OSCE SERIES ( Questions & Answers ) - Set 3.pdf

Q1.
A 30 year old male presented with history of chronic diarrhea and
weight loss. Investigations showed iron deficiency anemia , poorly
responsive to therapy. He also has autoimmune thyroid disease and a
skin disease with vesicles and severe pruritus.
1. What is the probable diagnosis ? 1
2. Mention some investigations that can be done. 2
3. What is the skin disease likely to be ? 1
4. What are the treatment options ? 1

Answers
1. Celiac disease
2.
● Tissue transglutaminase IgA
antibody , IgA anti endomysial
antibody
● Tissue transglutaminase IgG
antibodies & IgG deamidated
gliadin peptide antibodies ( these
are useful in patients with IgA
deficiency )
● Endoscopy with small bowel
biopsy is the confirmatory test
3. Dermatitis herpetiformis
4.
● A strict gluten free diet
● Serologic follow up ( recommended in
patients whose symptoms resolve , to
confirm compliance with a gluten free
diet )
● Follow up biopsy ( to document
complete healing of villous atrophy )

Q2.
A 30 year old lady was admitted with tonsillitis. She was given amoxicillin clavulanic injection , and
after a few minutes , she developed generalized itching and rashes all over the body. She felt dizziness
and breathlessness. Her husband immediately rushed to the nursing station and informed the duty
nurse. The nurse examined the patient and found that she had erythematous rashes all over the body
, tachypnoea , audible wheeze and low BP.
1. What is the likely diagnosis ? 1
2. What is the drug of choice ? 1
3. Which are the second line agents to treat this condition ? 2
4. Which are the common triggers for this condition ? 1

Answers
1. Anaphylaxis to amoxicillin clavulanic acid
2. Adrenaline ( 1 : 1000 ) 0.3 - 0.5 ml IM ; Repeat the dose if necessary at 5 - 20
minute intervals. Oxygen ( titrate to SaO2 ≥ 90 % ) and IV fluids ( 1-2 L bolus ) are
also considered as first line therapies.
3. Antihistamines ( H1 blockers & H2 blockers ) , Corticosteroids , Bronchodilators
4. Foods , drugs , stings

Q3.
A 25 year old , 3 months pregnant woman came with fever and vomiting for 4 days.
Peripheral smear is shown in the figure.
1. What are the marked structures ? 1
2. Name two other tests for diagnosing this disease. 1
3.Which drug will be contraindicated in the treatment of this disease in this patient ? 1
4. Name two life threatening complications of this condition which are more common in
pregnancy. 2

OSCE SERIES ( Questions & Answers ) - Set 3.pdf

Answers
1. Crescent shaped gametocytes of Plasmodium falciparum
2.
● Rapid diagnostic tests ( detect P. falciparum–specific, histidine-rich
protein 2 (PfHRP2), lactate dehydrogenase, or aldolase antigens in
finger-prick blood samples ;
● Molecular diagnosis by polymerase chain reaction (PCR) amplification
of parasite nucleic acid
3. Primaquine
4. Renal failure , Pulmonary edema
The definitive diagnosis of malaria rests on the demonstration of asexual forms of the parasite in
stained peripheral-blood smears.

Q4.
A 66 year old male , chronic smoker
presented with worsening breathlessness
and hemoptysis for the past 6 months.
He also gave a history of weight loss. His
chest X ray is given.
1.Describe the radiological findings . 1
2. What are your differential diagnoses ?
2
3. How will you confirm the diagnosis ? 2

Answers
1. A non homogenous opacity in the right upper zone and
mid zone , with a cavitary lesion inside the opacity.
2. Malignancy , Pulmonary TB , Necrotizing pneumonia
3.
● HRCT thorax ,
● Sputum Gram stain & culture ,
● Sputum AFB , CB NAAT
● Sputum cytology ,
● Image guided biopsy

Q5.
A 35 year old female presented with bilateral maxillary sinusitis , fatigue , low
grade fever with diffuse joint pains of 6 months duration with a history of facial
puffiness and bilateral pedal edema of 2 weeks duration. The image of the
nose is shown. Work up revealed urine RBC casts and proteinuria.
1. What is your likely diagnosis ? 1
2. What is the deformity seen in the image ? 0.5
3. Outline the diagnostic approach in this case ? 1.5
4. Develop a management plan for this patient. 2

