SCE Qassim OSCE Course For Internal Medicine QOSCE 1 course Name Date P= delsester inca © 050 690 5091Qassim OSCE Course For Internal Medicine @ 050 690 5031 SCE] & gosces@gmail.com OSCE STATION DURATION : 10 MIN SCENE : WARD A 70-year-old bedbound patient was admitted with pneumonia, then 3 days later he developed a new right lower limb swelling. The patient was not on DVT Prophylaxis. The patient was angry because he discovered that he was Not on DVT prophylaxis. have to perform the following: - Approach this angry patient. (Your communication skills will be observed) -Respond to the examiner questions.Qassim OSCE Course For Internal Medicine Sc Examiner E] 2 050 690 S081 © QoscEs@gmail.com ‘Communication skill (angry patient with a missed medication) Candidate Introduction and permission: ~ Introduces him-herself and take permission o - Identify patient name and age 0 ~ Explains task for the patient and gain consent 0 Safety: 0 - Ensure safety (staff/patient) e.g., sit near to door or door is open, not sit close to the patient, ask the patient to si Emotions and attitude: 0 ~ Identify reasons for patient anger, expectations and fears (ideas, expectations and concerns) ~ Give patient an opportunity to express and release anger 0 - Acknowledge patient's anger in an empathic, and non- 0 judgmental manner using verbal and non-verbal empathy, and by calm voice tone giving simple, clear, understandable language to patient ~ Listen carefully, and non-verbal communication e.g., keep eye 0 contact with the patient and avoid interruptions... Apology and clarifications: 0 ~ Apologize to patient and accept his/her grievance ~ Explain to patient that the main intention is to treat him/her 0 appropriately - Avoid blaming others or any individual, department, or service and avoid defensive character 0 ‘Actions: 0 - Provide and share with patient the solutions and plans for current problem ~ Reassure patient that current event will be investigated and 0 analyzed in a transparent and efficient to prevent occurrence in the future ~ Explain the complaint procedure to patient if they want to 0 official complaint through the hospital/health care center ~ Explain to patient that this complaint will not affect the current 0 care given to the patient ~ Arrange follow up plan for current problem e.g., appointment, 0 phone call, specialized staff consultation... = Address safety concerns by contacting doctor or reaching the 0 hospital for any issue appeared in future ~ Provide him with further information resources e.g., websites, 0 Pamphlets, support groups... = Check patient understanding 0 ~ Invite him for any further questions 0Qassim OSCE Course For Internal Medicine Sc E] 2 050 690 S081 © QoscEs@gmail.com ~ Thank patient 2Ei| 20 Total out of 50 | [_s0 Examiner ‘Mention 8 differential diagnosis of the right lower limb swelling (give 2 marks for each differential) Candidate = Infections: cellulitis, abscess... - Lymphatic: lymphedema /16 - Vascular: superficial and deep venous thrombosis, superficial thrombophlebitis, hematoma, arterial or venous insufficiency, post-thrombotic syndrome... - Inflammatory: myositis, myonecrosis, rhabdomyolysis... - Traumatic: compartment syndrome, or sport related injuries... or ruptured baker cyst. - _ Neurogenic: neuropathic pain/neuropathy... ‘Tumors: lipoma, hemangioma, nerve sheath tumor... Examiner Please inform the candidate that patient did US doppler and showed right lower limb DVT Mention 4 indications for thrombop! (give 3 marks for each indication) work up in case of Thromboembolism. Candidate Recurrent Thromboembolism ‘Thromboembolism at young age Family history of Thromboembolism Thrombosis at unusual sites. Total out of 12 /12 Examiner ‘Mention 2 indications for anticoagulation in patients with SUPERFICIAL venous thrombosis. (Give 12 marks if mentioned 2, give 6 marks if mentioned only 1, zero for none.) Candidate Examiner Length = 5 cm "extensive", Proximity to deep vein " close to proximal vein by < 5 cm", Positive d-dimer. Total out of 12 2 Your patient was found to have brain metastasis in addition to DVT. Is it safe to anti-coagulate him? What is your choice? For how long you will anti-coagulate? Candidate ~ Yes, safe. | 3 | oOQassim OSCE Course For Internal Medicine @ 050 690 5031 SCE] © gosces@gmail.com Coe ~ anticoagulation of choice is Enoxaparin (Clexane) the duration is indefinite duration (or till the cancer is cured). - (Any of these answers will be considered as correct and give a full mark) - Total out of 10 Examiner Final mark out of 100 270 clear pass 60-69 borderline pass 50-59 borderline fail < 50 clear failsSCE Qassim OSCE Course For Internal Medicine QOSCE 1 course Name Date P= delsester inca © 050 690 5091Qassim OSCE Course For Internal Medicine 050 690 5091 sce} & © QoscEs@gmail.com OSCE STATION DURATION : 10 MIN SCENE: ER 26-year-old gentleman, came to ER with gross hematuria since yesterday. Please take: Focused history and do focused physical exam. Give differential diagnoses Suggest the workup Give the most likely diagnosis with line of managementSc Qassim OSCE Course For Internal Medicine | 2 050 690 5091 © QoscEs@gmail.com poe ete Examiner | Please take focused Hx and do focused physical exam Candidate| History: ~ introduce yourself and take permission 2 |1 |o = Comorbideties esp. Hemolysis or SCD, Hx of stone 2 [1 fo = hematuria :, clot, Amount, dark urine or true blood 2 [1 fo = Hx of CKD, nephrotic symptoms. 