OSCE SERIES - Set 7 ( Questions & Answers ).pdf

Q1.
A 26 year old female presented to the OPD with a slowly enlarging painless swelling in
front of the neck of 1 year duration and palpitations. On examination , she was found
to have a non tender goitre and exophthalmos.
A TFT was done , and the reports are
● TSH - 0.021 µIU/mL (normal 0.35-4.94 µIU/mL)
● Free T3 - 2.97 pg/ml (2.27-4.47 pg/ml)
● Free T4 - 1.94 ng/dL (normal 0.79-1.34 ng/dL)
1. What is the likely diagnosis ? 1
2. How to proceed in this case ? 2
3. Discuss the treatment options. 2

Answers
1. Grave’s disease ( clues to diagnosis - young female , painless thyroid swelling ,
palpitations , exophthalmos , biochemical thyrotoxicosis picture )
2.
● The measurement of autoantibodies ( TSH receptor antibody , Anti thyroid
peroxidase antibody ) - elevated in Graves’ disease
● USG Thyroid can provide clues to the nature of the goitre
● Radionuclide uptake study ( Diffuse , high uptake in Graves’ disease )
3.
● Using antithyroid drugs ( carbimazole , methimazole or propylthiouracil ) &
Beta blockers
● Radioiodine ablation
● Total or near total thyroidectomy

Q2.
A chronic smoker with history of gradually progressive exertional breathlessness came to your
OPD with worsening of breathlessness over the last 2 weeks. A spirometry was done 6 months
ago which showed features of COPD.
He was using the following medications
● Tab Deriphyllin 100mg TDS
● Salbutamol 100 mcg MDI 2 puffs BD
He was admitted and managed as a case of COPD exacerbation.
1. How is COPD exacerbation classified ? 1
2. What is the recommendation regarding the administration of methylxanthine class of
drugs during an exacerbation ? 1
3. At the time of discharge , what all medications and advice should this patient be given ? 3

Answers
1. COPD exacerbation is classified into mild , moderate and severe , based on clinical &
lab parameters.
● Mild : Dyspnoea Visual analogue scale < 5 , RR < 24 breaths/min , HR < 95 / min ,
Resting SaO2 ≥ 92 % breathing ambient air ( or patient’s usual oxygen prescription )
and changes ≤ 3 % ( when known ) , CRP < 10 mg/L ( if obtained )
● Moderate : Dyspnoea Visual analogue scale ≥ 5 , RR ≥ 24 breaths/min , HR ≥ 95 /
min , Resting SaO2 < 92 % breathing ambient air( or patient’s usual oxygen
prescription ) and changes > 3 % ( when known ) , CRP > 10 mg/L. If obtained , ABG
may show hypoxemia ( PaO2 ≤ 60 mm of Hg and/or hypercapnia ( PaCO2 > 45 mm of
Hg ) but no acidosis.
● Severe : Dyspnoea , RR , HR , SaO2 & CRP are same as moderate. ABG show new
onset / worsening hypercapnia and acidosis ( PaCO2 > 45 mm of Hg and pH < 7.35 )

2. Methylxanthines are not recommended due to increased side effect
profiles.
3.
● Prescribe long acting bronchodilators ( Long acting acting beta
agonists & Long acting muscarinic antagonist )
● Prescribe inhaled corticosteroids if blood eosinophils ≥ 300
● Appropriate inhalation device should be chosen & inhalation
technique should be taught
● Counsel regarding smoking cessation
● Advice regarding vaccination
● Pulmonary rehabilitation
● Physical activity

Q3.
A pulmonary TB patient was found to have deranged LFT during
the follow up blood test.
1. Which among the first line anti TB drugs is the most
hepatotoxic ? 1
2. What is to be done for this patient ? 3
3. This patient has a 3 year old granddaughter at his home.
Does she require ATT ? 1

