1. Accident and Emergency OSCE Examination
End Posting Assesment
(Answer is provided)
Group 7
Phase III, Year 5
Academic Session 2010/2011
Universiti Sains Malaysia

2. Accident & Emergency OSCE
Pediatric Resuscitation
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)
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3. 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.
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, related to the diagnosis in B (2m)
related
d) Outline your management in Emergency department for the patient. (5m)
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4. 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)
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5. 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)
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6. 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)
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7. 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
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8. 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.
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9. 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.
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10. 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.
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11. 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]
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