2 [1 [eo = previous episodes Paap = Recent URTI or skin infection 2 [1 [o = fever, flank pain, dysurea va taetlro) = weak stream or dribbling 2 |1 fo = medications 2 [1 fo = bleeding from other orifices 2 [1 [o = muscle pain or Hx of rhabdo or trauma 2 [1 [o = Connective tissue diseases Sx : joint pain, skin rash. 2 [1 [o = FHx of same condition, or renal diseases or malignancy 2 [1 [o = smoking, Benzen exposure, cyclophosph or chemo exposure 2 [1 fo Physical Exam: = Vital signs : BP, HR, RR, Temp, 02 aualinenlio. = BMI, built, and nephrotic signs 2 [1 fo = Nose and chest for pulmonary-renal syndrome and for fluid assessment 2 |1 Jo = Abdomen : for flank and suprapubic area 2 [1 [o = Skin and joint for skin rash active arthritis 21 [o ~ urine dipstick avlinetlio. Total out of 40 40 Examiner | 26-year-old gentleman, medically free, smoker, came with gross hematuria which was cola-like, since yesterday with no clots. That was his 3rd episodes since few years. He has B/L flank discomfort, but there were no fever, dysurea, frothy urine or other urinary Sx. No muscles pain or trauma. His drugs and FHx were -ve. He never had a stone in the past. He just recovered from URTI 2 days ago. O/E, his BP 156/98. HR 78, sat well on RA. No puffy face however there was +2 LL edema, 8MI 24. Chest was clear, Abdomen was soft and lax with no organomegaly or tenderness. No skin rash or active synovitis. Urine dipstick : 3+ blood, 2+ protein. No WBC Give 5 DDx for his presentation? ( 2mark for each , total of 10) Candidate] Glomerular : Non-glomerular : - Iga - Cancer - Lupus - Stone - post infectious -uTl - MPGN. hoQassim OSCE Course For Internal Medicine 050 690 5091 sce} & © QoscEs@gmail.com poe ete Examiner | What workup you are going to ask for him? Candidate| - cBc and KFT allio = electrolytes and Albumin vate fo) = Urine analysis with microscopy 2 [1 [o = urine culture 2 [1 [o = 24hr urine prot, or prot/cr or albumin/cr ratio 2 |i lo = lipid profile ava fuel fo) = ASO titer. - PT, PTT 2 [1 fo = renal US or CT for stones 2/1 [o = C3, C4, ANA, ANCA 2 [1 fo Total out of 20 20 Examiner | Hb:14 Cr: 158 umol (1.8 mg/dL) Na 138 K 4.9 Albumin 38 Urine analysis : please show the image then show the results wec :4/ HPF RBC: 50/HPF.. Prot: +3 -ve Urine culture. 24hr urine protein : 1.3. gm LOL 3.9 PT, PTT, C3, C4, ANA, Viral : all WNL US: showed normal sized kidneys with mild increased ehcogenisty with good cortico-medullary differentiation. No stones or hydronephrosis What does the image show? Give your top DDx for the patient presentation? And how are going to confirm it. Candidate| Urine microscopy showing RBC cast (left) and dysmorphic RBC (Right) |3 |15 | 0 Glomerulonephritis or nephritic syndrome w | 5 jo Do a renal biopsy 2 [1 Total out of 15 15 Examiner | Renal biopsy done and showed mesangial expansion with IgA deposition, going with the Dx of IgA nephropathy. Mention 5 lines of management? (3 marks for each , total of 15) Candidate] - Nephro Consultation Control BP| - sta - start ACEi or ARB - high dose Omega 3 ns - low Na and low protein diet | - consider steroid - diuretics Examiner | Final mark out of 100 100 Final mark out of 10 10 270 clear pass | 60-69 borderline pass | 50-59 borderline fail < 50 clear failQassim OSCE Course For Internal Medicine SCE @ 050 690 5091 © QOSCES@gmail.com Sard | "ea Urine microscopy showing RBC cast (left) and dysmorphic RBC (Right)SCE Qassim OSCE Course For Internal Medicine QOSCE 1 course Name Date P= delsester inca © 050 690 5091Qassim OSCE Course For Internal Medicine © 050 690 5091 SCE] 6 gosces@gmail.com OSCE STATION DURATION : 10 MIN SCENE : OPD 45 years old Female patient, known case of DM, HTN presented to Internal Medicine Clinic with history of palpitations.Qassim OSCE Course For Internal Medicine E] 2 050 690 S081 SCE] @ gosces@gmail.com Coe Examiner ‘Candidate 1. Active focus History = Palpitations (onset, duration, warm up, aggravating or relieving factors, similar attack before, associated symptoms (with sweating, syncope, chest pain, SOB). Drug history (anticoagulation, BB, bronchodilator ) Past medical history - DM and its complication = Stork/TIA = History of bleeding from any orifices. Family history - IHD, SCD Total out of 16 Examiner Palpitation was on/off episodes lasted for 4 hours, for last 2 years, increase by exersional and also come at rest, no syncope sweating or chest pain, there is dyspnea which is exersional and progressive and currently when she line supine. History DM and HTN which is well control and no opthalmopathy or nephropathy No history of medication No history of Stack No family history of IHD or SCD 2.What you want to do next: Candidate | Clinical Examination - General appearance of patient (malar flush, elevated JVP, LL swelling) -__ Neck swelling (thyroid goiter) -_V/S Pulse (rhythm, rate ,character) BP, Oxygen saturation Cardiovascular Examination : -__Inspection - scar sternotomy, ICD device? = Auscultation (heart sound and add sound) - Lung auscultation examination if there is crepitation. Total out of 10 Examiner Clinical Examination Patient look ill, JVP mildly 7 mmHg, mild lower swelling limbs , No scar Auscultation : ~ patient has loud S1, diastolic murmur at apex radiating to axillaSc Candidate Qassim OSCE Course For Internal Medicine E] 2 050 690 S081 © QoscEs@gmail.com Coe And loud S2 in pulmonary area. -there is mild basal chest crepitation Mitral stenosis AF Pulmonary hypertension Heart failure Arrhythmia) Hyperthyroidism. ‘Anemia Total out of 17 Examil ner 3.What you want to do next ? - CBC, Chemistry (renal function), coagulation, CXR 4 = ECG(AF control rate) 5 ~ Transthoracic echocardiography = TFT 2 Total out of 16 /16 Examiner Hb 12.5 , wbc 6, platlet 254, INR 1, ne 92, BUN 6, NA 145, K 4.0, mg 0.8 ‘SH 3.1, T4 20 (NI) ECG = AF Chest X-ray = increase pulmonary artery size TTE =LV function normal , RV function normal , Rheumatic mitral stenosis moderate, RVSP = 45 mmHg Candidate Discussion ‘A. What is your Diagnosis (Mitral stenosis (5) + AF (5) + pulmonary hypertension (2)) B. Whats the type of AF (paroxysmal (1) , persistence (1) , Permanente (1) , chronic(1) ) 12 C. Whats the management (rate control (3) , anticoagulation (3), diuretic (3) )Qassim OSCE Course For Internal Medicine © 050 690 5091 © QoscEs@gmail.com SCE Coe D. What is the scores used in AF (CHA2 DS2 VAS score (2), HASBLEED (2) E. What's the patient score based on CHA2 DS2 VAS score (score is 3) F. The score of AF can be used in this case and why? (the score not used due to valvualr AF G. Ifthe patient is still symptomatic on rate control, what other line of treatment ? (RYTHEM CONTROL EITHER CARDIOVERSION , CARDIAC ABLATION) Examiner 270 clear pass Total out of 39 Final mark out of 100 60-69 borderline pass 50-59 borderline fail < 50 clear failQassim OSCE Course For Internal Medicine sce} 2 080 690 5081 CE] & qosces@gmail.comSCE Qassim OSCE Course For Internal Medicine QOSCE 1 course Name Date P= delsester inca © 050 690 5091Qassim OSCE Course For Internal Medicine © 050 690 5091 SCE] @ gosces@gmail.com OSCE STATION DURATION : 10 MIN SCENE: ER Mrs.Fatima 45 years old female presents to the clinic with exertional dyspnea for | year. HAVE TO DO THE FOLLOWING: 1) OBTAIN BRIEF RELEVANT HISTORY. 