Answers
1. Pyrazinamide
2. A diagnosis of ATT related hepatitis is made based on the symptoms and the AST/ALT levels.
The diagnosis can be made
- If the patient has clinical symptoms ( abdominal pain , vomiting , unexplained fatigue ,
yellowing of sclera and altered sensorium ) and the AST/ALT is increased to 3 times of
baseline or upper limit of normal and bilirubin increased to 2 times upper limit of normal )
- If the patient has no clinical symptoms , but AST/ALT is increased to 5 times of baseline or
upper limit of normal
- Exclude viral hepatitis
- Perform PT/INR & USG liver
- Stop all hepatotoxic drugs
- If urgent ATT is needed , start a new regimen with non hepatotoxic drugs
- If urgent ATT is not required , repeat LFT after a week & reintroduce ATT with careful
monitoring

3. The child should be screened for active TB. If no active TB is found ,
TB preventive treatment should be offered.
The treatment regimens are
6H ( 6 months of daily INH ) or 3HP ( 3 months if weekly INH &
Rifapentine )

Q4.
During a session at school , you were asked to talk about
vaccines that can be given to adolescents.
1. What is the recommendation regarding HPV vaccine ? 2
2. What is the schedule of Td vaccine in the universal
immunisation program ? 1
3. A few students who wish to enrol for the nursing asked you
about hepatitis B vaccine. What advice will you give them ?
2

Q5.
1. The procedure shown
is ? 1
2. Mention any 4
indications 2
3. Mention any 2 post
procedural
complications. 2

Answers
1. Renal biopsy
2.
● Nephrotic syndrome in adults
● Systemic disease with renal dysfunction (
indicated in patients with small vessel vasculitis ,
anti glomerular basement membrane disease &
systemic lupus )
● Acute kidney injury ( indicated if obstruction ,
reduced renal perfusion & acute tubular necrosis
have been ruled out )
● Unexplained CKD
3.
● Pain
● Hemorrhage

Q6.
A 60 year old female was brought to the emergency department with
history of seizures. She gives history of total thyroidectomy several
years ago and is on thyroxine replacement.
Upon evaluation , she was found to have low calcium levels and low
PTH.
1. Mention any 4 causes of low calcium and low PTH 2
2. How to treat this patient ? 2
3. The ECG of this patient is shown in the next slide. What is the
finding ? 1

Answers
1.
● Parathyroid agenesis
● Surgical removal of
parathyroid gland
● Radiation induced
hypoparathyroidism
● Hypomagnesemia
3. QT prolongation
2. This patient most likely developed seizures due to
hypocalcemia , which occurred as a complication of thyroid
surgery due to inadvertent removal of parathyroids.
● Administer calcium gluconate ( 10% weight/volume ) -
10 mL diluted in 50 mL normal saline or 5% dextrose ,
over 5 minutes , followed by infusion of calcium
gluconate ( 10 ampoules / 900 mg of calcium in 1 L of 5
% dextrose or normal saline , over 24 hours )
● After correcting serum calcium levels , oral Calcium (
1000 - 1500 mg/day of elemental calcium in divided
doses ) and vitamin D supplementation should be started

Q7.
A 70 year old male was brought to the emergency department with
complaints of acute onset of right sided weakness and slurring of
speech of 30 minutes duration. He is a known case of DM , HTN and is
a smoker. However , on examination , his speech was normal and there
was no weakness in the right upper & lower limbs. MRI brain showed
no acute infarcts.
2. What is ABCD2 score ? 1
3. How to treat this patient ? 2
4. What is NIHSS ? 1

Answers
1. Transient ischemic attack
2. The ABCD2 score is a clinical
prediction tool used to
estimate the risk of stroke in
the days after a transient
ischemic attack (TIA).

3.
● Start the patient on antiplatelets & statins
● Perform investigations for etiologic evaluation
● Risk factor modification ( adequate control of DM & HTN ;
Smoking Cessation )
4. NIHSS - National Institutes of health stroke scale. The NIHSS can
help physicians quantify the severity of a stroke in the acute setting.

