OSCE SERIES ( Questions & Answers ) - Set 5.pdf

Q1.
Given below are the blood reports
of a diabetic patient admitted with
seizures.
Blood sugar : 720 mg / dL
Blood urea nitrogen : 180 mg / dL
Serum creatinine : 2.8 mg / dL
Serum sodium : 155 meq/L
Serum potassium : 6 meq / L
1. What is the difference between
osmolality and osmolarity ? 1
2. What is the normal plasma osmolality
? Mention any two causes of increased
osmolality. 2
3. What is the plasma osmolality of this
patient ? 1
4. What is the formula for calculating
corrected sodium ? 1

Answers
1. Osmolarity : the number of
particles of solute per liter of
solution.
Osmolality : the number of
particles of solute per kilogram of
solvent.
2. The normal serum osmolality
ranges from 275 to 295 mOsm/kg.
Osmolality is increased in
hyperglycemia & hypernatremia
3. Calculated serum osmolality =
(2 x serum [Na]) + [glucose, in mg/dL]/18 +
[blood urea nitrogen, in mg/dL]/2.8
Here , ( 2 x 155 ) + ( 720/18 ) + ( 180 / 2.8 ) =
310 + 40 + 64.2 = 414.2 mOsm/kg
4. Plasma Na+ concentration falls by
~1.6–2.4 mM for every 100-mg/dL increase
in glucose, due to glucose-induced water
efflux from cells. Here , the corrected
sodium is 165 - 170 mEq/L

Sodium correction for hyperglycemia

Q2.
A young male was brought to the emergency department in a
confused state. He had hyperventilation , poor coordination ,
decreased vision , hypothermia and severe metabolic acidosis on
ABG. His relatives informed that he is a chronic alcohol user.
1. What might be the diagnosis ? 1
2. What is the treatment ? 3
3. What is the prognosis in this condition ? 1

Answers
1. Methanol poisoning
The diagnostic clues are history of alcohol abuse , confusion , visual impairment and severe
metabolic acidosis.
2.
● Admit the patient in an ICU
● Correct the metabolic acidosis ( by IV bicarbonate infusion )
● Metabolic blockade with either fomepizole or ethanol ( to prevent the formation of
formic acid , which is the toxic metabolite of methanol )
● Hemodialysis if necessary
● Vitamin therapy - either folate or folinic acid ( helps to break down formic acid , the
toxic metabolite into carbon dioxide and water )
3. Visual impairment can be a permanent complication of methanol poisoning

Q3.
A 58 year old woman presented to the emergency department with
complaints of chest pain and breathlessness of 6 hours duration. A 12 lead
ECG was taken , which showed ST elevation in the anterior leads.
The patient was shifted to the cath lab and a coronary angiogram was
done , but no obstructive lesions were seen in the coronaries.
A ventriculography was done and the images are shown in the next slide.

Ventriculography in RAO view
showing motion abnormalities of
the left ventricle.
(A) end-diastole,
(B) end-systole,
(C) the same image seen in A but
with enhanced endocardial
border which shows normal
cavity contours, and
(D) the same image seen in B but
with enhanced endocardial
borders showing a pattern of
apical ballooning, impaired
mid-ventricular contractility
and normal motion of the basal
segments.

1. What is the likely diagnosis ? 1
2. How to treat this condition ? 2
3. Which are the various causes of ST segment elevation in ECG ? 2

Answers
1. Takotsubo syndrome ( Broken heart syndrome )
2.
● Admit the patient in a coronary care unit
● Supportive care
● ACE inhibitor / ARB
● Beta blocker
● Diuretics
● Nitroglycerin
● Treat arrhythmias and thromboembolic
complications
● Treat associated diseases like CAD and Depression /
anxiety
3.
● Acute myocardial infarction
● Left ventricular hypertrophy
● Left bundle branch block
● Brugada syndrome
● Benign early repolarization
● Acute pericarditis
● Ventricular aneurysm

MANAGEMENT OF TAKOTSUBO SYNDROME

A 20 year old lady presented with bleeding from the oral cavity and petechiae on limbs. No
history of recent fever.
There is no pallor / splenomegaly.
CBC is normal except for thrombocytopenia ( PLC - 25,000 cells/microL ). LFT - Normal ; LDH -
Normal
Peripheral smear - Occasional large platelets and thrombocytopenia. RBCs and leukocytes
normal.
Serologic tests for infections - negative
ANA - negative
Bone marrow - Increased number of megakaryocytes
Q4.