2) PERFORM A FOCUSED PHYSICAL EXAMINATION. a. think aloud during the physical examination. b. before performing any maneuver or intervention, inform the patient of your intentions. 3) DISCUSS THE MOST IMPORTANT INVESTIGATIONS WITH INTERPRETATION OF THE GIVEN MATERIAL. 4) DISCUSS THE MOST PROBABLE DIAGNOSIS BASED ON FINDINGS PROVIDED. 5) WHAT IS THE MANAGEMENT FOR THIS PATIENT.Qassim OSCE Course For Internal Medicine © 050 690 5081 SCE] © gosces@gmail.com Co TC Wg | _Examiner | Please take focused History and do focused physical exam Candidate History: roduce yourself and take permission ~ SOB onset, character, duration, alleviating/aggravating factors, severity, continues or intermittent. ~ Associated symptoms, ~ Cough ( dry or productive) - Chest pain, orthopnea, PND ~ Constitutional symptoms ( Fever, night, sweating, weight loss) ~ Syncope -Hemoptysis -Cyanosis, discoloration of the hand - History of trauma, contact with sick patient/TB - Occupational and environmental history = History of chronic disease - history of autoimmune diseases -Medication history History of previous venous thromboembolism Physical Exam: - Vital signs : BP(Hypotension), HR(Tachypnea), RR(Tachypnea), Temp, 02(Hypoxemia) ~ Looks for surround the patient, connection, general condition. - Attempted to do General physical examination include: Hand ( Clubbing, cyanosis ) Neck and head (Eyes for pallor, JVP{ Prominent ‘a” wave & “v” wave}), LL edema ~ Attempted to examine the chest: Inspection, Palpation, Percussion 0 and auscultation - Attempted to examine cardiovascular for signs Pulmonary| 2 [1] 0 hypertension (7*S3, Parasternal heave, Loud palpable P2, Pan- Systolic Murmur) ~ Attempted to examine the Abdomen mainly for hepatomegaly| 2 [1] 0 and ascites. Total out of ... Examiner 45 years old female presents to the clinic with exertional shortness of breath for 1 year, gradual onset, progressive, mild to moderate in severity WHO class II-III, Associated with mild chest pain, not radiating and fatigue. NoQassim OSCE Course For Internal Medicine © 050 690 5081 SCE] © gosces@gmail.com oS orthopnea. He had history of autoimmune diseases. History of DVT with pulmonary embolism 1 year ago, she is still on anticoagulation rivaroxiban. Physical examination: Vital Signs, BP: 100/55 mmHg, HR: 110 b/m. RR: 26 b/m. saturation 91% room air. -7 JVP with Prominent “a” wave -Chest: bilateral basal crepitation -CVS: Palpable P2 at LUSB 2nd ICS, Loud P2, Holosystolic murmur at LLSB 4 With inspiration. -Abdominal Examination: Hepatomegaly Bilateral lower limbs pitting edema ‘Mention 3 differential diagnosis? (2 marks for each , total of 6) Examine! Candidate Pulmonary hypertension Community acquired pneumonia corp is © Congestive Heart failure + Bronchiectasis Examiner Mentions the most important investigations: Candidate ~ CBC, RFT, LFT - CK, Troponin, Pro-BNP ~ ESR, CRP = ABG, ECG ~ Chest images: include CXR, Chest CT angio. , V/Q scan - Echocardiogram ~ Right heart cath. ~ PFT and 6-minute walk test. ~ Autoimmune Profile Send for hypercoagulability ( APS, ,,,etc) Total out of 20 Examiner CBC: WBC: 8550, Hb: 14 Renal profile & LFT: normal Cardiac enzyme,: Normal Pro-BNP : 1200 Autoimmune Profile: Negative PFT: Low DLCO, 6-MWT: walked 300 m Echocardiogram: EF>55, RV dilated, Moderate TR, PASP: SS mmHg ECG, CXR and V/Q scan: will be shown and interpreted in the next questions Examiner ‘What is the ECG findingQassim OSCE Course For Internal Medicine E] 2 050 690 S081 © QoscEs@gmail.com Sc oS Candidate | Right atrial enlargement, RV hypertrophy, RV strain Examiner What does the Chest X-ray showed. Candidate Prominent main PA, RA enlargement, peripheral pruning Examiner What does the V/Q scan show? Candidate Multiple area of ventilation-perfusion mismatch Examiner | What is the next step? Candidate Right heart cath. Examiner Right hear cath resul Mean PA pressures: 40 mmHg Pulmonary capillary wedge pressure:12 mmHg. Examiner ‘What is your final diagnosis Candidate | Chronic thromboembolic Pulmonary Hypertension Examiner ‘What is the management for this this condition? Candidate Supportive treatment ( Diuresis } * Continue Anticoagulation + Pulmonary endarterectomy in operable patient + PAH-therapy (Vasodilator medication) in patients with persistent PH post-surgery or inoperable (Riociguat) Refer to Pulmonary Final mark out of 100 ) 60-69 borderline pass 50-59 borderline fail < 50 clear fail Examiner 270 clear passQassim OSCE Course For Internal Medicine © 050 690 5091 SCE] 6 gosces@gmail.com Planar perfusion Planar ventilationQassim OSCE Course For Internal Medicine SCE @ 050 690 5091 © QOSCES@gmail.comSCE Qassim OSCE Course For Internal Medicine QOSCE 1 course Name Date P= delsester inca © 050 690 5091Qassim OSCE Course For Internal Medicine @ 050 690 5031 SCE] & gosces@gmail.com OSCE STATION DURATION : 10 MIN SCENE: ER 24-year-old female patient , presented to ER with history of headache and convulsion. Please take: - Focused history and do focused physical exam. - Give differential diagnoses - Suggest the workup - Give the most likely diagnosis with line of managementQassim OSCE Course For Internal Medicine E] 2 050 690 S081 © QoscEs@gmail.com Sc Coed WETS Please take focused Hx and do focused physical exam Candidate | History: troduce yourself and take permission 2[1]0 Headache: onset, site, duration, severity, character, 2[ 1 fo = Red Flags sign SNOOP (fever, neck pain, altered mental status, 6[ 3 fo projectile vomiting, visual