Q8.
A 25 year old male patient came to your OPD with history of recurrent episodes of
syncope. The second episode of syncope occurred while he was having fever and the
primary care doctor noticed an ECG abnormality and referred to you for evaluation. His
family history is notable for sudden cardiac death of his his elder brother and father. The
CVS examination was within normal limits. His 12 lead ECG is shown in the next slide.
1. What is the ECG abnormality ? 1
2. What is the etiology ? 1
3. How to manage this patient ? 1
4. Mention any 4 causes of sudden cardiac death . 2

Answers
1. Coved ST segment elevation > 2 mm in >1 of V1-V3 followed
by a negative T wave
2. Brugada syndrome ( due to mutations in cardiac sodium
channel genes )
3. Implantable Cardioverter Defibrillator
4. Coronary artery disease , Nonischemic cardiomyopathies ,
Valvular heart disease , Myocarditis

Q9.
In respiratory clinic ,
you review a 43 year
old female patient
with a 6 month
history of dry cough
and shortness of
breath. You perform
spirometry , which
reveals the following :
1. Interpret the spirometry 3
2. Mention the likely etiologies 1
3. Mention any two
contraindications to spirometry 1

Answers
1.
➔ The FEV1/FVC ratio is 0.82 , suggesting that there is no obstruction.
➔ The FVC is only 68% of predicted , suggesting that there is restriction.
➔ A normal FEV1/FVC ratio with a reduced FVC is suggestive of a restrictive airway
disease.
2. Restrictive lung diseases may be
● Pulmonary parenchymal diseases ( eg. Idiopathic pulmonary fibrosis ,
Sarcoidosis )
● Extrapulmonary diseases ( eg. Kyphoscoliosis , Obesity , Neuromuscular diseases
like muscular dystrophy )
3.
● Recent myocardial infarction
● Recent thoracic surgery

Q10.
A 60 year old diabetic patient was admitted in ICU with pneumonia. His
condition continued to worsen - he developed hypoxemia and hypotension.
The hypotension responded to vasopressors but he was intubated as
hypoxemia was not responding to supplemental oxygen. A repeat CXR was
taken just before intubation - it showed new onset infiltrates.
1. Which are the recommended vasopressors in septic shock ? 1
2. Define ARDS. 1
3. Mention any 4 causes of ARDS 1

Answers
1. Norepinephrine , Vasopressin ,
4.
➔ Continue mechanical ventilation ( low tidal volume & High PEEP - Adjust
the settings so as to minimise ventilator induced lung injury & alveolar
collapse ) ; Prone position ventilation can be tried
➔ Glucocorticoids
➔ Extracorporeal membrane oxygenation ( ECMO ) may be used
➔ Adequate treatment of pneumonia
➔ Critical care

Q11.
A patient , who is a chronic alcohol user , presented to the OPD with yellowish discoloration of
eyes and abdominal discomfort. History of binge drinking present. On examination , he had
icterus and hepatomegaly.
Liver function tests showed
Total bilirubin - 4.5 mg/dL ; Direct bilirubin - 2.5 mg/dL ; ALT - 250 IU ; AST - 600 IU ; ALP - 200
IU ; Total protein - 6.5 g/dL ; Albumin - 4.0 g/dL ; Prothrombin time - 24s ; Prothrombin time (
control ) - 12s
1. What is De Ritis ratio ? 1
2. What is Maddrey’s Discriminant Function ( MDF ) ? 1

Answers
1. De Ritis ratio : The ratio of Aspartate Aminotransferase ( AST ) to
Alanine Aminotransferase ( ALT )
2. The Maddrey's Discriminant Function suggests which patients
with alcoholic hepatitis may have a poor prognosis and benefit
from steroid administration.
Maddrey’s discriminant function =
4.6 x ( Increase in prothrombin time in seconds ) + serum bilirubin ( in
mg/dL )