2. What is the significance of ANA testing in this patient ? 1
3. Mention any 4 causes of thrombocytopenia. 1
4. How to manage this patient ? 2

Answers
1. Immune thrombocytopenic purpura
( ITP )
2.
● Patients with SLE can have secondary ITP. So
ANA can be used as a screening test for SLE in
patients presenting with ITP.
● Patients with primary ITP may also have
positive ANA. Patients with primary ITP with
positive ANA are at significantly increased risk
of developing connective tissue diseases,
especially SLE.
3. Infections , Drugs , Thrombotic
thrombocytopenic purpura (TTP ) ,
Disseminated intravascular coagulation (
DIC )
4.
● A short course of corticosteroids is
required .
● Frequent monitoring of platelet count
and to decide regarding alternative
therapies based on the response to
treatment

American Society of Hematology 2019 guidelines for immune thrombocytopenia

OSCE SERIES ( Questions & Answers ) - Set 5.pdf

Q5.
A 50 year old male presented to the
emergency department with shortness
of breath of 2 weeks duration and
edema of lower extremities of 1 week
duration. On examination , he was
found to have bilateral pitting edema
upto knees , elevated JVP , bibasal
crackles and S3 gallop.
A chest X ray was taken which is shown.

1. What are the radiologic findings ? 2
3. Mention the etiologies of this condition. 1
4. What are the classic JVP abnormalities seen in this condition ? 1

Answers
1. Pericardial calcifications , Increased cardiothoracic ratio , Prominent central
vessels , Right sided pleural effusion & basal atelectasis
2. Constrictive pericarditis ( patient is in congestive heart failure )
3. Tuberculosis , Idiopathic pericarditis , Viral pericarditis , Mediastinal
irradiation , Neoplastic disease
4. Elevated JVP ( JVP does not decrease with inspiration - Kussmaul’s sign ) ; A
prominent y descent ( Friedreich’s sign )
● Kussmaul’s sign is also seen in tricuspid stenosis , RV infarction and restrive
cardiomyopathy
● Pericardial calcification is most common in tuberculous pericarditis

Q6.
A 40 year old diabetic male presented
with vesicles on the right side of chest
associated with severe pain.
1.What is your diagnosis ? 1
2.Write a prescription for this patient. 2
3.Mention the most common
complications of this disease. 2

Answers
1. Herpes zoster
2.
# Acyclovir 800 mg 5 times daily for 7 - 10 days
Or
# Valacyclovir 1 g TDS daily for 5 - 7 days.
Valacyclovir, the prodrug of acyclovir, accelerates
healing and resolution of zoster-associated pain
more promptly than acyclovir.
# Analgesics for pain
3.
- Pain associated with acute neuritis and
post herpetic neuralgia
- Meningoencephalitis , Granulomatous
angiitis , Transverse myelitis , Cutaneous
dissemination ( in immunocompromised
individuals )

Q7.
A 26 year old male presented with 5 day
history of high grade fever , right upper
abdominal pain & vomiting. He consumes
alcohol in moderate to large amounts for 5
years. On examination , he was febrile with
tender hepatomegaly. The CT abdomen of the
patient was taken and is shown below.
1. Describe the CT findings 2
2. What is the most likely diagnosis ? 1
3. Describe the management. 2

ANSWERS
1. CT abdomen ( axial view ) showing a hypoattenuated lesion in the liver
2. Liver abscess ( based on the clinical picture and radiologic findings )
3.
● Identification of the source of infection ( biliary tract / pelvic infection etc )
● Aspiration of the lesion for microbiology and culture
● Treatment with appropriate antibiotics.
● For large abscesses , drainage may be required. Drainage approach may be
percutaneous , transluminal or surgical.

