OSCE Series ( Questions & Answers ) - Set 6.pdf

1
A 45 year old patient presented to the OPD with episodes of
giddiness. On examination , he was found to have bradycardia.
An ECG was taken ( shown in the next slide )
1. Mention any 4 etiologies of sinus bradycardia. 1
2. Mention any 2 causes of pseudo bradycardia. 1
3. What is the ECG finding ? 1
4. How to proceed in this case ? 2

Answers
1. Hypothyroidism , Hypothermia , Sleep apnoea , Increased intracranial
pressure
2. Ventricular bigeminy , Frequent nonconducted early atrial premature beats
3. Sinus rhythm , Unifocal premature ventricular complexes in a bigeminy
fashion
4.
● Admit the patient
● ECHO to rule out structural heart disease
● Measurement of Hb , TSH , serum electrolytes
● Holter monitoring to look for significant arrhythmias
● Rule out other causes of syncope also

2
An 8 year old child was brought to the OPD by parents with complaints of
decreased height for age. Parents told that the child has history of recurrent
fractures and is on vitamin D supplements. Her CBC was normal. She had
normal blood sugars , hypokalemia , a low urine pH , glycosuria and
phosphaturia. An ABG was done which showed normal anion gap metabolic
acidosis. X rays showed severe osteopenia.
1. What is the likely diagnosis ? 1
2. What are the factors contributing to osteopenia ? 1.5
3. How does hypokalemia occur in this condition ? 1.5
4. Mention any 4 causes of non anion gap metabolic acidosis. 1

Answers
1. Renal tubular acidosis ( Proximal RTA
due to Fanconi syndrome )
2.
● Chronic metabolic acidosis increases
alkali mobilization from the bone and
thus demineralisation of bone
● Chronic hypophosphatemia due to
renal phosphate wasting
● Reduced level of the active form of
vitamin D because of the inability of the
proximal tubule to convert 25 ( OH )
vitamin D to 1,25 (OH)2 vitamin D
3.Due to loss of NaHCO3 in the urine , there is
intravascular volume depletion. This leads to
activation of renin angiotensin aldosterone
system. Due to impaired proximal reabsorption
of sodium , there is increased distal delivery of
sodium. Because of the associated
hyperaldosteronism and increased distal
nephron Na+ reabsorption, there is increased
K+ secretion. The net result is renal potassium
wasting and the development of hypokalemia.
4.Diarrhoea , Renal tubular acidosis , Drug
induced hyperkalemia , Mineralocorticoid
resistance

CAUSES OF NON ANION GAP
METABOLIC ACIDOSIS

3
A 60 year old man came to the OPD complaining of inability to attain a
firm erection over the last few months. He is a smoker , and has DM and
CAD. The physical examination of the genitalia was within normal limits.
1. What is the likely cause of erectile dysfunction ( ED ) in this patient ? 1
2. Which are the drugs associated with ED ? 1
3. Mention any 3 pharmacologic agents approved to treat ED ? 1.5
4. What are the interventions other than pharmacologic agents useful in
ED ? 1.5

Answers
1. Vasculogenic ( atherosclerosis due to DM & smoking )
2. Antidepressants ( SSRIs , TCAs ) ; Antihypertensives ( Thiazide
diuretics , Beta blockers )
3. Sildenafil , Tadalafil , Vardenafil , Avanafil
4. Vacuum constriction devices , Surgery ( implantation of a
semirigid or inflatable penile prosthesis / vascular surgery ) ,
Sex therapy

4
A patient with DM , HTN , coronary artery disease and chronic liver disease
presented to the emergency dept with gradually progressing breathlessness. A
chest X ray was taken ( shown in the next slide )
1. What will be the examination findings in this case ( palpation , percussion
and auscultation of the chest ) ? 3
2. How to differentiate between hepatic hydrothorax and pleural effusion due
to heart failure ? 1
3. Assuming this is hepatic hydrothorax , how will you manage ? 1

Answer
1.
● Palpation - Decreased chest
expansion & Decreased vocal
fremitus on right side
● Percussion - Dull note to percussion
on right side
● Auscultation - Decreased breath
sounds , Decreased vocal resonance
on right side
2.
● Clinical assessment
● Serum and pleural fluid NT proBNP
3.
- Thoracentesis as the pleural effusion
is symptomatic
- Dietary sodium restriction
- Diuretics
- Appropriate management of CLD
Serum / Pleural fluid assay of
NT-pro BNP > 1500 pg/mL is
suggestive of pleural effusion due
to heart failure.

