OSCE

Raika Jamali M.D.Gastroenterologist and hepatologist

Sina hospitalTehran University of Medical Sciences

Case 23A middle age man with severe back pain,

polydipsia and polyuria.

Lab findings Hb= 9.4 gr/dl, RBC=3.1x10 6 , MCV=102, MCH, MCHC= normal , PLT=117000 .

WBC= 7100 , poly=68% lymph=27% ESR=102 , PT=12, sec. Ca = 10.1 mg/dl Albumin = 3.4 & total protein = 6.7 g/dl BUN, Creatinine = normal

24hr Urinary protein= normal

What is your diagnosis?Metastasis to lumbar spineIdiopathic hypercalcemiaPrimary polydipsiaMultiple myelomaChronic lymphocytic leukemia

Case 24A middle age man presented with acute

dyspnea (Figure A). After diuretic therapy and TNG infusion his symptoms relieved, (Figure B).

What do you see in the radiographs ?Round PneumoniaPulmonary metastasis (cannon ball)Pulmonary tumorPnemothoraxPulmonary edemaPulmonary edema with pleural effusion

Case 25 a young man presented with bloating and epigastric

tenderness. You see the endoscopic view of antrum.

• What is your endoscopic diagnosis?– Lymphoid hyperplasia– Raised erosions– Ulcer– Fine nodularity

• What is the most probable cause?– Drug reaction– Helicobacter pylori– Eosinophilic gastroenteritis

Case 26

• A middle age man presented with crampy abdominal pain and melena. There is history of kidney transplant and use of cyclosporine and azathioprine for 6 years.

• You see the small bowel transit and the histology of resected segment.

• What do you see in the radiograph?• Bowel obstruction in jejunum• Bowel obstruction in duodenum• Gastric outlet obstruction

• What is the most probable diagnosis?• Lymphoma• CMV infection• Tuberculosis

Case 27• A lady that was diagnosed as a case of

ulcerative colitis. She is taking 1 gram mesalazine three times a day and is in remission.

• In her past history she mentions an operation for anal fistula.

• During her routine check-up a moderate iron deficiency anemia and three plus occult blood was discovered.

A barium enema was performed:

• Colonoscopy and biopsies from the stenotic area revealed inflammation, depletion of goblet cells, granuloma and ulceration.

• No dysplasia was observed.

• What is your diagnosis? – Crohn disease– Celiac disease– Lymphoma– Ulcerative colitis

• What is your therapy of choice?– Surgical resection of the stenotic area– Infliximab– Metronidazole and ciprofloxacin

Case 28• A lady referred with malaise and dark urine. She had

cesarian section 3 weeks ago. Halothane was NOT used. • During operation she had developed severe bleeding and

received 3 units of packed cells. She has had no previous operation.

• Wt: 68 kg• AST: 580 IU/L, ALT: 730 IU/L, • Alkaline phosphatase: 490 IU/L (normal: 306),• Total bilirubin: 2.1 mg/dL, Direct bilirubin: 1.3 mg/dL, • PT: 12.3 sec (control 12)• HBsAg –, HCV Ab: +, • sonography: normal

• With impression of hepatitis C, peg-interferon 180µgr weekly and ribavirin 1000 mg per day were started.

• One week later the patient developed jaundice, nausea, mild fever, and right upper quadrant pain.

Laboratory findings:• AST: 2150 IU/L, ALT: 2010 IU/L, Alkaline phosphatase: 470

IU/L,• Total bilirubin: 8.4mg/dL, Direct bilirubin: 6.1 mg/dL,

PT: 17.3 sec (control 12.5)• Total protein 8.3 gr/dL, albumin: 3.7 gr/dL, • HCV Ab RIBA: +• HCV RNA PCR: -• HBV DNA PCR: -• K-F ring: -• ANA: 1/320,• ASMA: 1/10,• AMA: 1/10,• ALKM1: -• Serum ceruloplasmin: 15 mg/dL (normal: 20 to 35 mg/Dl)

• What is the next step in management?– Evaluation for possible liver transplant– Start prednisolone– Check for 24 h urinary copper– All of the above

Case 29• A 78 years old man presents with

longstanding history of heartburn. • Physical examination is unremarkable.• You see the upper GI endoscopy:

• What is the diagnosis ? – GERD induced esophagitis– Eosinophilic esophagitis– Corrosive esophagitis– Candidiasis esophagitis

• What is the best management?– Proton pump inhibitor– Endoscopic dilation– Cromolyn inhaler

Case 30• A young lady with acute dysphagia after

recurrent vomiting. She is taking warfarin.• You see the endoscopic view.

• What is the diagnosis ? – GERD induced esophagitis– Esophageal hematoma– Candidiasis esophagitis

• What is the best management?– Proton pump inhibitor– Endoscopic dilation– Check of PT, PTT, PLT

Case 31• An old female underwent hepatic

transplantation because of liver failure . • On 7th day of admission she developed fever

and increasing jaundice.

• What is your diagnosis?– Hepatic artery trombosis– Hepatic vein trombosis– Biliary leak

• What is the best management?– Stent placement– Recurrent surgery for repair– anticoagulation

Case 32• A young man presented with RUQ pain.• He had history of jaundice 6 months ago.• Span of liver is 16 cm.

AST= 27 U/LALT= 23 U/LALP = 380 U/L Bilirubin T = 2 mg/dl

• What is your diagnosis?– Liver abcess– Liver cystadenocarcinoma– AD Polycystic kidney disease

• What is the management?– Albendazole– Surgical removal– PAIR

Case 33

• You see the barium swallow and endoscopic picture of distal esophagus in a 35 lady with progressive dysphagia to liquids.

• What is your diagnosis?– Achalasia– Scleroderma– GERD

• What is you treatment of choice?– Surgical myotomy– Balloon dilatation– TNG– Calcium channel blocker

Case 34

• A patient with fever, RUQ pain, and ichterus from 3 months ago.

• Liver pathology is shown.

• What is the diagnosis?– Liver shistosomiasis– Hydatid cyst– Tuberculoma– Sarcoidosis

• What is the treatment?– Metronidazole– Albendazole– Isoniazid– Steroid– Praziquantel