OSCE

January 19 2009

DrDahhan

OSCESimulation1

January19th2009

1st Station

24 year old male, Factory laborer,

presented with 3 months fever,
night sweats, constipation, and
polyurea clinically had stable vital
signs and unremarkable examination.
a) Describe findings
PA view with bilateral hilar fullness
Could be lymphadenopathy, pulmonary artery widening
b) Mention 4 differential diagnosis
a. Sarcoidosis
b. Lymphoma (Hodgkins disease)
c. Tuberculous Lymphadenitis
d. Beryliosis
c) Mention 3 diagnostic tests, helping in your diagnosis.
a. Angiotensin Converting enzyme level
b. Tuberculin skin test
c. Bronchoscopy with lavage (can give a clue)
d) What is the explaination of constipation, polyurea
Hypercalcemia from activation of vitamin D n
granulomatous tissue
e) Mention one definitive diagnostic investigation.
Mediastinoscopy with histopathological staining and
probable immunohistochemistry staining

DrDahhan

OSCESimulation1

January19th2009

2nd Station

56 year-old male, diabetic, hypertensive and 40 pack-year

smoker, presented with central chest pain and diaphoresis.
BP 80/50, pulse was 50, RR 24, Sat 93% in room air, clinically
has normal chest, audible hear sounds, abdomen within normal,
has the following EKG.
a) Describe the electrocardiogram
12 lead ECG of sinus rhythm, left axis deviation, rate of 50
bpm, shows ST segment elevation in lead II, III, aVF and
ST segment depression in leads I, aVL, V2, V3 +
pathological q wave in leads III, aVF.
b) Mention one clinical sign helping in diagnosis.
Kaussmaul Sign: Rise in JVP with inspiration instead of a
decrease
c) Highlight important management steps.
a. IV fluid boluses
b. Analgesia
c. Oxygen
DrDahhan

OSCESimulation1

January19th2009

d. Aspirin
e. Primary angioplasty vs Fibrinolytic therapy
according to availability
f. Temporary pacing if had hemodynamically unstable
bradycardia
g. Avoid Nitroglycerin (possibly morphine) as may
precipitate hypotension here

3rd Station
34 year-old female with new onset of
right arm weakness and diplopia lasted
for 2 days and disappeared completely.
T1 weighted MR images are shown
a. Describe findings
Sagital MR T1-weighted images showing periventricular
hyperintense white matter changes
b. Mention a possible diagnostic investigations with two tests
in it:
CSF examination in Lumbar Puncture with testing for
oligoclonal bands and IgG index
c. How to manage this patient in Emergency room with
persisting weakness.
Intravenous pulse steroid with methylprednisone 1000mg
every day for 3-5 days after ruling out infection.
d. Chronic management options:
a. Rebif (Beta-interferon)
b. Natalizumab
c. Rituximab
DrDahhan

OSCESimulation1

January19th2009

4th Station

40 year old male stated post allogenic bone marrow

transplantation 2 months ago, maintained on cyclosporine
Presented with fever, headache and photophobia
Clinically there was meningism and vital signs were remarkable
for a temperature of 39 degrees.
CSF gram stain is shown
a) Describe the findings
Gram stain of CSF fluid showing gram positive threads
with budding yeasts
b) Additional work up on slide can help to diagnose:
KOH (Potassium hydroxide) prepration
c) Describe two other possible clinical presentations.
a. Hepatosplenic Candidiasis (Systemic involvement)
b. Oropharyngeal Candidiasis
d) Mention two additional helpful diagnostic investigation
not necessary related to above clinical presentation
a. Computed tomography of abdomen and pelvis with
contast given intravenously
b. Esophagogastroduodenoscopy.
DrDahhan

OSCESimulation1

January19th2009

e) Mention important therapeutic interventions:

a. Hold immunosuppression
b. Start broad spectrum antifungal agents
(Amphotericin-B, Voriconazole or Caspofungin)
c. Consider isolation and ruling out infection

DrDahhan

OSCESimulation1

January19th2009

5th Station

50 years old male with abdominal pain and hematuria for 5

hours, no history of trauma
Following CT abdomen was done in Emergency room upon
presentation
a) Describe findings.
a. Computed tomography of abdomen without contrast
showing bilateral hypodense cysts in both kidneys
b) Mention 3 (three) important clinical presentations
a. Hypertension
b. Symptoms of Polycythemia (Headache, decrease
quality of sleep and pruritis relieved with worm
shower)
DrDahhan

OSCESimulation1

January19th2009

c. Symptoms of chronic kidney disease

c) Mention a fatal complication related to the disease
a. Subarachnoid hemorrhage (ruptured berry
aneurysms)
d) Mention three related investigations
a. Magnetic Resonance Angiography
b. Urea and creatinine, with serum electrolytes (K,
HCO3)
c. Serum Erythropoitin level (EPO)
e) Mention mode of transmission in relation to this disease
Autosomal Dominant disease

DrDahhan

OSCESimulation1

January19th2009

6th Station

DrDahhan

OSCESimulation1

January19th2009

50 years old patient with Rheumatoid Arthritis, received

infliximab infusion 3 weeks back
Presented with fever, weight loss
Unremarkable clinical examination, had this Chest x-ray
a) Describe the findings
Chest X-Ray of PA view showing bilateral military shaow
involving all lung lobes
b) Mention a working diagnosis with this Chest X-Ray
Miliary Tuberculosis
c) Mention three other possible Differential diagnosis may
look radiologically similar, not necessarily related to
above clinical presentation:
a. Infections: VZV pneumonitis, Histoplasmosis
b. Sarcoidosis
c. Hypersensitivity pneumonitis (Extrinsic Allergic
Alveolitis)
d) Highlight important management steps:
a. Airborne isolation + send 3 sputum samples for acid
fast bacilli
b. Hold Anti-TNF therapy (infliximab)
c. Start 1st line anti-tuberculous therapy: INH,
rifampin, ethambutol and Pyrazinamide.

Good luck
DrDahhan

OSCESimulation1

January19th2009