OSCE
Raika Jamali M.D.
Gastroenterologist and hepatologist
Sina hospital
Tehran 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
BP  120
80
PR  84
min
Icteric sclera.
She was not pale ,
No peripheral LNP,
Heart and lung are normal.
Abdomen:
Shifting dullness: positive,
Murphy sign positive
Liver span=14 cm,
Mild RUQ & epigastric tenderness,
No edema.
T (oral) = 39.5°c
• What do you do for ascitis?
– Diagnostic paracentesis
– Diuretic therapy
– Plain abdominal radiograph
– Echocardiography

What diagnosis does not match the
patient?
Acute collangitis
 Budd chiari syndrome
 Auto immune hepatitis
 Acute fatty liver of pregnancy
 Drug induced hepatitis
 HELLP
 Shock 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/L
ALT= 328,1355 U/L
T= 12,12.8
Bilirubin
mg/dl ,
AlkPh = 769,623 U/L
D=5.8, 6.2
Alb ascitis: 0.6
WBC ascitis:80 (80% lymph)
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 pregnancy
 Ursodeoxycolic acid
 B6 infusion
 Steroid

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/L
ALT= 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.
1
ANA :
320

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