3. The Maddrey’s Discriminant Function of
this patient is 4.6 ( 24 - 12 ) + 4.5 = 59.7,
suggesting that this patient has severe
alcoholic hepatitis.
● Alcohol abstinence
● Nutritional support
● Screen for and manage liver disease
related complications
● Glucocorticoids , if not contraindicated
● Early liver transplantation if not
responding to glucocorticoids ( If not a
candidate for liver transplantation ,
supportive / palliative care )

Q12.
A 45 year old female was admitted with severe anemia. She was given 2 units of
PRBC to correct anemia.
1. Mention any 4 immune mediated adverse reactions to blood components. 2
2. What is TRALI ? 1
3. The following wastes were generated after the transfusion.
Gloves , Cotton swab , IV cannula , Needle , Tubings , Blood bag
Where to dispose these wastes ? 2

Answers
1. Hemolytic transfusion adverse reactions , Febrile non hemolytic
transfusion reactions , Allergic reactions , TRALI
2. TRALI - Transfusion related acute lung injury
3.
➔ Gloves , IV cannula , Tubings - Red
➔ Cotton swab , Blood bags - Yellow
➔ Needle - White

Q13.
A patent with headache and
blurring of vision was examined
with an ophthalmoscope. The
ophthalmoscopic image is shown
below.
1. Describe the finding. 1
2. Mention any 4 situations
where this can be seen. 2
3. Mention any 4 false localising
signs in neurology. 2

Answers
1. Papilledema
2.
● Intracranial space occupying lesions
● Idiopathic intracranial hypertension
● Meningitis
● Venous sinus thrombosis
3.
● Sixth cranial nerve palsy
● Aphasia
● Internuclear ophthalmoplegia
● Hutchinson’s Pupil
Causes of raised ICP that can
lead to papilledema

Q14.
A 15 year old girl was brought to the emergency department with complaints of fever , vomiting &
abdominal pain for the last 2 days. The patient's temperature is 102°F , the pulse is 116 / min ,
respiratory rate is 26 / min & BP is 100 / 60 mm of Hg. She is breathing deeply. The blood tests
showed
Hb - 12 g/dL ; TC - 16,000 cells/mm3 ; PLC - 400,000 cells/mm3 ; Glucose - 500 mg/dL ; Sodium - 130
meq/L ; Potassium - 5 meq/L ; pH - 7.23 ; Bicarbonate - 14 meq/L ; Creatinine - 1
2. How to differentiate between type 1 DM & type 2 DM ? 1.5
3. Mention some of the auto antibodies seen in type 1 DM. 1
4. How to manage this patient ? 1.5

Answers
1. Diabetic ketoacidosis
3. Antibodies to insulin , Glutamic acid decarboxylase ( GAD ) , Islet antigen-2 (
IA-2 ) , Zinc transporter 8 ( ZnT8)
4.
● Admit in ICU
● IV fluids
● Insulin infusion with monitoring of blood sugars and serum potassium
● Identification of the source of infection and it's adequate treatment
● The patient likely is a type 1 diabetic and will require lifelong insulin
therapy

One useful
clinical tool
for
distinguishing
the type of
diabetes is
the AAABBCC
approach.

The images shown in the previous slides are that of a patient who
had thickening of skin of long duration.
1. What do these images show ? 1.5
2. Expand CREST. 1
3. What are the gastrointestinal manifestations seen in this
condition ? 2.5

Answers
1.
● Figure 1 - Calcinosis cutis
● Figure 2 - Sclerodactyly
● Figure 3 - Raynaud’s
phenomenon
2. CREST - Calcinosis cutis ,
Raynaud’s phenomenon ,
Esophageal dysfunction ,
Sclerodactyly , Telangiectasias
3.

