patient suffering from? (0.5mark) Left Horner s syndrome

b. What other physical signs may be present? (1.5 marks)

b. What other physical signs may be present? (1.5 marks) Ipsilateral facial anhidrosis Ipsilateral impaired facial flushing (Harlequin sign) Apparent enophthalmos Enhanced accommodation

c. What pharmacological test to confirm the presence of this condition? (0.5 mark)

c. What pharmacological test to confirm the presence of this condition? (0.5 mark) Cocaine eye drop test Blocks reuptake of norepinephrine at the sympathetic nerve synapse Pupil dilatation in eyes with intact sympathetic innervation No effect on Horner pupil: 1mm increase in anisocoria Apraclonidine eye drop test

d. What are the possible causes? (2 marks)