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 therapy of choice? 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, peg-interferon 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 best management? 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 best management? 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 the best management? 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? What is the management? 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 you treatment of choice? 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? What is the treatment? Liver shistosomiasis Hydatid cyst Tuberculoma Sarcoidosis What is the treatment? Metronidazole Albendazole Isoniazid Steroid Praziquantel