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

2. Case 23
A middle age man with severe back pain, polydipsia and polyuria.

3. Lab findings Hb= 9.4 gr/dl, RBC=3.1x10 6 , MCV=102,
MCH, MCHC= normal , PLT=
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

4. What is your diagnosis? Metastasis to lumbar spine
Idiopathic hypercalcemia
Primary polydipsia
Multiple myeloma
Chronic lymphocytic leukemia

5. Case 24
A middle age man presented with acute dyspnea (Figure A). After diuretic therapy and TNG infusion his symptoms relieved, (Figure B).

6. What do you see in the radiographs ?
Round Pneumonia
Pulmonary metastasis (cannon ball)
Pulmonary tumor
Pnemothorax
Pulmonary edema
Pulmonary edema with pleural effusion

7. Case 25
a young man presented with bloating and epigastric tenderness. You see the endoscopic view of antrum.

8. What is your endoscopic diagnosis?
Lymphoid hyperplasia
Raised erosions
Ulcer
Fine nodularity
What is the most probable cause?
Drug reaction
Helicobacter pylori
Eosinophilic gastroenteritis

9. 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.

11. 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

12. 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.

13. A barium enema was performed:

14. Colonoscopy and biopsies from the stenotic area revealed inflammation, depletion of goblet cells, granuloma and ulceration.
No dysplasia was observed.

15. 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

16. 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

17. 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.

18. 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)

19. What is the next step in management?
Evaluation for possible liver transplant
Start prednisolone
Check for 24 h urinary copper
All of the above

20. Case 29
A 78 years old man presents with longstanding history of heartburn.
Physical examination is unremarkable.
You see the upper GI endoscopy:

21. 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

22. Case 30
A young lady with acute dysphagia after recurrent vomiting. She is taking warfarin.
You see the endoscopic view.

23. 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

24. Case 31
An old female underwent hepatic transplantation because of liver failure .
On 7th day of admission she developed fever and increasing jaundice.

25. 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

26. Case 32 A young man presented with RUQ pain.
He had history of jaundice 6 months ago.
Span of liver is 16 cm.
AST= U/L
ALT= 23 U/L
ALP = 380 U/L
Bilirubin T = 2 mg/dl

27. What is your diagnosis? What is the management? Liver abcess
Liver cystadenocarcinoma
AD Polycystic kidney disease
What is the management?
Albendazole
Surgical removal
PAIR

28. Case 33
You see the barium swallow and endoscopic picture of distal esophagus in a 35 lady with progressive dysphagia to liquids.

29. 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

30. Case 34
A patient with fever, RUQ pain, and ichterus from 3 months ago.
Liver pathology is shown.

31. What is the diagnosis? What is the treatment? Liver shistosomiasis
Hydatid cyst
Tuberculoma
Sarcoidosis
What is the treatment?
Metronidazole
Albendazole
Isoniazid
Steroid
Praziquantel