Answers
1. Granulomatosis with polyangiitis ( GPA )
2. Saddle nose deformity
3.
● Perform CBC , ESR , CRP , Urine RE , Rheumatoid factor , ANA , cANCA ,
pANCA , CXR PA , CT PNS
● Rule out renal , cardiac and hepatic causes of edema
● Biopsy of sinus tissue to look for granulomas

4.
Non organ threatening GPA: Methotrexate with with steroids - If remission
attained , continue Methotrexate with or without low dose steroids. If
refractory , consider rituximab , azathioprine or cyclophosphamide with
steroids
Systemic or organ threatening steroids : Cyclophosphamide or Rituximab with
steroids - If remission attained , continue Rituximab , Methotrexate or
Azathioprine with or without low dose steroids. If refractory , consider
cyclophosphamide or rituximab depending on initial agent chosen , otherwise
consider unproven therapies

Q6.
A 55 year old lady having CKD presents to the emergency department with
complaints of dizziness and palpitations. Her blood pressure is 100/48 mm of
Hg. She has missed her last session of dialysis. Her ECG is as seen in the
picture.
1. What are the ECG findings ? 1
2. What are the other ECG changes in the above condition ? 1
3. What is the antidote in the above situation ? Mention the preparations
available. 1
4. What is the definitive treatment of the above problem ? 1
5. What are the other treatment options ? 1

Answers
1. Tall symmetrically peaked T waves
2.
● T wave widening / flattening
● PR prolongation
● Bradyarrhythmias ( sinus
bradycardia , AV blocks )
● Conduction blocks ( bundle branch
blocks , fascicular blocks )
● QRS widening with bizarre QRS
morphology
3. Intravenous calcium ; Calcium
gluconate & calcium chloride
4. Hemodialysis
5.
● Administration of insulin & dextrose
● Administration of beta 2 agonists
● Administration of cation exchange
resins

Q7.
A 35 year old man presented with a history of fever , myalgia and skin
rashes of 3 days duration. On examination , the following lesion was
seen ( image next slide )
1.What is the most likely diagnosis ? 1
2.What is the causative organism and its vector ? 2
3.How will you manage such a case ? 2

Answers
1. Scrub typhus
2. Orientia tsutsugamushi ; Trombiculid mites
3. Doxycycline 100 mg BD X 7 - 15 days

Q8.
A 65 year old man was brought to the emergency department. He was waiting
at the railway station and had an episode of syncope. The doctor at the railway
station , upon examination , found that he was having low BP and so he shifted
him to the hospital in an ambulance. On examination at the emergency
department , he was found to have tachycardia , feeble pulses and tachycardia.
1. Define shock. 1
2. Which are the various types of shock ? 2
3. What is the MINUTES bundle while evaluating a patient with
undifferentiated shock ? 2

Answers
1.Shock is the clinical condition of
organ dysfunction resulting from an
imbalance between cellular oxygen
supply and demand.
2.
● Distributive shock
● Cardiogenic shock
● Obstructive shock
● Hypovolemic shock
3. The MINUTES acronym includes seven
sequential steps which should be
performed in the first 30 min following
shock recognition:
● Maintain “ABCs”,
● INfuse vasopressors and/or fluids (to
support hemodynamic/perfusion) and
● INvestigate with simple blood tests,
● Ultrasound to detect the type of
shock,
● Treat the underlying Etiology, and
● Stabilize organ perfusion

Q9.
A 40 year old female presented with tiredness. She gave history of heavy
menstrual bleeding . On examination , she was pale. Investigations results are as
follows :
Hb - 7.6 g / dL ; TC - 6800 ; DC - P 60 L40 ; PLC - 6.0 L ; MCV - 60 fL ; RDW - 18
1. Expand MCV & RDW. 1
2. What might be the reason for thrombocytosis ? 1
3. What are the peripheral smear findings in iron deficiency anemia ? 1
4. How will you treat this patient ? 2