Liver abscess : Antibiotic treatment using a combination of two or more antibiotics is
recommended. Metronidazole and clindamycin provide wide anaerobic coverage and
excellent penetration into the abscess cavity. Third-generation cephalosporins and
aminoglycosides are very effective against most Gram-negative organisms.
Bailey & Love's Short Practice of Surgery 28th Edition
Liver abscess : Cefoperazone-sulbactam or piperacillin-tazobactam with metronidazole
to cover for possible bacterial and amoebic etiology. The treatment should be changed
as per culture report and amoebic serology subsequently.
ICMR Treatment Guidelines for antimicrobial use 2022

Q8.
A chronic alcohol user was brought to the emergency department with history of
altered behaviour. On examination , he was confused , icterus + , bilateral pitting pedal
edema + , flapping tremor + and shifting dullness. A USG abdomen showed features of
chronic liver disease , splenomegaly and ascites.
The image shown is that of his abdomen.
1. What are the various physical examination findings that are seen in patients with
CLD ? 2
2. What does the image ( next slide ) show ? How does it occur ? 1
3. What is the complication which the patient is having ? What are it's risk factors ? 2

Answers
1. Icterus , Palmar erythema ,
Dupuytren's contracture ,
Leuconychia , Alopecia , Parotid gland
enlargement , Spider naevi ,
Gynecomastia , Ascites , Testis
atrophy , Umbilical hernia , Caput
medusae , Asterixis
2. Caput medusae ; Portal hypertension
3. Hepatic encephalopathy ;
The risk factors include
● Hypokalemia,
● Infection
● An increased dietary protein
load
● Volume depletion.

Portal hypertension is defined as increase in the portal venous
pressure resulting the formation of dilated veins at the site of
porto-systemic venous anastomosis causing shifting of the blood
flow from the portal venous system to the systemic circulation.
The sites of portosystemic anastomoses are shown in the table in the next slide

Q9.
A patient came to the OPD with the
following report :
Hb - 20 g/dL ; TC - 17,000 cells/mm3 ;
PLC - 500 x 103 cells / mm3
On examination , he was found to have
splenomegaly.
The physician decided to work up the
patient for polycythemia vera ( PV ).
1. What is the cut off for
hemoglobin in polycythemia vera
? 1
2. Which is the most common
gene mutation associated with
PV ? 1
3. How to treat PV ? 2
4. Long term complications of PV
? 1

Answers
1.Hb > 16.5 g/dL in men
Hb > 16 g/dL in women
2. JAK2 V617F
{ A point mutation that replaces the amino
acid valine (V) with phenylalanine (F) at
position 617 of the JAK2 gene }
3.
● Periodic phlebotomies to maintain the Hb
level ≤ 14 g/dL in men and ≤ 12 g/dL in
women.
● Ruxolitinib ( A non specific JAK inhibitor )
● Hydroxyurea ( a cytotoxic agent )
4.
● Thrombotic complications
● Myelofibrosis
● Acute leukemias
● Pulmonary hypertension

Q10.
A patient with COPD has MMRC grade IV dyspnoea and a resting
oxygen saturation of 84% at room air.
1. Is this patient a candidate for domiciliary oxygen therapy ? 1
2. What are the indications of domiciliary oxygen therapy ? 1.5
3. Which are the vaccines recommended in COPD patients ? 1.5
4. Are inhaled corticosteroids recommended for all COPD patients ? 1

Answers
1. Yes
2. Supplemental oxygen therapy should be considered when
● PaO2 ≤ 55 mm of Hg or SaO2 < 88 %
● PaO2 > 55 but < 60 mm of Hg with right heart failure or erythrocytosis
3. Influenza vaccine , COVID 19 vaccine , Pneumococcal vaccine , Vaccine
against Respiratory syncytial virue , Vaccine against pertussis , Zoster
vaccine
4. No

Q11.
A 30 year old male presented with
dysphagia.
1. What is the investigation done ? 1
2. What is the diagnosis ? 1
3. What are the treatment options ? 2
4. How is dysphagia classified ? 1

Answers
1. Barium swallow
2. Achalasia cardia
3.
● Pharmacologic therapies ( Nitrates
or CCBs , Botulinum injection under
endoscopic guidance , Sildenafil ) ;
● Endoscopic pneumatic dilatation
● Laparoscopic Heller myotomy
4.
Dysphagia can be classified as
● Oropharyngeal ( dysphagia localised
to neck ; nasal regurgitation ,
aspiration , associated ENT symptoms
present )
● Esophageal ( dysphagia localised to
chest or neck ; food impaction is
common )
This again can be subclassified as
structural or propulsive

Q12.
1. Mention any two indications of this
procedure. 1
2. What are the complications
associated with this procedure ? 1
3. What is Lights criteria ? 2
4. Mention any 2 etiologies of
exudative pleural effusion and
transudative pleural effusion. 1

