OSCE (Part one) Answers

1. OSCE (Part one)Answers RaikaJamali M.D. Gastroenterologist and hepatologist Sina hospital Tehran University of Medical Sciences

2. CASE 1 • Mention to the air and the leak of contrast material in the mediastinum. • The diagnosis is esophageal rupture. • First step in the management of patient is the evaluation of patient oxygenation and blood pressure. • Then the patient should be NPO. • Wide spectrum antibiotic administration and urgent surgical consult is needed. • Nasogastric tube insertion and endoscopy is not recommended in this case. • The best management strategy is early surgical intervention.

3. Case 2 • The typical esophageal web in the upper third of esophagus. • It is frequently seen in middle age woman with iron deficiency anemia.

4. Case 3 • The tall T wave with ST segment elevation in inferior leads are in favor of acute inferior wall MI. • The best management strategy that increases the patients survival is coronary reperfusion by PCI method.

5. Case 4 • Mention to the mediastinal widening in the first CXR. • Pulmonary edema is seen in the second CXR, most probably due to the extension of dissection to the base of coronary arteries causing ischemia and concomitant heart failure. • The best strategy is reducing the risk of further ischemia by surgical intervantion.

6. Case 5 • Tall T wave in leads V1 and V2 are clues to true posterior wall MI. • Notice to the clear lung fields and shock in this patient. • The patient may have right ventricular ischemia as well. • Evaluation of right pericordial and posterior leads are recommended. • Diuretic therapy and nitroglycerin is not recommended. • The best initial management is adequate hydration.

7. Case 6 • Mention to the stenotic areas in left common carotid and brachiocephalic arteries. • The typical signs of takayasovasculitis (pulseless syndrome) is seen in the CT angiography of patient. • The best treatment is steroid administration. • Surgical interventions and angioplastic methods for management of the stenotic areas are recommended if the initial treatment with steroid fails.

8. Case 7 • Mention to the thrombosis in right renal vein. • The best treatment is anticoagulation therapy. • The duration of treatment depends on the etiology of hypercoagulability state.

9. Case 8 • Mention to the schistocyte in the PBS indicative of microangiopatic hemolytic anemia. • This might be seen in all of the below conditions: • Hemolytic uremic syndrome • Disseminated intravascular coagulation • Thrombotic thrombocytopenic purpura

10. Case 9 • The patient has pneumonia. Mention to the increase of acute phase reactants in serum protein electrophoresis. • Toxic granulation is seen in neutrophils.

11. Case 10 • You see sickle cell in PBS. • In hemolytic crisis all of the below treatment options might be considered: • Hydration • Blood exchange • Control of infection and hypoxia • The best treatment strategy is bone marrow transplantation

12. Case 11 • Mention to the mass in the superior mediastinum (above the level of carina). • Ectopic thyroid, Thymus, Teratoma are the differential diagnosis of the mass in superior mediastinum.