Answers
1. MCV - Mean corpuscular volume ; RDW - Red cell distribution
width
2. Iron deficiency anemia
3. Hypochromic microcytic red cells ; Anisopoikilocytosis ;
Thrombocytosis
4.
● Correction of anemia with oral / parenteral iron supplements
● Evaluation of heavy menstrual bleeding

Q10.
A farmer wakes up in the morning with double vision. He notices difficulty
in swallowing followed by progressive weakness of both upper limbs
followed by lower limbs over the next one hour. His sensorium is intact.
1.List the most common cause of this presentation and one additional
differential. 2
2.List two specific treatment modalities. 2
3.List two other causes of acute binocular diplopia. 1

Answers
1. Neurotoxic envenomation ; Myasthenia gravis
2. Assuming the patient has neurotoxic envenomation ,
● Neostigmine atropine combination
● Ventilatory support
● Anti snake venom
3.
● Brainstem strokes
● Multiple sclerosis

Q11.
A 16 year old girl with history of alopecia and joint pains since 6 months presented with oral
ulcers and pleuritic chest pain of 2 weeks duration.
1. What screening investigation will u do to arrive at an etiological diagnosis ? 1
2. How will u manage this patient in the absence of any organ involvement ? 1
3. The patient reports with proteinuria of 500 mg / dL after 3 months. Name one investigation
which will help in planning further management. 1
4. Four years later , this patient presents with a positive urine pregnancy test. List two
additional investigations to evaluate pregnancy specific complications. 2

Answers
1. Antinuclear antibodies ( ANA )
2. Glucocorticoids + HCQs
3. Renal biopsy
4.
● Antiphospholipid antibodies
● Antibodies to Ro

Q12.
A 40 year old female presented with fever , yellowish discoloration of eyes and tiredness.
Investigations showed a total bilirubin of 4.5 mg/ dL , ALT of 2000 U / ml and AST of 1800 U
/ mL. The physician suspected acute viral hepatitis.
1. What are the common serological tests that are done to detect the etiology of acute viral
hepatitis ? 2
2. Mention any two conditions causing elevated transaminase in 1000s. 1
3. What is the management if this patient is found to have hepatitis A ? 1
4. What is the schedule of hepatitis B vaccination in adults ? 1

Answers
1. IgM anti HAV , HBsAg , anti HCV , IgM anti HEV
2. Viral hepatitis , Ischemic hepatitis
3.
● Adequate rest
● Fluids
● Avoid hepatotoxic drugs
● Serial monitoring of LFT
● Hospitalise only if the patient is unable to take orally , has features of
encephalopathy or coagulopathy
4. 1 mL of the vaccine IM at 0 ,1 and 6 months

Q13.
A 46 year old female smoker came to the OPD with exertional breathlessness ,
which has been present on and off since she was a teenager. You advised a
spirometry. The pre and post bronchodilator values are
Pre % Predicted
( Pre )
Post % Predicted
( Post )
FEV1 2.3 L 68 % 2.74 L 81 %
FVC 3.83 L 91 % 3.98 L 94 %
FEV1 : FVC 0.64 85 % 0.66 87 %

1. What is the likely diagnosis based on the spirometry ? 2
2. How is reversibility testing done ? 1
3. Give two examples of short acting and long acting beta agonists
useful in obstructive airway diseases. 1
4. What are the pharmacologic agents approved for smoking
cessation ? 1

Answers
1. The FEV1/FVC ratio is less than 0.7 , suggesting the presence of an
obstructive airway disease. The FEV1 improved by both more than 12 %
and more than 200 mL post bronchodilator administration consistent with
significant responsiveness.
2.
● Withhold bronchodilators prior to testing ( SABA ≥ 4 hours ; LABA 24 -
48 hours )
● Measure the baseline FEV1
● Administer 200 - 400 mcg of salbutamol ( or equivalent )
● Measure the reading after 10 - 15 minutes

3.
● Short acting beta 2 agonists : Salbutamol ,
Levosalbutamol
● Long acting beta 2 agonists : Salmeterol , Formoterol
4. Nicotine , Bupropion , Varenicline