disturbance, or focal deficit ) and history of Trauma. = Associated symptoms: fever, cough, Loss of appetite, Night] 2] 1 | 0 sweating, weight loss. = Seizure: Semiology, up rolling of the eye, tongue bite loss of 3[1sfo sphincter control, duration, previous attack, previous personal or family history. = Connective tissue disease: malar or skin rash, oral or genital ulcer, | 2 | 1 | 0 joint pain. ~_ History of travel or contact to sick patient 2{ 1 [0 ~ Medication History: OCP, Anticoagulation, steroid, vaccination ay | as7 fo (COVID vaccine) and over the counter medication ~ Past History, history of malignancy, thrombotic event, recurrent | 2] 1 | 0 miscarriage ~ Family History of seizure, connective tissues disease or ay |f0 malignancy. ~ Social History: marital status, smoking history, illicit druguseor | 2] 1 | 0 alcohol consumption and Out of marriage sexual ac al Exam: = General appearance, any sign of trauma 2z{[ilo = Vital signs : BP, HR, RR, Temp, 02 BMI 2[1 [o = CNS: conscious level, HMF 2,1 fo Meningeal signs Looking for any neurological deficits. Fundoscopic examination. = Chest: inspection, palpation and auscultation 2-1 fo = CVS: inspection, palpation and auscultation. 2,1 = Musculoskeletal: skin rash joint swelling 2,1 Total out of 40 /40 Examiner _| - History of present Illness: 24 years old female patient, not known to have any chronic medical illness, presented with sudden severe headache and seizure for the first time, headache started suddenly, affecting right temporo-occiptal area, pulsating in character, severity 8\10, duration 1 day, associated with nausea, 2 times vomiting, and blurring of vision, headache increase with supine position and coughing, no any reliving factors. No fever nor meningeal signs. Seizure happened for the first time, described as no aura, Ictally: GTC for 2 minutes with urinary incontinence, postictal drowsiness for 30 minutes.Qassim OSCE Course For Internal Medicine E] 2 050 690 S081 © QoscEs@gmail.com Sc Response Married before 4 months. Taking only OCPs No past similar complaint, previous history of unprovoked leg DVT not investigated Family history unremarkable - General physical exam including vital signs.Neurological exam: looking for focal defici Our patient was vitally stable, no meningeal signs, and right 6th never palsy otherwise unremarkable exam. Exai er__| Give 5 DDx for his presentation? (2mark for each , total of 10) Candidate - SAH = RVCS (reversible cerebral = Meningitis. vasoconstriction. = CVT (cerebral venous - ICH. thrombosis). /0 Exai er | what workup you are going to ask for him? electrolytes, RBS RFT, LFT, VBG. = Septic work up: Blood C/S, ESR, CRP Neuro-imaging: Plan CT brain, CT Venous, 2 MRI and MRV = ANA, ANCA, C3,C4 re oe] of of of o Prothrombin G20210A mutation. Factor V Leiden mutation Prothrombin mutation id antibody : Lupus anticoagulant, anti- Cardiolipin Ab , 82 glycoprotein-1 antibody Protein Cand Portien S and anti thrombin ‘Candidate CBC and Coagulation profile (PT, PTT, INR) Thrombophilia work up: Screening for malignancy if indicated Total out of 20 Examiner Positive finding:~ CBC, RFT,LFT and serum electrolyte were normal Thrombophilia and marker of antiphospholipid syndrome are still awaiting. Showed the CT and MRV to the candidate Describe the finding. Candidate ‘CT scan shows Intracerebral hemorrhage MRV Showed right transvers sinus thrombosis associated with mild intracerebral hemorrhage and mild edema.Qassim OSCE Course For Internal Medicine Sc E] 2 050 690 S081 © QoscEs@gmail.com Response Examiner What is your final diagnosis? Candidate = Cerebral Venous thrombosis 25} 0 Examiner What are the managements ? Candidate - Stabilize patient with ABCD - Medical Management of high ICP ( head elevation, hyperventilation, mannitol). - Good analgesic and adequate fluid intake - Seizure prophylaxis. - Anticoagulation + ( Duration). - Referral to Neurology 25} 0 Total out of 15 As Examiner What are the predisposing factors of CVT? Mention 5 lines of management? Candidate ~ Prothrombotic condition:- *Genetic eg. Factor V Leiden mutation , prothrombin mutation, Protein C and S deficiency, antithrombinlll deficiency, APS Acquired eg. OCP use, pregnancy and Puerperium Malignancy, infection, Head injury with mechanical precipitants. AS Examiner Final mark out of 100 100 270 clear pass 60-69 borderline pass 50-59 borderline fail < 50 clear failQassim OSCE Course For Internal MedicineQassim OSCE Course For Internal MedicineSCE Qassim OSCE Course For Internal Medicine QOSCE 1 course Name Date P= delsester inca © 050 690 5091Qassim OSCE Course For Internal Medicine @ 050 690 5091 SCE] & gosces@gmail.com OSCE STATION DURATION : 10 MIN SCENE: ER A 22-year-old man undertook a 15-mile charity run in hot weather . He has been brought to the emergency department having dizziness towards the end of the event lead to discontinue. He has severe new leg weakness associated with cramps and back pain. -Please take focus history . ~ Please ask for focus clinical examination -Please mention possible differential diagnosisQassim OSCE Course For Internal Medicine E] 2 050 690 S081 SCE] @ gosces@gmail.com Pod ied Examiner Please start to take proper focus History and Examination Candidate ~ introduce yourself and take permission 21] 0 ~ Lower limb weakness ( onset , duration , course , unilateral or bilateral , associated with numbness , similar presentation inthe | 2] 1] 0 past , other neurogical dicit ) ~ Back Pain (onset , duration , course, character ,radiation , ale aggravation factor ) ~ Fever 20 | fia | aio) ~ Asks about any recent illnesses & flu like symptoms 2/1] 0 ~ CVS: Palpitation , syncope 2/1| 0 ~ Renal : change in UOP and colure oa lrie lao) ~ Autoimmune conditions: Arthralgia .Vitiligo ,Skin rashes , al conjunctivitis. = MSK : deformity , sign of limb ischemia 2[1[ 0 ~ Past medical history : same presentation , demyelination disease | > |, | 5 _ autoimmune disease ~ Red flag signs : weight loss , loss of sphincter tone 2[1[ 0 ~ Family members/contacts with similar symptoms 27 |B |e) = Family history: neurological disease , malignancy 2{1{ 0 Drug history: new use of statin , antibiotics doxycycline, cocaine, | > |, |g amphetamines ~ Social history : Alcohol Smoking, Illicit drug use 21] 0 Examiner On Examination : Candidate General Look , GCS, orientation , Vitals ( temperature , heart rate , ee o blood pressure ) Body built , color ( jaundice , pale , cyanosis) 2 [al[e ‘CNS examination for muscle weakness 2 {10 CVS, respiratory , volume status & abdominal examination 2 [21] 0 ‘Skin examination for temperature , redness, sweating 7 ]~21]0 Blood sugar & urine dipstick 2 [alo Examiner | pifferential diagnosis & causes can induce same presentation : Candidate | Rhabdomyolysis T]os]o Traumatic injuries os |o25| 0 Viral infections 1 [os | o Heat stroke 1 fos | oQassim OSCE Course For Internal Medicine © 050 690 5081 SCE] © gosces@gmail.com Response Malignant hyperthermia Inflammatory myositis Neuroleptic malignant syndrome Metabolic emergencies :phaeochromocytoma or thyroid storm Serotonin syndrome Drugs: statins, cocaine, amphetamines Total out of 50 Candidate ‘22 year old who ls medically free . He undertook a 15-mile charity run in hot weather , After 6 hours he start to have muscle cramp in the lower limb which is increasing gradually associated with lower back pain til he is fall down in the floor not able to stand . He is giving history of numbness felling all over the body Other systematics review was unremarkable . (On Examination : Patient complains of sever back pain that is making it difficult to put the patient on setting position . Looks lethargic Not in distress Vitals signs showed : Value Patient reading Normal range Heart Rate 114) ‘60-100 beats /min Temperature 37.2 36.2-37.4 degrees Celsius Blood pressure 95/50 '90-120/60-80 mmHige Respiratory rate 2 14-18 breath/min ‘Oxygen saturation 98 % on 2LNG ‘96-100 on room alr Dry oral mucosa No jaundice , cyanosis or pallor CVS : sinus tachycardia Respiratory : unremarkable Abdomen : unremarkable MK : bilateral tenderness over hi NS : Generalized weakness of the lower extremities with power 3/5 and hyporeflexia in deep tendon reflex . Upper limb and carinal nerve within normal . Sensory examination within normal . What is the lab investigation want to ask ? ‘Blood gas Imaging ECG with interpretation , CXR ‘CBC, Coagulation profile, Renal function test, Liver function test Electrolytes: K+, Mgr, Car, Poa CKTever Uric acid level Hormones level: TSH, 13, T4, cortisol Tactate dehydrogenase (LOA) ni xrtrlrfrtr|r tn elololo}fololojoQassim OSCE Course For Internal Medicine Sc E] 2 050 690 S081 © QoscEs@gmail.com Coe Urine Myoglobin ai Others : CT/ MAI brain & spine, EMG , NCS alee Total Out 20 Examiner Give your top Differential diagnosis for the patient presentation? Candidate Rhabdomyolysis 2] 1]0 Examiner What is your management Plan? Candidate | Admit the patient to ICU / mentor bed, ICU Consult T]os Jo ABC T fos fo Insert two large bore cannulae and commence large volume V erystalloid os | 025] o IVF NS 200-250 mt /hr T fos fo Close observation of UOP os | o25]o Correction of electrolytes with close observation Tos fo Consider urinary alkalization with bicarbonate to keep pH> 6.5 (although thereis | 05 | 025 | 0 limited evidence above fluid alone), Renal replacement therapy & Nephrology referral T [os DVT prophylaxis T [os GI prophylaxis os | o25 0 Total Out 10 Examiner What is your interpretation of ECG & treatment plan for ECG changes ? Candidate Hyperkalemia : Tinted T wave 2/1 lo IV calcium gluconate or IV calcium chloride 2 }|1 |o IV insulin 10 Units with DSO 21 |o Ventolin Nebs 2 }1 jo In refractory cases : renal replacement therapy 2 }1 jo Exami is the indicat i i xaminer What is the indication of renal replacement therapy in such scenario ? Candidate | Oliguric AKI Volume over load & pulmonary edema Electrolytes correction refractory to medical treatment a]2 fo Metabolic acidosis Symptomatic uremia Exami i z ee Mentation 3 possible complication ? Candidate | Acute kidney injury (AKI). Electrolyte emergencie: - Hyperkalaemia - Hyperphosphataemia 1s = __HypermagnesemiaSCE Qassim OSCE Course For Internal Medicine © 050 690 5091 © QoscEs@gmail.com Examiner Examiner 270 clear pass Coe - Hypocalcaemia Disseminated intravascular coagulopathy. DVT & PE Total Out 20 Final mark out of 100 60-69 borderline pass 50-59 borderline fail < 50 clear failQassim OSCE Course For Internal Medicine @ 050 690 5031 SCE] @ gosces@gmail.com A 22 year old who is medically free . He undertook a 15-mile charity run in hot weather . After 6 hours he start to have muscle cramp in the lower limb which is increasing gradually associated with lower back pain till he is fall down in the floor not able to stand . He is giving history of numbness felling all over the body .Other systematics review was unremarkable . ‘On Examinatior Patient complains of sever back pain that is making it difficult to put the patient on setting position . Looks lethargic Not in distress Vitals signs showed : Value Patient reading Normal range ] Heart Rate 114 60-100 beats /min | Temperature 37.2 36.2-37.4 degrees Celsius | Blood pressure 95/50 90-120/60-80 mmHge | Respiratory rate 22 14-18 breath/min | Oxygen saturation 98% on 2LNC 96-100 on room air | - Dry oral mucosa ~ _ No jaundice , cyanosis or pallor - CVS: sinus tachycardia ~ Respiratory : unremarkable - Abdomen : unremarkable - MSK : bilateral tenderness over his low back - CNS : Generalized weakness of the lower extremities with power 3/5 and hyporeflexia in deep tendon reflex . Upper limb and carinal nerve within normal . Sensory examination within normal - What is the lab investigation want to ask ?Qassim OSCE Course For Internal Medicine sce} 2 080 690 5091 © QOSCES@gmail.com> Qassim OSCE Course For Internal Medicine @ 050 690 5031 © QoscEs@gmail.com Mel a) Patient's UrineSCE Qassim OSCE Course For Internal Medicine QOSCE 1 course Name Date P= delsester inca © 050 690 5091Qassim OSCE Course For Internal Medicine @ 050 690 5031 SCE] @ gosces@gmail.com OSCE STATION DURATION : 10 MIN SCENE: ER A 45-year-old woman presented to the ER with petechia and gingival bleeding for 3 days. Please take: - Focused history and do focused physical exam. - Give differential diagnoses - Suggest the workup - Give the most likely diagnosis with line of managementQassim OSCE Course For Internal Medicine E] 2 050 690 S081 SCE] @ gosces@gmail.com Co i Examiner Please take focused Hx and do focused physical exam Candidate | History: ~ Present illness (bleeding onset, site, frequency, spontaneous or after challenge, pattern 1ry or 2ed hemostasis defect, symptoms of anemia) ~ previous episode of bleeding, symptoms of anemia) - B-symptoms (unintentional weight loss more than 10 % over 6 months, fever 38 > 2weeks, drenching night sweating) ~ joint pain, mouth ulcer. ~ History of recent URTI or viral illness. ~ Past medical history (liver, kidney, autoimmune disease) ~ Medication (anticoagulant, antiplatelet, herbal) ~ Family history of bleeding disorder ~ Menstrual history = Recent vaccination (vaccine induces ITP) ~ Recent transfusion (anemia, post transfusion purpura) Physical Exam: ~ Vital signs : BP, HR, RR, Temp, 02 Skin (mucocutenus bleeding, rash), jaundice CNS examination’ ‘Abdomen: looking for hepatosplenomegaly, stigmata of chronic liver disease) lymph node examination Joint Exam (SLE) Total out of 50 Examiner __ | A 45-year-old woman presents with petechiae, easy bruising, and gum bleeding for 3 days. There is no history of active bleeding from other orifices. There is no previous similar presentation. No history of SOB, B-symptoms, joint pain, or mouth ulcer. She has no personal or family history of a bleeding disorder. She is a known case of hypertension on amlodipine and aspirin. No history of recent vaccination. No recent blood transfusions. Physical examination is normal except for petechiae and bruising. Specifically, she has normal vital signs, no stigmata of chronic liver disease, no lymphadenopathy or hepatosplenomegaly. The joint exam was normal. [| _Examiner | What is your initial workup?Qassim OSCE Course For Internal Medicine E] 2 050 690 S081 © QoscEs@gmail.com Sc Co i Candidate Peripheral blood film Examiner A full blood count reveals thrombocytopenia with a platelet count of 12 x 10°/L (12 x 10°/microlitre) but other cell lines are within normal limits. A peripheral blood smear shows thrombocytopenia but no other abnormalities. PT and PTT were within the normal range. What is your differential diagnosis? Give 5 DDx for her presentation? (2mark for each , total of 10) Candidate ~ Primary Immune thrombocytopenia (ITP) 10 ~ Drug-induced immune thrombocytopenia (DITP) ~ Infections (HIV, HCV, Helicobacter pylori, EBV, malaria) ~ Hypersplenism due to chronic liver disease ~ Myelodysplastic syndromes (MDS) ~ Systemic lupus erythematosus(SLE) Antiphospholipid syndrome (APS) What other useful tests? ( 1mark for each , total of 5) Examiner Candidate = Coomb test 5 - HCV, HIV ~ Pregnancy test - Blood group - ANA, thyroid function test, Antiphospholipid antibody, H-pylori Examiner __| Laboratory workup revealed: - Negative Coomb, pregnancy test - HCV, HIV, ANA, antiphospholipid antibody, and H-pylori tests were all negative. = She is (A+) blood group with a normal thyroid function test, Do you want to do Bone marrow biopsy and aspiration, And why? Candidate No, because there are no atypical ITP features (blast in peripheral, 4],2]o blood film, MDS features) present. Examiner ‘How to manage the patient? Candidate ~ Admit the patient and control bleeding. 2]1]0 - Withhold any medications that are causing the bleeding to ae | worsen (aspirin). (aspirin), 6 alia ~ Start IVIG and/ or anti-D immunoglobulin and/or steroid 2]}1]o Start PPI, calcium and vitamin dQassim OSCE Course For Internal Medicine sce} 2 080 690 5081 © QoscEs@gmail.com Co i ~ Use an antifibrinolytic agent (Tranexamic acid) to treat mucocutenus bleeding) - Rx iron deficiency anemia - Consult a hematologist Examiner __| List three treatment options for the second line of management? Candidate - Splenectomy ~ Rituximab - Thrombopoietin (TPO) receptor agonists (Romiplostim, Eltrombopag) a ee | | 270 clear pass ‘60-69 borderline pass 50-59 borderline fail < 50 clear failSCE Qassim OSCE Course For Internal Medicine QOSCE 1 course Name Date P= delsester inca © 050 690 5091Qassim OSCE Course For Internal Medicine © 050 690 5091 SCE] @ gosces@gmail.com OSCE STATION DURATION : 10 MIN SCENE : EMERGENCY DEPARTMENT A 27-year-old pregnant female (12 weeks), presenting with left side chest pain for 4 weeks. Listen carefully to the examiner's instructions and answer the questions. You have 10 minutes to do the following: I- Take focused history 2- Discuss the physical exam you want to perform 3- What is your differential diagnosis? 4- What work up would you like to order? 5- How would you manage this patient?Qassim OSCE Course For Internal Medicine E] 2 050 690 S081 SCE] @ gosces@gmail.com Response Examiner Take focused history Candidate ~ Details about presenting symptoms: onset, duration, course, 16 relieving and aggravating factors ‘Associated symptoms: SOB, dry cough is Other respiratory infection symptoms: fever, chills, sore throat, 3 weight loss, night sweats Review of systems, including: palpitation, syncope, joint is pain/swellings, skin rash, LE swelling History of trauma iz History of similar presentation /4 History of sick contact /4 Past medical/surgical history /4 = Social history: smoking, alcohol, illicit drugs /4 = Travel and animal exposure history 14 Examiner ‘A 27-year-old pregnant female with no significant PMH, who started to have gradual localized left side chest pain 4 weeks ago. No much change in severity since then. It gets aggravated sometimes with deep breathing. She also reports occasional mild SOB and dry cough. She denies fever, chills, weight loss, night sweats, or hemoptysis. No joint swelling or pain. No skin rash. No LE swelling. ROS otherwise negative. No history of trauma. No ‘ory of similar presentation. She had a Ugandan housekeeper 6 months ago who was constantly coughing. 