Answers
1. Diagnostic - To aid in the etiologic
evaluation of pleural effusion
Therapeutic - Symptomatic relief of
dyspnoea in large pleural effusions
2.
● Bleeding , pain & infection at the site
of needle entry
● Pneumothorax
● Splenic / hepatic injury
● Re expansion pulmonary edema ( if
too much fluid is removed or if the
fluid is removed too rapidly )
3. Light’s criteria helps to determine if a pleural
effusion is exudate or transudate.
● Pleural fluid protein/serum fluid protein ratio:
Greater than 0.5
● Pleural fluid lactate dehydrogenase
(LDH)/serum fluid LDH ratio: Greater than 0.6
● Pleural fluid LDH: Greater than 2/3 the upper
limit of the laboratory's reference range of
serum LDH
Exudative pleural effusions meet at least one of the
following criteria, whereas transudative pleural
effusions meet none.

● These criteria misidentify ~25%
of transudates as exudates.
● If one or more of the exudative
criteria are met and the patient
is clinically thought to have a
condition producing a
transudative effusion, the
difference between the protein
levels in the serum and the
pleural fluid should be
measured. If this gradient is >31
g/L (3.1 g/dL), the exudative
categorization by these criteria
can be ignored because almost
all such patients have a
transudative pleural effusion

Q13.
28 yr old male presented with 4 month history of recurrent fever,
night sweats & cervical lymphadenopathy. The picture of his lymph
node biopsy given below
1. What is the characteristic finding in this? 1
2. What is the probable diagnosis? 1
3. What staging investigation will you do? 1
4. What is the treatment regimen? 2

Answers
1. Reed Sternberg cell
2. Hodgkin's lymphoma
3. PET/CT
4. ABVD regimen is most commonly used. It combines the drugs
doxorubicin, bleomycin, vinblastine, and dacarbazine.

Q14.
A 60 year old lady presented with the following report.
LDL C - 150 mg /dL ; Triglycerides - 300 mg/dL ; HDL C - 30 mg /d
1. Calculate the total cholesterol level of this patient. 1
2. Mention the various lifestyle modifications recommended to lower LDL C . 1
3. Mention any two side effects of statin therapy. 1
4. What is the mechanism of action of
a. Ezetimibe
b. Bempedoic acid. 2

Answers
1. The total cholesterol is
calculated using the formula
Total cholesterol = LDL
cholesterol + HDL cholesterol
+ ( Triglycerides / 5 )
Here , Total cholesterol = 150
+ 30 + ( 300/5 ) = 240 mg/dL
2.
● Avoid dietary trans fats ,
● Reduce dietary saturated fats ,
● Increase dietary fibre ,
● Use functional foods enriched
with phytosterols ,
● Reduce excessive body weight ,
● Increase habitual physical
activity

3. Myopathy , Elevation in the levels of transaminases
4.
a. Ezetimibe : Inhibits the intestinal cholesterol absorption
b. Bempedoic acid : Inhibits cholesterol synthesis by inhibiting the
enzyme ATP citrate lyase

Q15.
A renal transplant patient presented with heartburn and dysphagia. He is on
immunosuppressive agents ( prednisolone , tacrolimus and mycophenolate ).
An upper GI endoscopy was performed which showed extensive longitudinal
esophageal deep ulceration and whitish plaque in the mid and distal
esophagus.
The histopathological exam of the esophageal biopsy showed ulcerated
esophageal mucosa with viral inclusion-like structures in the epithelium,
suggestive of virus-induced esophagitis.

1. Which are the most common pathogens that cause opportunistic infections in the early post
transplant period ( 1 - 6 months ) ? 1.5
2. Which are the various manifestations of CMV infection in transplant patients ? 1.5
3. Which are the antivirals useful in the above scenario ? 1
4. Which are the major causes of death in kidney transplant recipients ? 1

Answers
1. Pneumocystis carinii , CMV , Legionella , Listeria ,
Hepatitis B , Hepatitis C
2. Asymptomatic viremia , Fever , Leukopenia , Hepatitis ,
Gastroenteritis , Retinopathy
3. Ganciclovir , Valganciclovir
4. Cardiovascular events , infection , and malignancy are the
major causes of death in kidney transplant recipients