Q14.
A 50 year old lady was referred to you by a primary care doctor , as her office BP
recordings are elevated. She iis on multiple antihypertensives ( amlodipine ,
telmisartan & chlorthalidone ) . She is obese , has diabetes , dyslipidemia and
hypothyroidism.
1. What is white coat hypertension ? 1
2. Mention any two advantages of ambulatory BP monitoring ( ABPM ) ? 1
3. Define resistant hypertension ? 1
4. Briefly outline the approach to a patient with resistant hypertension ? 2

Answers
1. White Coat hypertension refers to the untreated condition in which office BP
measurements are elevated while out of office BP readings are normal
2.
● To detect white coat hypertension and masked hypertension
● To detect apparent resistant hypertension from true resistant hypertension
3. Systolic BP ≥ 140 or Diastolic BP ≥ 90 mm of Hg provided that
● Maximum recommended and tolerated doses of a three drug combination
including a RAS blocker , a CCB or a thiazide / thiazide like diuretic were used
● Inadequate BP control has been confirmed by ABPM
● Various causes of pseudo resistant hypertension and secondary hypertension
have been excluded

4.
● Rule out pseudo resistant hypertension
● Optimize lifestyle changes and ongoing drug therapy
● Treat the comorbidities of the patient
● If the patient is having eGFR ≥ 30 mL / min / 1.73 m2 , and BP is not
controlled with ACE i/ARB + CCB + thiazide or thiazide like diuretic ,
add either spironolactone or a beta blocker or alpha 1 blocker or a
centrally acting agent or consider renal denervation
● If the eGFR < 30 mL / min / 1.73 m2 , and the BP is not controlled
with ACE i/ARB + CCB + loop diuretic , consider adding either a
thiazide or thiazide like diuretic or a beta blocker or alpha 1 blocker
or a centrally acting agent

Q15.
1. Mention any two indications for lumbar
puncture ? 2
2. What are the structures pierced while
performing lumbar puncture ? 1
3. What is the normal CSF opening
pressure ? 1
4. Mention the CSF findings in bacterial
meningitis ? 1

Answers
1.
● Suspected meningitis / meningoencephalitis
● Intrathecal administration of drugs ( like anaesthetics , chemotherapeutic
agents )
2. Skin , superficial fascia , Supraspinous ligament , Interspinal ligament ,
Ligamentum flavum, Dura mater , Epidural space , Arachnoid mater
3. 50 - 180 mm of H2O
4. Elevated CSF opening pressure , Polymorphonuclear leucocytosis , Elevated
protein levels , hypoglycorrhachia

Q16.
The egg of a roundworm that infects
humans is shown.
1. Which is the roundworm ? 1
2. How does it enter the humans ? 1
3. List two symptoms of infection. 2
4. How will you treat ? 1

Answers
1. Ancylostoma duodenale
2. The infectious filariform
larvae penetrate the skin
( and reach the lungs by
way of blood stream.
There they invade the
alveoli and ascend the
airways before being
swallowed and reaching
the small intestine )
3.
● Iron deficiency anemia
● Hypoproteinemia
● Pruritic maculopapular dermatitis ( ground
itch ) at the site of skin penetration
● Mild transient pneumonitis
● Epigastric pain , inflammatory diarrhoea (
in the early intestinal phase )
4.
● Albendazole 400 mg ( single dose ) or
Mebendazole 500 mg ( single dose )
● Treatment of iron deficiency anemia
● Nutritional support

Q17.
A 40 year old alcoholic on binge drinking for the past 4 hours starts to vomit over the last one
hour.
1. Emergency room ABG showed : pH - 7.55 , pCO2 - 47 mm of Hg , HCO3 - 40 meq/L , Cl - 80
meq/L , K - 2.8 meq/L , AG - 10 meq/L
a. List the abnormalities.
b. What is your diagnosis ? 2.5
2. Vomiting stopped 30 minutes after injection chlorperazine. Repeat ABG revealed pH : 7.40 ,
pCO2 - 40 mm of Hg , HCO3 - 25 meq/L , Cl - 80 meq/L , K - 4.2 meq/L , AG - 30 meq/L
a. List the changes noticed.
b. What is your diagnosis now ? 2.5