Q16.
A 70 year old male experiencing bladder outlet
obstruction from benign prostatic hyperplasia and
chronic constipation , and currently using a Foleys
catheter presented with a concern about a purplish
discoloration observed in his urine collection bag.
1. What is the diagnosis ? 1
2. The causative agent is ? 1
3. How to treat this condition ? 2
4. Mention any 4 etiologies of chronic constipation
1

Answers
1. Purple urine bag syndrome
2. Bacteria like E. coli, Proteus mirabilis,
Pseudomonas aeruginosa, Klebsiella,
Enterococci and Group B Streptococci.
3.
● Change the urinary catheter and the collection
bag
● Treatment of underlying UTI & constipation

Q17.
A bone marrow examination was performed
for a patient with long standing back ache ,
anemia and renal dysfunction. The bone
marrow aspirate is shown.
1. Identify the cells seen 1
3. Mention any 4 complications
associated with this disease. 2
4. Mention any 2 pharmacologic agents
used to treat this condition. 1

Answers
1. Plasma cells
2. Multiple myeloma
3. Anemia , Renal failure , Infections , Amyloidosis
4. Bortezomib , Lenalidomide

Q18.
A 5 year old boy presented with recurrent episodes of knee pain and
swelling of knees following minor trauma. H/o epistaxis also present.
1. What are the possibilities to consider ? 2
2. Mention any two causes of
- Prolonged prothrombin time only 3
- Prolonged aPTT only
- Prolonged PT & aPTT

Answers
1.
● Hereditary bleeding disorders like hemophilia
● Acquired bleeding disorders like advanced liver disease
2.
➔ Prothrombin time prolonged - Factor VII deficiency , Warfarin
anticoagulation
➔ aPTT prolonged - Factor VIII & IX deficiency , heparin anticoagulation
➔ Both PT & aPTT prolonged - Factor II , V , X or fibrinogen deficiency ;
Vitamin K deficiency ( late )

Q19. Watch the attached video ( Chorea )
This boy had history of fever and joint pains , and parents noticed this
particular movement for the last few days.
1. What do you think is the condition ? 2
2. What long term complications can occur in this child ? 1
3. Mention the other causes of this particular movement disorder 2

Answers
1. The movement disorder is chorea , and the child likely has
acute rheumatic fever ( fever , joint pains , chorea )
2. Rheumatic heart disease
3. SLE , Huntington’s disease , Pregnancy , Encephalitis ( NMDA
receptor antibody positive encephalitis , HSV encephalitis ) ,
Hyperthyroidism , HIV infection , Sjogren’s syndrome ,
Polycythemia vera , Medications ( (especially anticonvulsants,
cocaine, CNS stimulants, estrogens, and lithium )

Q20. Watch the attached video ( Romberg sign )
1. Describe the manoeuvre 3
2. Mention any 4 conditions in which it can be seen. 1
3. This patient is a strict vegetarian and has anemia. What could be
the possible diagnosis ? 1

Answers
1. The patient is able to stand and maintain balance when his eyes are
open. But when he closes his eyes , he loses his balance and tends to
fall. This is the positive Romberg’s sign.
2. Diabetic peripheral neuropathy , Brown sequard syndrome , Posterior
cord syndrome ( posterior spinal artery infarction ) , Subacute
combined degeneration of spinal cord due to B12 deficiency , Tabes
dorsalis
3. Subacute combined degeneration of spinal cord due to B12
deficiency

When proprioception is disturbed, the patient may be able to stand with eyes
open but sways or falls with eyes closed (Romberg or Brauch-Romberg sign).
In order to test this function, the patient must have a stable stance eyes open
and then demonstrate a decrease in balance with eyes closed, when visual
input is eliminated and the patient must rely on proprioception to maintain
balance.
Some authorities recommend the arms be held at the sides, others that the
arms be crossed on the chest. Whether arm position makes any difference in
test sensitivity is unknown. Turning the head side to side eliminates vestibular
clues and increases the reliance on proprioception ( Ropper’s refined
Romberg test ).

OSCE SERIES - Set 7 ( Questions & Answers ).pdf

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