5
A 60 year old lady came to the OPD complaining of low back ache. The
physical examination was unremarkable. The X ray of the LS spine showed
osteopenia. You decided to do lab tests. You asked the patient to perform
CBC , RBS , RFT , TSH & Vitamin D.
1. Which is the blood test done to assess vitamin D deficiency ? o.5
2. Which are the major causes of vitamin D deficiency ? 2
3. How to treat vitamin D deficiency ? 1.5
4. How to assess the response to treatment ? 1

Answer
1. 25 ( OH ) vitamin D
2. Impaired cutaneous production , Liver disease , Chronic Kidney
Disease
3.
● Assess the cause of vitamin D deficiency and appropriate
management
● Vitamin D & calcium supplementation
➔ If the pathway required for vitamin D activation is intact ,
severe vitamin D deficiency be treated with pharmacologic
repletion initially ( 50,000 IU weekly for 3-12 weeks ) ,
followed by maintenance therapy ( 800 IU /day )
➔ Calcium supplementation should include 1.5 - 2 g/day of
elemental calcium
4.
● Measurement of serum
and urinary calcium
levels. In patients who
are vitamin D replete and
are taking adequate
calcium supplementation
, the 24 hr urinary
calcium level should be in
the range of 100 - 250
mg / 24 hours.
● Vitamin D levels should
be rechecked 3 months
after initiating
supplementation

6
A 70 year old male came to the OPD with tiredness. On examination , he was pale.
Upon enquiry , he reported the passage of black tarry stools for the last 2 months.
You ordered for a CBC and a stool occult blood test. The CBC showed a Hb level of
7.6 g/dL and the stool occult blood was positive.
a. List any 4 causes of melena in an elderly individual ? 2
b. Which are the clues to iron deficiency anemia in CBC ? 1.5
c. How to proceed in this case ? 1.5

Answers
1. Peptic ulcers , Esophageal varices , Erosive disease , Neoplasms
2. Anemia , Decreased mean corpuscular volume , Increased red cell
distribution width , Thrombocytosis
3.
● GI endoscopy & CECT abdomen to look for the site and etiology of
bleeding , and once the etiology is identified , its appropriate
management
● Correction of anemia

7
A 26 year old male presented with history of recurrent headache , vomiting and
seizures. The MRI of the patient is given below.
1. Comment about the MRI findings. 2
2. List any two causes for this particular lesion in an immunocompromised and
immunocompetent individuals. 2
3. Which are the treatment options for raised ICT ? 1

Answers
1.
(A) Axial contrast-enhanced T1-weighted magnetic
resonance imaging showing ring-enhancing lesions
(white arrows)
(B) Axial T2-weighted images showing ring-enhancing
lesions surrounding hyperintensity, consistent with
vasogenic edema (white arrows).
2.
● In the immunocompetent host : tumours ( primary &
metastatic ) & pyogenic abscesses
● In the immunocompromised host , toxoplasmosis &
primary CNS lymphoma
3.
● Elevate head of the bed ; Midline
head position
● Osmotic agents ( mannitol / 3 %
hypertonic saline )
● Glucocorticoids are useful in
vasogenic cerebral edema
● Sedation ; Add neuromuscular
paralytic agents if necessary
● Pressor therapy ( to maintain
adequate mean arterial pressure )
● Decompressive craniectomy
● Extraventricular drainage of CSF

8
A 40 year old male presented to the emergency department with history of gradually
progressive exertional breathlessness and edema of lower extremities. He denied history of
substance abuse. On examination , he had no pallor , bilateral pitting pedal edema , elevated
JVP and a prominent second heart sound. A 2D ECHO was taken which showed an EF of 55%
, severe right ventricular and atrial dilatation and elevated pulmonary artery pressure.
1. Mention any 4 causes of exertional breathlessness. 1
2. What are the ECG changes seen in right ventricular hypertrophy ? 1
3. How is pulmonary hypertension classified ? 2
4. Mention any two pharmacological agents approved to treat pulmonary arterial
hypertension. 1

