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OSCE

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

  2. Case 12 • Old man with acute knee arthritis. • You see the synovial fluid aspirate.

  3. What is the diagnosis? • Gouty arthritis • Pseudogout arthritis • Septic arthritis • Rheumatoid arthritis • What is the best treatment? • NSAID • Colshicin • Intraarticular steroid • Allopurinol

  4. Case 13 • A young boy with fever, dyspnea from 3 months ago. Anemia, splenomegaly, and systolic murmur in LSB.

  5. What do you see? • Splintar hemorrhage • Blue toe • Reynaud disease • What is the treatment? • Intravenous antibiotic • Echocardiography and anticoagulation • Calcium channel blocker

  6. 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.

  7. What is the diagnosis? • Crigler najjar syndrome • Gilbert disease • Favism • Spherocytosis • What is the best treatment? • Iron supplement • Folate supplement • Splenectomy and cholecystectomy

  8. Case 15 • Old man presented with severe anemia and huge splenomegaly.

  9. What is the diagnosis? • Multiple myeloma • Acute leukemia • Aplastic anemia • Hairy cell leukemia • What is the best treatment? • Chemotherapy • Bone marrow transplant • plasmapheresis

  10. Case 16 • Old alcoholic man presented with severe anemia and dementia. • You see his PBS.

  11. 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

  12. Case 17 • Bedridden patient Presented with distention and vomiting. You see the MRI of abdomen and serum protein electrophoresis.

  13. What is the diagnosis? • Carcinoid tumor • Adenocarcinoma of sigmoid • Fecal impaction • Adrenal mas • Inguinal hernia

  14. CASE 18 • A young girl with bulimia presented with abdominal pain.

  15. What do you see? • Gastroparesis • Gastric outlet obstruction • Pancreas divisum • pancreatic pseudocyst

  16. CASE 19

  17. What diagnosis does not match with the patient? • Chollangitis • Typhoid fever • Leptospirosis • Acute viral hepatitis • Pancreatitis

  18. 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.

  19. 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

  20. What do you do for ascitis? • Diagnostic paracentesis • Diuretic therapy • Plain abdominal radiograph • Echocardiography

  21. 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

  22. 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.

  23. 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 : +

  24. 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

  25. 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

  26. What is the best treatment strategy? Termination of pregnancy Ursodeoxycolic acid B6 infusion Steroid

  27. 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.

  28. 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

  29. 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.

  30. You see the serum protein electrophoresis in this patient.

  31. 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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