Answers
1.
a.Elevated arterial pH , elevated pCO2 , elevated HCO3 , low levels of chloride , low levels
of K+
b.Metabolic alkalosis with hypokalemia and hypochloremia ; There is compensatory
alveolar hypoventilation and hypercarbia. These abnormalities are likely due to prolonged
vomiting
2.
a.pH decreased to 7.40, HCO3 decreased from 40 to 25 and there is Increase in anion gap
b. Vomiting stopped after administration of the antiemetic agent . There is a high anion
gap metabolic acidosis now , likely due to starvation / alcoholic ketoacidosis

Q18.
1. What is the osmolarity of normal saline ? 1
2. Mention any two disadvantages of administering large
volumes of normal saline in a patient ? 2
3. Why is 5 % dextrose not used as a plasma volume
expander ? 1
4. Give two examples of balanced crystalloid solutions. 1

Answers
1. 308 mOsm/L
2.
● Hyperchloremic metabolic acidosis
● Increased risk of acute kidney injury
● A greater need for renal replacement
therapy
● Higher hospital mortality
● Coagulopathy
● Hyperkalemia
● More pronounced interstitial fluid
retention
3.
● Poor expansion of intravascular
volume
● Increased urine output due to
osmotic diuresis
4.
● Ringer’s lactate
● Plasma-Lyte

Q19.
A 24 year old male presented with complaints of headache and palpitations. History of
bleeding from gums present.
On examination , pallor + ; HR - 120 / min ; afebrile
Hb - 4.7 g/dL ; Reticulocyte count - 18.7 % ; PLC - 10,000 cells /cumm ; S.Cr - 1.4 ; Indirect
bilirubin - 3.2 mg/dL ; LDH - 1885 U/L
PT , INR & aPTT - Normal ; Direct Coombs test - Negative
Peripheral smear is shown in the next slide
About four hours after admission , patient developed word finding difficulty. CT head -
unremarkable
ADAMTS13 : < 10 %

1. What is the significance of Direct Coombs test ? 1
2. What is ADAMTS13 ? 1
3. What are the findings in peripheral smear ? 1
4. What is the likely diagnosis ? 1
5. How to treat this patient ? 1

Answers
1. To detect the presence of antibodies bound to red blood
cells - a useful test in autoimmune hemolytic anemia
2. ADAMTS13 ( a disintegrin and metalloproteinase with
a thrombospondin type 1 motif, member 13 )- this
enzyme degrades large von Willebrand multimers , thereby
decreasing their activity
3. Schistocytes ( helmet cells )
4. Thrombotic thrombocytopenic purpura
5. Plasma exchange

Q20.
A 56 year old man is admitted to the hospital with worsening dyspnoea
and 8 kg weight gain and is diagnosed with acute decompensated heart
failure ( ADHF ).
1. What are the common factors precipitating heart failure
hospitalisation with ADHF ? 1
2. Comment about the use of diuretics in this patient. 2
3. Which are the 4 stages of heart failure ? 2

Answers
1. Acute coronary syndromes , Uncontrolled hypertension , Atrial
fibrillation , Anemia
2.
● Prompt treatment with intravenous loop diuretics is necessary
● At least 2 times the daily home diuretic dose is to be administered
intravenously
● Diuretics may be given either as bolus or as continuous infusion
● Diuretics should be given at the time of discharge as well

3.
Stage A : At risk for heart failure : No symptoms , evidence of structural heart disease or
cardiac biomarkers of stretch or injury
Stage B : Pre Heart failure : No symptoms or signs , but at least one of the following
● structural heart disease ,
● evidence for increased filling pressures or
● patients with risk factors and increased levels of BNPs or persistently elevated cardiac
troponin
Stage C : Structural disease with current or previous symptoms of heart failure
Stage D : Marked heart failure symptoms that interfere with daily life and with recurrent
hospitalizations despite attempts to optimize GDMT

OSCE SERIES ( Questions & Answers ) - Set 3.pdf

More Related Content

More from Jim Jacob Roy (20)

Recently uploaded (20)

OSCE SERIES ( Questions & Answers ) - Set 3.pdf