Answers
1. COPD , Left ventricular failure ,
Interstitial lung disease ,
Pulmonary hypertension
2.
● Right axis deviation
● Dominant R wave in V1 ( R/S
ratio > 1 or R wave > 7 mm )
● Dominant S wave in V5 or V6
( S wave > 7 mm or R/S < 1 )
● QRS duration < 120 ms
3. Pulmonary hypertension ( PH ) is divided
into 5 categories (as per the Sixth World
Symposium on Pulmonary hypertension 2018 )
● Pulmonary arterial hypertension ( PAH )
● PH due to left heart disease;
● PH due to chronic lung disease or
sleep-disordered breathing;
● Chronic thromboembolic PH; and
● A group of miscellaneous diseases that
rarely (or inconsistently) cause PH
4. Sildenafil , Macitentan

9
A 50 year old HIV patient presented to the OPD with fever , non
productive cough and breathlessness. The patient was non compliant
to ART. On examination , the patient was tachypnoeic with an Spo2 of
90%. There were bibasal crackles on chest auscultation. The physician
suspected pneumocystis jiroveci pneumonia
1. How to confirm the diagnosis ? 1.5
2. How to treat this patient ? 2
3. Comment about the prophylaxis to prevent pneumocystis
pneumonia. 1.5

Answers
1. Histopathologic or cytopathologic demonstration of the
organism in tissue , bronchoalveolar lavage fluid or induced
sputum
2. The patient likely has mild to moderate PCP.
● Oxygen supplementation
● TMP : SMX ( 160 mg / 800 mg ) 2 tablets orally TDS x 21 days
● TMP SMX needs to be given IV if the patient has severe PCP.
● Steroids need to be given if PaO2 < 70 mm of Hg or if the
A-a gradient is > 35 mm of Hg.
● Ensure strict compliance to ART
● Secondary prophylaxis after treatment completion
3.
● Primary prophylaxis against
PCP is offered if CD4 cell
count is < 350 cells / mm3 or if
the patient is in WHO clinical
stage 3 or 4.
● The secondary prophylaxis is
offered to all patients who
have successfully completed
treatment for PCP until CD4
count > 350 cells/mm3 ( at
least on two occasions , done
at least 6 months apart )
● The preferred regimen is
Cotrimoxazole 1 DS tablet
daily.

10
A patient presented to the emergency department with acute onset of
breathlessness. He is a known case of HTN & CAD. On examination , he
was found to have low SpO2 and bibasal crackles on chest auscultation.
A bedside ultrasound was done , and an image of the same is shown ( in
the next slide )
1. What is the image shown ? 0.5
2. What is the likely cause of dyspnoea ? 0.5
3. What is BLUE protocol ?. 2
4. How to manage this patient ? 2

Answers
1. B lines
2. Pulmonary edema
3. Bedside Lung Ultrasound in Emergency
4. The clinical and the radiologic picture is suggestive of acute pulmonary edema
● Non invasive ventilation
● Oxygen supplementation
● IV loop diuretics
● Cardiac evaluation ( ECG , ECHO , cardiac biomarkers )

BEDSIDE LUNG ULTRASOUND IN EMERGENCY
➔ The BLUE protocol is a lung ultrasound technique used to
diagnose acute respiratory failure.
➔ It is a rapid, step-by-step approach that uses a universal probe
and standardized points of analysis to diagnose the main
causes of acute respiratory failure, including pulmonary
edema, pulmonary embolism, pneumonia, pneumothorax

11
Shown is the pedigree of two
families having the same
disorder.
1. Describe this pedigree 2
2. What is the mode of
inheritance ? 1
3. List any 4 disorders that are
inherited in this manner. 2

Answers
1.
● In the first pedigree , when a female has a
disorder , all of her offsprings have the disorder.
● In the second pedigree , the females having the
disorder does not transmit it to all of her
offsprings.
2. Mitochondrial inheritance ( the first pedigree
shows that the inheritance is maternal , the
second pedigree shows the inheritance is
variable )
3. Leigh’s syndrome , MELAS , MERRF , Pearson’s
syndrome
The expression of mitochondrial
conditions is variable.
Inside each cell, there are several
mitochondria. The number of
mitochondria that carry the mutation
can vary.
A certain proportion of mutant
mitochondria within a cell can be
tolerated and the disease will not
be expressed in the organism.
A larger proportion of mutant
mitochondria however, may cause
the disease to be expressed in the
organism.

