OSCE

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

2. Case 23 • A middle age man with severe back pain, polydipsia and polyuria.

3. Labfindings • 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

4. What is your diagnosis? • Metastasis to lumbar spine • Idiopathic hypercalcemia • Primary polydipsia • Multiple myeloma • Chronic lymphocytic leukemia

5. Case 24 • A middle age man presented with acute dyspnea (Figure A). After diuretic therapy and TNG infusion his symptoms relieved, (Figure B).

6. What do you see in the radiographs ? • Round Pneumonia • Pulmonary metastasis (cannon ball) • Pulmonary tumor • Pnemothorax • Pulmonaryedema • Pulmonary edema with pleural effusion

7. Case 25 a young man presented with bloating and epigastric tenderness. You see the endoscopic view of antrum.

8. What is your endoscopic diagnosis? • Lymphoid hyperplasia • Raised erosions • Ulcer • Fine nodularity • What is the most probable cause? • Drug reaction • Helicobacter pylori • Eosinophilic gastroenteritis

9. 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.

11. 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

12. 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.

13. A barium enema was performed:

14. Colonoscopy and biopsies from the stenotic area revealed inflammation, depletion of goblet cells, granuloma and ulceration. • No dysplasia was observed.

15. 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

16. 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

17. 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.

18. 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)

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

20. Case 29 • A 78 years old man presents with longstanding history of heartburn. • Physical examination is unremarkable. • You see the upper GI endoscopy:

21. 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

22. Case 30 • A young lady with acute dysphagia after recurrent vomiting. She is taking warfarin. • You see the endoscopic view.

23. 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

24. Case 31 • An old female underwent hepatic transplantation because of liver failure . • On 7th day of admission she developed fever and increasing jaundice.

25. What is your diagnosis? • Hepatic artery trombosis • Hepatic vein trombosis • Biliary leak • What is the best management? • Stent placement • Recurrent surgery for repair • anticoagulation

26. 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/L ALT= 23 U/L ALP = 380 U/L Bilirubin T = 2 mg/dl

27. What is your diagnosis? • Liver abcess • Liver cystadenocarcinoma • AD Polycystic kidney disease • What is the management? • Albendazole • Surgical removal • PAIR

28. Case 33 • You see the barium swallow and endoscopic picture of distal esophagus in a 35 lady with progressive dysphagia to liquids.

29. What is your diagnosis? • Achalasia • Scleroderma • GERD • What is you treatment of choice? • Surgical myotomy • Balloon dilatation • TNG • Calcium channel blocker

30. Case 34 • A patient with fever, RUQ pain, and ichterus from 3 months ago. • Liver pathology is shown.

31. What is the diagnosis? • Liver shistosomiasis • Hydatid cyst • Tuberculoma • Sarcoidosis • What is the treatment? • Metronidazole • Albendazole • Isoniazid • Steroid • Praziquantel