OSCE

Raika Jamali M.D.Gastroenterologist and hepatologist

Sina hospitalTehran University of Medical Sciences

Case 12

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

• What is the diagnosis?– Gouty arthritis– Pseudogout arthritis– Septic arthritis– Rheumatoid arthritis

• What is the best treatment?– NSAID– Colshicin– Intraarticular steroid– Allopurinol

Case 13• A young boy with fever, dyspnea from 3

months ago. Anemia, splenomegaly, and systolic murmur in LSB.

• What do you see?– Splintar hemorrhage– Blue toe– Reynaud disease

• What is the treatment?– Intravenous antibiotic– Echocardiography and anticoagulation– Calcium channel blocker

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.

• What is the diagnosis? – Crigler najjar syndrome– Gilbert disease– Favism– Spherocytosis

• What is the best treatment?– Iron supplement– Folate supplement– Splenectomy and cholecystectomy

Case 15• Old man presented with severe anemia and

huge splenomegaly.

• What is the diagnosis? – Multiple myeloma– Acute leukemia– Aplastic anemia– Hairy cell leukemia

• What is the best treatment?– Chemotherapy– Bone marrow transplant– plasmapheresis

Case 16• Old alcoholic man presented with severe

anemia and dementia. • You see his PBS.

• 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

Case 17• Bedridden patient Presented with distention

and vomiting. You see the MRI of abdomen and serum protein electrophoresis.

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

CASE 18• A young girl with bulimia presented with

abdominal pain.

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

CASE 19

• What diagnosis does not match with the patient?

– Chollangitis– Typhoid fever– Leptospirosis– Acute viral hepatitis– Pancreatitis

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.

Physical examination: Conscious, cooperative

80120BP min

84PR T (oral) = 39.5°c

Icteric sclera.She was not pale ,No peripheral LNP, Heart and lung are normal.Abdomen: Shifting dullness: positive,Murphy sign positiveLiver span=14 cm, Mild RUQ & epigastric tenderness,No edema.

• What do you do for ascitis?

– Diagnostic paracentesis– Diuretic therapy– Plain abdominal radiograph– Echocardiography

What diagnosis does not match the patient?

Acute collangitisBudd chiari syndromeAuto immune hepatitisAcute fatty liver of pregnancyDrug induced hepatitisHELLPShock liver

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.

Lab findings: Hb= 12.3 gr/dl, RBC=4x10 6 , MCV=84, MCH, MCHC= normal PLT=127000 LDH: 1250 WBC= 10000 , poly=77% lymph=20% PT=19, sec. INR=2.3, Ca=8.1 Alb=2.6 & total protein =3.9 g/dl BUN, Creatinine = normal U/A : normal Viral markers: negative FANA : +

AST=194,1444 U/LALT= 328,1355 U/L

Alb ascitis: 0.6WBC ascitis:80 (80% lymph)

T= 12,12.8 Bilirubin mg/dl , AlkPh = 769,623 U/L D=5.8, 6.2

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

What is the best treatment strategy?

Termination of pregnancyUrsodeoxycolic acidB6 infusionSteroid

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.

Lab findings

Hb= 9.4 gr/dl, RBC=5.1x10 6 , MCV=102, MCH, MCHC= normal , PLT=117000 .

WBC= 7100 , poly=68% lymph=27% ESR=22 , PT=32.5 , sec. INR=5.1,

Ca=8.1 Albumin = 3.4 & total protein = 6.7 g/dl BUN, Creatinine = normal 24hr Urinary protein= normal

AST=87 U/LALT= 123 U/L

T= 4.4 Bilirubin mg/dl , AlkPh = 215 (NL) D=1.8

US: Heterogenous Liver 110mm , Mild Ascites, normal GB, normal portal and hepatic vein , spleen=110mm.

You see the serum protein electrophoresis in this patient.

3201:ANA

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