12
The image shows a fingertip pulse
oximeter.
1. What is the difference between
SpO2 and SaO2 ? 1
2. What is “ PI “ shown in the pulse
oximeter ? 1
3. Mention any two situations where
pulse oximeter is not reliable.2
4. State Beer Lambert law. 1

Answers
1. SaO2 measures the oxygen saturation of arterial blood, while SpO2
measures the oxygen saturation of peripheral blood using a pulse oximeter
2. Perfusion index (PI). PI is the ratio of pulsatile blood flow to non-pulsatile
static blood flow in a patient’s peripheral tissue.The normal perfusion index
(PI) ranges from 0.02% to 20%.
3. Presence of nail polish , Excessive motion of the pulse oximeter placed site :
Can lead to inaccurate readings
4. The Beer-Lambert law defines that the light attenuation through a medium
is proportional to the concentration of the light absorbers present in the
substance , the optical properties of the light absorber and the optical path
length traveled by the light beam.

13
A 70 year old diabetic patient presented to the OPD with complaints of burning and
tingling sensation in both his feet. On examination , there was hypoaesthesia of
both the feet , decreased vibratory sensation and absent ankle jerk. A diagnosis of
peripheral neuropathy was made.
1. Which are the different forms of peripheral neuropathy seen in patients with
diabetes ? 1
2. Which is the most common form of diabetic neuropathy ? 1
3. Which are the treatment options ? 2
4. What specific advice should be given to patients with peripheral neuropathy ? 1

Answer
1. Distal symmetric sensory
or sensorimotor
polyneuropathy , Autonomic
neuropathy , Radiculopathies
, Mononeuropathies
2. Distal symmetric sensory
or sensorimotor
polyneuropathy
3.
● Glycemic control
● Lifestyle modifications
● Treat hypertension and dyslipidemia
● Avoid neurotoxins like tobacco and alcohol
● Correction of vitamin deficiencies if present
- For pain relief , duloxetine , gabapentin , pregabalin ,
tricyclic antidepressants , venlafaxine , carbamazepine ,
tramadol or topical capsaicin products may be used.
4. Meticulous foot care : Check feet daily ; Prevent the
formation of calluses or ulcerations in the foot.

14
A 56 year old female who was recently
diagnosed with hepatitis C related
chronic liver disease presented to the
OPD with the following oral lesion.
1. Identify the lesion 1
2. Mention any 2 cutaneous lesions
seen in patients with chronic liver
disease 2
3. Describe the treatment for hepatitis
C related chronic liver disease 2

Answers
1.Oral lichen planus
2. Spider angioma , Palmar erythema
3.
● If a patient with chronic hepatitis C related CLD has compensated cirrhosis , start the
patient on sofosbuvir ( 400 mg ) and Velpatasvir ( 100 mg ) for 12 weeks
● If the patient has decompensated cirrhosis , start the patient on sofosbuvir ( 400 mg ) ,
Velpatasvir ( 100 mg ) & Ribavirin ( 600 - 1200 mg ) for 12 weeks
● Test HCV RNA levels 12 weeks after completion of treatment
● If HCV RNA is not detected , treatment is completed. However if HCV RNA is detected ,
refer the patient to a higher centre for further management

15
You are planning to liberate a patient from mechanical
ventilation.
1. What are the criteria to check for prior to extubation ? 2
2. What is RSBI ? 1
3. What is spontaneous awakening trial ( SAT ) and
spontaneous breathing trial ( SBT ) ? 2

Answers
1.The important criteria indicating a patient
may be ready for extubation include the
following :
- Underlying disease process has improved
- The patient is awake and largely off
sedative medications
- FiO2 ≤ 0.5
- PEEP < 8 cm of H2o
- SaO2 > 88%
- Stable hemodynamics
- Manageable respiratory secretions with
adequate cough
2. The RSBI ( Rapid Shallow Breathing Index )
is defined as the ratio of respiratory rate in
breaths / minute to tidal volume in litres.
People on a ventilator who cannot tolerate
independent breathing tend to breathe rapidly
and shallowly (low tidal volume), and will
therefore have a high RSBI. It can be used in
intubated patients breathing spontaneously
who meet other clinical criteria for weaning
from mechanical ventilation. The RSBI should
not be the sole determinant of extubation.
A normal rapid shallow breathing index (RSBI)
is less than 105 breaths per minute per liter
(breaths/min/L). An RSBI of 105 or higher is
associated with a higher likelihood of weaning
failure.

