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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

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Osce

OSCE

Raika Jamali M.D.

Gastroenterologist and hepatologist

Sina hospital

Tehran University of Medical Sciences


Case 12

Case 12

  • Old man with acute knee arthritis.

  • You see the synovial fluid aspirate.


Osce

  • What is the diagnosis?

    • Gouty arthritis

    • Pseudogout arthritis

    • Septic arthritis

    • Rheumatoid arthritis

  • What is the best treatment?

    • NSAID

    • Colshicin

    • Intraarticular steroid

    • Allopurinol


Case 13

Case 13

  • A young boy with fever, dyspnea from 3 months ago. Anemia, splenomegaly, and systolic murmur in LSB.


Osce

  • What do you see?

    • Splintar hemorrhage

    • Blue toe

    • Reynaud disease

  • What is the treatment?

    • Intravenous antibiotic

    • Echocardiography and anticoagulation

    • Calcium channel blocker


Case 14

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.


Osce

  • 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

Case 15

  • Old man presented with severe anemia and huge splenomegaly.


Osce

  • 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

Case 16

  • Old alcoholic man presented with severe anemia and dementia.

  • You see his PBS.


Osce

  • 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

Case 17

  • Bedridden patient Presented with distention and vomiting. You see the MRI of abdomen and serum protein electrophoresis.


Osce

  • What is the diagnosis?

    • Carcinoid tumor

    • Adenocarcinoma of sigmoid

    • Fecal impaction

    • Adrenal mas

    • Inguinal hernia


Case 18

CASE 18

  • A young girl with bulimia presented with abdominal pain.


Osce

  • What do you see?

    • Gastroparesis

    • Gastric outlet obstruction

    • Pancreas divisum

    • pancreatic pseudocyst


Case 19

CASE 19


Osce

  • What diagnosis does not match with the patient?

    • Chollangitis

    • Typhoid fever

    • Leptospirosis

    • Acute viral hepatitis

    • Pancreatitis


Case 20

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

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 positive

Liver span=14 cm,

Mild RUQ & epigastric tenderness,

No edema.

Physical examination:

Conscious, cooperative


Osce

  • What do you do for ascitis?

    • Diagnostic paracentesis

    • Diuretic therapy

    • Plain abdominal radiograph

    • Echocardiography


Osce

  • 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

Case21

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

Lab findings:

  • Hb= 12.3 gr/dl, RBC=4x10 6 , MCV=84,

    MCH, MCHC= normal

  • PLT=127000LDH: 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 : +


Osce

AST=194,1444 U/L

ALT= 328,1355 U/L

Alb ascitis: 0.6

WBC ascitis:80 (80% lymph)

T= 12,12.8

Bilirubin mg/dl , AlkPh = 769,623 U/L

D=5.8, 6.2


Ultrasonography

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


Osce

What is the best treatment strategy?

Termination of pregnancy

Ursodeoxycolic acid

B6 infusion

Steroid


Case 22

Case22

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 findings1

Labfindings

  • 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


Osce

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

You see the serum protein electrophoresis in this patient.


Osce

  • 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


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