OSCE
Raika Jamali M.D.
Gastroenterologist and hepatologist
Sina hospital
Tehran University of Medical Sciences
Case 23

A 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 spine
 Idiopathic hypercalcemia
 Primary polydipsia
 Multiple myeloma
 Chronic lymphocytic leukemia

Case 24

A 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 Pneumonia
 Pulmonary metastasis (cannon ball)
 Pulmonary tumor
 Pnemothorax
 Pulmonary edema
 Pulmonary 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, peginterferon 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/L
ALT= 23 U/L
ALP = 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