1B, alcohol or drug use. Lives with her husband and 2 children. No recent travel or animal exposure. Family history is unremarkable. Examiner Discuss the physical exam you want to perform Candidate Vital signs: T, Pulse, BP, RR and O2 sat ‘1/4 Respiratory examination 74 CVS examination 72 General examination including: skin rash, joint swelling, LE swelling. 72 VS: 137.5, P:91, BP: 103/66, RR: 18 with O2 sat 98% on RA PE: Not in acute distress. Clear breath sound with no added sounds on lung exam. No local tenderness. CVS exam with $1+S2+0. No LE edema. No LAD, joint swelling/tenderness, or skin rash. Rest of exam unremarkable. What is your differential diagnosis? Candidate ~ TBQassim OSCE Course For Internal Medicine Sc E] 2 050 690 S081 © QoscEs@gmail.com Candidate ~ Viral infection with pleuritis 2 ~ Bacterial pneumonia complicated by abscess Vs parapneumonic effusion R ~ Other: PE, malignancy, anxiety 2 Se What work up would you like to order? Candidate cBC [2 RFP 2 Ler 2 xR R LE U/S and D-dimer R Inflammatory markers: CRP, ESR 2 PPD or Interferon gamma release assay (IGRA) R ‘Sputum sample for bacterial culture and AFB stain 2 Examiner © CBC: WBC 11, Hgb 11.2, Hct 33.9, Plt 434, © RFP and LFT WNL. © LEU/S negative for DVT. D-Dimer was negative. * CXR is shown, mild left pleural effusion. © CRP: 87, ESR: 62 © IGRA: positive © Induced sputum: negative for AFB and TB PCR. ‘© Negative work up: TSH, T4, ANA, anticardiolipin, RF, HBV, HCV, HIV, RPR. TTE: Normal What to do next? Candidate | Diagnostic thoracentesis. i Send pleural fluid for: cell count, protein, LDH, glucose, AFB smear and Zs culture. ADA level Examiner | Thoracentesis: 650 mi of fluid, 1000 WBC with 80% lymphs, LDA 400, protein 5.4 g/dl, glucose 66, ADA 50 units/L. © Pleural fluid sample: negative for AFB and TB PCR Earninat How would you manage this patient? Candidate | Admit the patient 2 Isolate the patient (Airborne isolation), until r/o TB infectiousness 7a Antituberculosis therapy- Treat as active TB, INH, RIF, PYR, ETH, 6 74 monthsQassim OSCE Course For Internal Medicine @ 050 690 5031 SCE] @ gosces@gmail.com Coe Consult ID Consult Obe/Gyn | _Examiner | Final mark out of 100 /100Qassim OSCE Course For Internal Medicine e| 2 050 690 5091 SCE] @ gosces@gmail.com CBC: WBC 11, Heb 11.2, Hct 33.9, Plt 434, RFP and LET WNL. LE U/S negative for DVT. D-Dimer was negative. CXR is shown. CRP: 87, ESR: 62 IGRA: positive Induced sputum: negative for AFB and TB PCR. Negative work up: TSH, T4, ANA, anticardiolipin, RF, HBV, HCV, HIV, RPR. TTE: NormalQassim OSCE Course For Internal Medicine @gmail.comSCE Qassim OSCE Course For Internal Medicine QOSCE 1 course Name Date P= delsester inca © 050 690 5091Qassim OSCE Course For Internal Medicine © 050 690 5091 SCE] 6 gosces@gmail.com OSCE STATION DURATION : 10 MIN SCENE : OPD SCENE: OPD 36 years old female complaint of palpitations, heat intolerance, and weight loss. Please take: Focused history and do focused physical exam. THEN RESPOND TO THE EXAMINER QUESTIONSQassim OSCE Course For Internal Medicine E] 2 050 690 S081 © QoscEs@gmail.com Sc Coed Examiner Please take focused Hx and do focused physical exam Candidate History: ~ introduce yourself and take permission 2|a1] 0 - Hx of chronic diseases esp. Dm, HTN, cardiac diseases 2 -Weight loss (how many Kg, duration, with increased appetite) 2[a] 0 ~ increased sweating, diarrhea, 2[a] 0 -eye redness, pain, protrusion of eyeballs 2[1] 0 = neck pain or swelling »muscle weakness and wasting 2[a] 0 - anxiety, agitation, Fever 2[a] 0 -chest pain, SOB,Loc, convulsion 2[1] 0 = mentrual cycle: oligomenorrhea 2[a] 0 ~ previous episode and simillar attacks 2[a] 0 = medications amiodarone, recent contrast administration 2[1] 0 -recent viral infection, pregnancy within the past year 2[1] 0 - FHx of same condition, or thyroid diseases 2[a] 0 = smoking, Thyroid hormone exposure 2[1] 0 Physical Exam: - Vital signs : BP, HR, RR, Temp, O2 2|1] 0 -Fine tremor,sinus tachycardia or atrial fibrillation 2[1] 0 ~ warm & moist skin, Palmar erythema, brisk reflexes 2[a] 0 -thyroid exam: goiter, tenderness,thyroid bruit 2[;] 0 = eye exam : lid lag, lid retraction, exopthalamus Zaleas| exo ~ peritibial myxedema, thyroid acropathy 2[1] 0 Total out of 40 40 Examiner 36 yrs old female, medically free, smoker, complaint of palpitation with heat intolerance and lost 6 kg of her weight during the last month. Also complaint of increase appetite &sweating & diarrhea,she complaint of eye redness with protrusion of eyeballs, no neck pain or muscle weakness or chest pain or Loc or convulsion , no hx of simillar attcks. Her drugs and FHx were -ve. past. No hx of recent infection or pregnancy O/E, her HR 109, regular rhythm, BP 156/98., afebrile There is Fine tremor, palmar erythema and warm skin Neck exam: symmetrical thyroid enlargement, no tenderness or bruit Eye exam: lid retraction>2mm,proptosis>3mm,mild corneal exposure,constant diplopia spain with eye movement,eyelids redness & no swelling, no optic neuropathy (Show him the image) No pretebial myxedema What is the most likely diagnosis?Qassim OSCE Course For Internal Medicine © 050 690 5081 SCE] © gosces@gmail.com Candidate Response Graves diseases with graves Hyperthyrodism opthalmopathy (5 mark , total of 10) (10 mark , total of 10) Graves disease (7 mark , total of 10) Wg /10 Examiner What workup you are going to ask for it? Candidate -ECG = CBC and LFTS, KFT. ~ electrolytes: K -TSH, FT4,FT3 - Thyroid antibodies : TSH receptor Abs,AntiTG Abs,Anti Tpo Abs wlio] rf rl] wo e}o}ololo Total out of 20 15 Examiner ECG : sinus tachycardia WBC: 6 Hb:14 Cr: 1 mg/dl Na 139 K 4 AST10 ALT 12 TSH 0.002 mIU/L ( refrence range 0.5-5 mlU/L) FT4: 3 ng/dl ( refrence range 0.7-1.8 ne/dl) FT3: 6 pg/ml ( refrence range 2.3-4.1 pg/ml) TSH receptor Abs :positive What are the causes for the patient presentation? And how are going to defferentiate b/w all of them? Candidate ‘Causes of hyperthyrodism: toxic multinodular goiter, graves, Toxic thyroid nodule,iodine,thyroditis painless or