OSCE

1
OSCE

• Raika Jamali M.D.
• Gastroenterologist and hepatologist
• Sina hospital
• Tehran University of Medical Sciences

2
Case 12

• Old man with acute knee arthritis.
• You see the synovial fluid aspirate.

3

• What is the diagnosis?
• Gouty arthritis
• Pseudogout arthritis
• Septic arthritis
• Rheumatoid arthritis
• What is the best treatment?
• NSAID
• Colshicin
• Intraarticular steroid
• Allopurinol

4
Case 13

• A young boy with fever, dyspnea from 3 months
  ago. Anemia, splenomegaly, and systolic murmur in
  LSB.

5

• What do you see?
• Splintar hemorrhage
• Blue toe
• Reynaud disease
• What is the treatment?
• Intravenous antibiotic
• Echocardiography and anticoagulation
• Calcium channel blocker

6
Case 14

• A young man with anemia and recurrent episodes of
  jaundice from childhood.
• Mild splenomegaly was detected in
  ultrasonography. Hb 12.5 mg /dl.

7

• What is the diagnosis?
• Crigler najjar syndrome
• Gilbert disease
• Favism
• Spherocytosis
• What is the best treatment?
• Iron supplement
• Folate supplement
• Splenectomy and cholecystectomy

8
Case 15

• Old man presented with severe anemia and huge
  splenomegaly.

9

• What is the diagnosis?
• Multiple myeloma
• Acute leukemia
• Aplastic anemia
• Hairy cell leukemia
• What is the best treatment?
• Chemotherapy
• Bone marrow transplant
• plasmapheresis

10
Case 16

• Old alcoholic man presented with severe anemia
  and dementia.
• You see his PBS.

11

• What is the diagnosis?
• Sideroblastic anemia
• Multiple myeloma
• Megaloblastic anemia
• What is the treatment?
• B6 supplement
• B12 supplement
• B1 supplement
• Which test is needed to discover the etiology?
• Shilling test
• Bone marrow biopsy

12
Case 17

• Bedridden patient Presented with distention and
  vomiting. You see the MRI of abdomen and serum
  protein electrophoresis.

13

• What is the diagnosis?
• Carcinoid tumor
• Adenocarcinoma of sigmoid
• Fecal impaction
• Adrenal mas
• Inguinal hernia

14
CASE 18

• A young girl with bulimia presented with
  abdominal pain.

15

• What do you see?
• Gastroparesis
• Gastric outlet obstruction
• Pancreas divisum
• pancreatic pseudocyst

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CASE 19
17

• What diagnosis does not match with the patient?
• Chollangitis
• Typhoid fever
• Leptospirosis
• Acute viral hepatitis
• Pancreatitis

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CASE 20

• A 27 yr pregnant woman admitted for evaluation of
  sustained RUQ pain.
• She had bilious vomiting and skin rash.
• There is recent history of coamoxiclave use for
  sinusitis.

19

• Physical examination
• Conscious, cooperative

T (oral) 39.5c
Icteric sclera. She was not pale , No peripheral
LNP, Heart and lung are normal. Abdomen
Shifting dullness positive, Murphy sign
positive Liver span14 cm, Mild RUQ
epigastric tenderness, No edema.
20

• What do you do for ascitis?
• Diagnostic paracentesis
• Diuretic therapy
• Plain abdominal radiograph
• Echocardiography

21

• What diagnosis does not match the patient?
• Acute collangitis
• Budd chiari syndrome
• Auto immune hepatitis
• Acute fatty liver of pregnancy
• Drug induced hepatitis
• HELLP
• Shock liver

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Case 21

• A 27 yr pregnant woman admitted for evaluation of
  sustained RUQ pain.
• Exam
• Ichteric sclera
• Positive shifting dullness
• Murphy sign negative
• Liver span 14 cm,
• Mild RUQ tenderness,
• No edema.

23
Lab findings

• Hb 12.3 gr/dl, RBC4x10 6 , MCV84,
• MCH, MCHC normal
• PLT127000 LDH 1250
• WBC 10000 , poly77 lymph20
• PT19, sec. INR2.3, Ca8.1
• Alb2.6 total protein 3.9 g/dl
• BUN, Creatinine normal
• U/A normal
• Viral markers negative FANA

24

• AST194,1444 U/L
• ALT 328,1355 U/L
• Alb ascitis 0.6
• WBC ascitis80 (80 lymph)

T 12,12.8 Bilirubin
mg/dl , AlkPh 769,623 U/L
D5.8, 6.2
25
Ultrasonography

• Liver with normal echo and size ,
• Ascitis is seen in pelvic cavity,
• Gall bladder wall thickness 6 mm,
• Billiary ducts with normal diameter
• normal portal and hepatic vein diameter ,
• Spleen with normal echo and size .
• No thrombosis in hepatic, splenic and portal
  veins

26

• What is the best treatment strategy?
• Termination of pregnancy
• Ursodeoxycolic acid
• B6 infusion
• Steroid

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Case 22

• A 37 yr woman admitted for evaluation of
  sustained RUQ pain and fatigue.
• Exam
• Ichteric sclera
• Positive shifting dullness
• Murphy sign negative
• Liver span 14 cm,
• Mild RUQ tenderness,
• No edema.

28
Lab findings

• Hb 9.4 gr/dl, RBC5.1x10 6 , MCV102,
• MCH, MCHC normal , PLT117000 .
• WBC 7100 , poly68 lymph27
• ESR22 , PT32.5 , sec. INR5.1,
  Ca8.1
• Albumin 3.4 total protein 6.7 g/dl
• BUN, Creatinine normal
• 24hr Urinary protein normal

29

• AST87 U/L
• ALT 123 U/L

T 4.4 Bilirubin
mg/dl , AlkPh 215 (NL)
D1.8
US Heterogenous Liver 110mm , Mild Ascites,
normal GB, normal portal and hepatic vein ,
spleen110mm.
30
You see the serum protein electrophoresis in this
patient.

31

• What is your diagnosis ?
• Autoimmune hepatitis
• Amyloidosis
• Multiple myeloma
• Common variable immune deficiency
• What is your treatment?
• Steroid
• Bone marrow transplant
• Gamma globulin infusion monthly