Q16.
A 28 year old lady presented to the OPD with pain and swelling in the left lower limb of 1 week
duration.
She gave history of 3 spontaneous abortions.
A Venous Doppler was done which showed deep vein thrombosis.
2. What is the criteria to diagnose this condition ? 2
3. How to treat this condition ? 1
4. Suppose this patient presents with the skin lesion shown in the image. What is the skin lesion ? 1

Answers
1.Antiphospholipid syndrome
3. This patient with has an unprovoked venous thrombosis
, so vitamin K antagonists should be given lifelong , with a
target INR of 2 - 3
4. Livedo reticularis

2. The presence of at least
one clinical and one
laboratory criterion is
compatible with the
diagnosis, in the absence of
other thrombophilia
causes.

Q17.
A 24 year old female is scheduled to undergo flexible sigmoidoscopy because of bloody bowel
movements of 4 days duration. She had diarrhea for about 10 days , but 4 days ago she
developed frequent low volume bloody stools that are associated with urgency. Upon enquiry ,
she informed that she has had 4 episodes of bloody diarrhea in the preceding 6 months.
The sigmoidoscopy revealed inflammatory changes in the rectum to 20 cm with no areas of
normal intervening mucosa.
1. Mention the differential diagnoses of bloody diarrhea 2
2. What is the probable diagnosis here ? 1
3. How to treat this patient ? 2

Answers
1.
● Infections ( E.coli ,
Campylobacter , Salmonella ,
Shigella )
● Ischemic colitis
● Inflammatory bowel disease
● Diverticulitis
● Colon cancer
2. Ulcerative colitis
3.
● 5 ASA agents
● Glucocorticoids
● Depending on the response to
treatment , other classes of
drugs ( like azathioprine ,
biologics , tofacitinib ) can be
used )

Q18.
A staff nurse accidentally suffered a needle stick injury , after collecting the blood of an HIV
positive patient. The nurse sustained a deep injury with the needle.
The patient was not on ART and the CD4 T cell count was low.
After applying proper first aid , the nurse came to you. You are the designated physician to
help the staff with such events.
1.How to decide regarding post exposure prophylaxis in an exposed individual ? 2
2. What is the recommended first line regimen for post exposure prophylaxis ? 1
3. What is the recommended duration of post exposure prophylaxis ? 1
4. Assuming that the blood collected from this patent spills to the floor of the hospital ,
what all should be done ? 1

Answers
1.
○ Assess the severity of exposure and risk
of transmission.
○ The category of exposure may be mild ,
moderate or severe. The exposure can
be coded as EC 1 , EC 2 or EC 3.
○ The source of exposure may be an HIV
negative , or HIV positive ( the source
may be coded as SC 1 or SC 2 )
○ Post exposure prophylaxis is
recommended as per the table shown.
2. Tenofovir ( 300 mg ) ,
Lamivudine ( 30 mg ) &
Dolutegravir ( 50 mg ) - as fixed
dose combination ( FDC ) ,once
daily
3. 28 days

Q19. See the attached video ( Extensor plantar
response )
1. What is being elicited here ? 1
2. Mention any two situations where sign is seen. 2
3. Which are the various methods of eliciting this ? 2

Answers
1. Extensor plantar response ( Babinski sign )
2. Stroke , Multiple sclerosis
The plantar reflex is a nociceptive segmental spinal reflex that serves the purpose of
protecting the sole of the foot. The clinical significance lies in the fact that the
abnormal response reliably indicates metabolic or structural abnormality in the
corticospinal system upstream from the segmental reflex. Thus the extensor reflex has
been observed in structural lesions such as hemorrhage, brain and spinal cord tumors,
and multiple sclerosis, and in abnormal metabolic states such as hypoglycemia,
hypoxia, and anesthesia

Q20. See the attached video ( Left sided LMN
facial palsy )
1. Describe the examination findings ? 3
2. Mention any two causes for this. 2

Answers
1. Absence of wrinkles on forehead on left side , Inability to
close the eye on left side , Absent nasolabial fold on left side
, Deviation of angle of mouth to right side : The overall
picture is suggestive of left sided LMN facial palsy.
2. Bell’s palsy , Ramsay Hunt syndrome

OSCE SERIES ( Questions & Answers ) - Set 5.pdf

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OSCE SERIES ( Questions & Answers ) - Set 5.pdf