We all approach cranial nerves in the same way..... we ignore cranial nerve I and VIII.
However a very valid question would be to discuss how you would differentiate between a conductive versus sensorineural hearing loss in the exam.
Really simple if you've pre-thought it.
It's all about the Rinne and the Weber.
The Rinne test involves a 512Hz tuning fork to try and decide of conductive or not. Tap the tuning fork on your knee and hold it onto the patient’s mastoid. When the sound is no longer heard, place it 3-4cm in front of the ear.
A normal test is one where the air conduction is better heard than the bone conduction ie., when the patient no longer hears the sound with the tuning fork held against the mastoid, but then hears it when placed in front of the ear.
The Weber test identifies lateralisation. Tap the tuning fork and hold it high against the middle of the forehead. In a conductive loss of one side, the sound is heard more on that side
It's an exciting announcement that we have 100% of the last group pass the OSCE exam. Congratulations to everyone.......FACEMs all of them. How cool!!!
It really shows that if you tune in every week and do the work, you will get the exam!
Now let's do the same for the next few groups!
A 22/M, has presented to ED via ambulance who picked him with police and has brought him to your tertiary ED. He admits to 2 points of meth over the course of the afternoon and tried to evade the police whilst burglarizing a flat by jumping out of a 1st floor window to flat. The ambulance handover is painful swollen foot and there is note of R foot and ankle swelling and tenderness. They have given a total of 10 mg Morphine IV about 20 minutes ago. Other pertinent exam findings are dilated pupils (6 mm, equal and reactive) and the following obs...
SaO2 98% 4L O2
T 37.7 C
Foot xrays were taken and the images are attached.
He is currently in a cubicle in a monitored treatment area.
The police have left but want to be notified if he is for discharge
Instructions for the candidate
Please review the images and on entering the room, perform the following tasks:
1) You have 2 minutes to describe and interpret the images shown to your junior registrar
2) A 5 minute case based discussion will follow around the further assessment and management of this trauma patient
Domains being examined
For the examiner
Allow 2 mins for X ray interpretation and prompt to move ion to rest of discussion at 2 mins.
Obs are now
HR now 145
T 38.2 C
SaO2 98% RA
You may prompt with:
What other injuries do you suspect?
How will you facilitate further assessment of this patient?
How will you manage him?
The patient is agitated and aggressive and in pain. They are not assessable in the present state and the mechanism is enough to be highly suspicious of multisystem injury.
Attempts to deescalate the patient and provide adequate parenteral opioid analgesia should be initiated early. Anxiolytics with IV or oral benzos should be provided.
The cspine cannot be cleared in the intoxicated patient.
Domains Assessment Objectives
- Adequate and systematic description and interpretation of foot xrays
--Presence of homolateral Lis Franc fracture dislocation foot
-- An unstable fracture with high risk of midfoot compartment unless managed promptly
-- Pertinent negatives
Unable to clear C spine or head given intoxication
May require intubation and pan scan if non compliant with immobilisation.
- Recognition of sympathomimetic toxicity requiring treatment (benzodiazepines)
-- recognises and verbalises seizure risk, complications such as hyperthermia, rhabdomyolysis
- Considers/rules out differentials for agitation
-- head injury
-- heat stroke
- Takes measures to ensure patient and staff safety
Prioritisation And Decision Making
In management of sympathomimetic syndrome
- Staff and patient safety (i.e, security, considers physical restraint depending level of agitation of actor)
- Preparation for intubation for ct and management of foot seizures/status epilepticus
- Appropriate disposition theatre for reduction and fixation the ICU