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. 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.

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. 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.

23. 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 : +

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. 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.

28. 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

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