3. SPONTANEOUS
AWAKENING
TRIAL

3. SPONTANEOUS BREATHING TRIAL

16
A 32 year old female was brought to the emergency department with low back
ache. X ray showed that she had a compression fracture of the lumbar spine. Upon
enquiry , she reported amenorrhoea of 3 months duration. The physician was
called in for evaluation. On examination , she had facial hair , acne , high BP
recordings , proximal muscle weakness and striae in the abdomen.
1. What is the most probable diagnosis ? 1
2. How will you screen for this disease ? 2
3. How to confirm the diagnosis ? 2

Answers
1. Cushing’s syndrome
2.
● 24 hour urinary free cortisol excretion
increased above normal ( ≥ 2 times )
● Dexamethasone overnight test ( 1 mg
of dexamethasone is given at 11 PM.
Plasma cortisol is measured at 8 -9
AM the next day ; Plasma cortisol > 50
nmol/L is a positive test )
● Midnight salivary cortisol > 5 nmol/L
3.
● Determine if Cushing’s is ACTH dependent or
not , by assessing the ACTH levels
● If ACTH levels are high , it suggests ACTH
dependent Cushing’s syndrome. Look for the
source of ACTH - MRI pituitary to look for a
pituitary lesion or if an ectopic source is
suspected , CT chest / abdomen should be
done. A CRH test and/or a high dose
dexamethasone test may be also be done to
know if the source is pituitary lesion.
● If ACTH levels are suppressed , image the
adrenals.

The most important first step in the management of patients with
suspected Cushing’s syndrome is to establish the correct diagnosis.
Most mistakes in clinical management, leading to unnecessary imaging
or surgery, are made because the diagnostic protocol is not followed .
This protocol requires establishing the diagnosis of Cushing’s beyond
doubt prior to employing any tests used for the differential diagnosis
of the condition.
In principle, after excluding exogenous glucocorticoid use as the cause
of clinical signs and symptoms, suspected cases should be tested if
there are multiple and progressive features of Cushing’s, particularly
features with a potentially higher discriminatory value.

17
A nurse is ordered to give an injection to a patient. The wastes generated as a part
of the procedure are
Gloves , Swab , Plastic syringe , Needle , wrapper of syringe , Wrapper of needle ,
Vial of injection , Packaging of injection & instruction leaflet
1. As per the BMW rules 2016 , in which bag / container would you dispose
these items ? 2
2. Mention any 3 universal precautions. 3

Answers
1.
● Gloves - Red
● Swab - Yellow
● Plastic syringe - Red
● Needle -White
● Injection vial - Blue
● Wrapper of syringe & Wrapper of
needle , packaging of injection &
instruction leaflet - General
wastes - Green
2.
● Handwashing
● Personal protective equipment (
Barrier protection )
● Proper disposal of contaminated
materials

18
A patient with long standing rheumatoid
arthritis (RA) presented to the OPD. An
image of his hand is shown.
1. What is the deformity ? 1
2. Mention any 2 classes of drugs used
to treat rheumatoid arthritis with
examples. 2
3. Mention any four extra articular
manifestations of RA. 2

Answers
1. Swan neck deformity
2.
● NSAIDs - Aceclofenac , Ibuprofen
● Conventional DMARDs - Hydroxychloroquine , Methotrexate
3. Rheumatoid nodules , Pleuritis , Pericarditis , Interstitial lung
disease

19. Watch the attached video - 3rd nerve palsy
1. Describe the eye movements. 3
2. What is the likely diagnosis ? 1
3. List any two etiologies. 1

Answers
1. There is ptosis in the right eye ; Abduction is normal in the right
eye , however adduction , supraduction and infraduction are
impaired. The movements of left eye are normal.
2. Right 3rd nerve palsy.
3. Stroke , Diabetes , Trauma , Compression from neoplasm &
aneurysm

20. Watch the attached video - Left parasternal
heave
1. What does left parasternal heave indicate ? 1
2. Mention any 2 causes of left parasternal heave. 2
3. Describe Grade 2 & Grade 3 left parasternal heave. 2

Answers
1. Right ventricular
hypertrophy
2. Pulmonary stenosis ,
Pulmonary hypertension

OSCE Series ( Questions & Answers ) - Set 6.pdf

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OSCE Series ( Questions & Answers ) - Set 6.pdf