subacute, factitious hypethrodism Do RAI uptake scan : show diffuse homogenous uptake in Graves Total out of 15 15 Examiner What is the management? _(5 marks for each, total of 20)Qassim OSCE Course For Internal Medicine © 050 690 5081 SCE] © gosces@gmail.com Coe Candidate | - Endocrinology consultation Graves opthalmopathy: -Medical:8-blockers,anti opthalmology consultation,stop thyroidal drugs: methimazole | smoking, steroid - Radioactive iodine therapy, surgery: thyroidectomy Examiner Final mark out of 100 100 Final mark out of 100 270 clear pass 60-69 borderline pass 50-59 borderline fail < 50 clear failQassim OSCE Course For Internal Medicine @ 050 690 5031 © QoscEs@gmail.com SCESCE Qassim OSCE Course For Internal Medicine QOSCE 1 course Name Date P= delsester inca © 050 690 5091Qassim OSCE Course For Internal Medicine © 050 690 5091 SCE] 6 gosces@gmail.com OSCE STATION DURATION : 10 MIN SCENE :OPD A 36-year-old man, presented to internal medicine clinic complaining of diarrhea for last 2 months. HAVE TO DO THE FOLLOWING: 1) OBTAIN FOCUSED HISTORY 2) DISSCUSS A FOCUSED PHYSICAL EXAMINATION 3) DISCUSS WITH THE PATIENT THE INVESTIGATIONS REQUIRED. 4) INTERPERT THE AVAILABLE INVESTIGATIONS RESULTS. 5) DISCUSS POSSIBLE UNDERLYING CONDITIONS 6) DISCUSS MANAGEMENT PLAN.Qassim OSCE Course For Internal Medicine © 050 690 5081 SCE] © gosces@gmail.com Looe Examiner Please take focused Hx and physical exam Candidate A ~ _ introduce yourself and take permission 21] 0 = Onset (how it started), Timing, Nocturnal symptoms, 2a] o duration, frequency, progression. - Consistency: Watery, Loose, Greasy, Well formed, Mucus, 2;al o hard lumps = Volume, Color: contain blood, Smell - Alleviating factors: dietary factors 2/1] 0 - _ Exacerbating factors: Gluten-containing foods, d Psychosocial stressors ~ Associated Symptoms (Fever, decrease appetite, weight loss, | 4 | 2] 0 abdominal pain, bloating, Nausea or vomiting, anal pain or fistula, mouth ulcer, joint or back pain, Skin lesions, constipation, tenesmus, fecal incontinence) = Severity: sleep disturbance, affect his daily activity. products, Similar episodes before - PMH: Diabetes, Radiotherapy, Hypothyroidism ni xfrtn elofolo = PSH: Abdominal surgery (short bowel syndrome) , Appendectomy - Drug History: Antibiotics, laxatives, artificial sweetene, 22 || Metformin, Iron, PPI. ~ Family history: Colon ca, IBD, Coeliac disease 2;alo = Allergy, previous hospitalization 2/2 - Social history: Travel, contact with patient have diarrhea, 2 [a type of diet, smoking & alcohol, presence of stressors = Physical Exam: 2]al oo = __Vital signs: BP, HR, RR, Temp, O2 ~ General appearance, nutritional and volume status aE - Head & Neck: Uveitis, episcleritis, Conjunctival pallor, mouth | 2 | 1 ulcers - Extremities: Clubbing, leukonychia, koilonychia, muscle 2{afo wasting, changes of ankylosing spondylitis (abnormal spinal curvature), arthropathy, Skin lesion (erythema nodosum, pyoderma gangrenosum). ~ Abdominal Examination: scars, tenderness or Peritoneal 2;al o signs, fistulas, stoma, Stigmata of chronic liver disease. Total out of 40 40Qassim OSCE Course For Internal Medicine E] 2 050 690 S081 SCE] @ gosces@gmail.com Response Examiner Mr. Ahmed is 36-year-old male presented to clinic with diarrhea for last 2 months. Diarrhea is watery of 3-4 times pre pay, moderate amount getting worse recently. Sometimes it awakes him up from sleep. He noticed blood with stool occasionally. Itis associated with right lower abdominal pain that is not radiating and it gets worse after eating. He has low back pain. He lost around 5 kgs over 2 months. There is no fever, mouth ulcers or other Gl symptoms. PMH: GERD, IBS Drug History: Nexium PSH: Appendectomy 2 years ago, Cholecystectomy 1 year ago FH: none Social: Smoking 1 pack for 6 years, work as accountant in bank, single, lives in buraidah. Physical Examination: Vital signs Temperature 37, BP; 120/80 mmHg, HR; 90 bpm, RR 16/min 02 sat. 99% on room air. BMI 19 Alert oriented not distressed, looks malnourished, dehydrated, Pallor conjunctiva, no skin rash Peripheral exam normal. Abdomen soft, RLQ tenderness with 5cm palpable mass. No fistulas Rectal exam: normal Give 5 DDxfor his presentation? _( 2mark for each, total of 10) Candidate | - IBD (Crohn’s disease) ~ Chronic pancreatitis. - Infectious diarrhea (T8, - Drug induced diarrhea Entameba..) - Microscopic colitis - coeliac disease - Malignancy; Colon cancer, 710 - Bile acid malabsorption lymphoma Ba What workup you are going to ask for him? Candidate ~_ CBC. RFT, LFT, electrolytes, CRP, TSH, 4]2]0 ~__ PPD/quantiferon, HIV 2,10 ~ Stool Ova & parasite, Fecal calprotectin, Lactoferrin, FOB 4a[2]o ~__ Stool osmotic gap and electrolyte a|[2]o = Coeliac serology 2,410 = Abdomen CT/ MRI, CT Enterography, U/S abdomen 2faf[o - Colonoscopy 27,219 Total out of 20 20 Examiner 1. Show lab investigations. 2. Show CT abdomen and Colonoscopy result if requestedQassim OSCE Course For Internal Medicine Sc Candidate E] 2 050 690 S081 © QoscEs@gmail.com Co TC Wg Give your top DDx for the patient presentation? Inflammatory bowel disease (Crohn’s disease) Total out of 15 270 clear pass Examiner Mention 5 lines of management? _( 3 marks for each , total of 15) Candidate - Admission to medical Further management by floor. specialist: - IV fluid for hydration. - Steroids - DVT prophylaxis - Biological therapy 1s - Broad spectrum, (infliximab, Soli Adalimumab...) = Gland surgical — consultation. ~ Azathioprine - Surgical intervention. Examiner Final mark out of 100 Final mark out of 100 60-69 borderline pass 50-59 borderline fail < 50 clear failQassim OSCE Course For Internal Medicine E] 2 050 690 S081 SCE] @ gosces@gmail.com Investigations: WBC 12 x1000/mm? (4-10) Hb 10 gmidl (14-18) MCV65{L_ (77-97) Platelet 400 x1000/mm® (140-440) LFT and RFT, Electrolytes are normal CRP Qmg/L — (<1mg/L) Stool for Ova & Parasite and C. diff toxins was negative Fecal calprotectin 450 ug/g (< 100) Celiac serology negative Iron study pending CT abdomen and Pel Long segment of active terminal ileitis with a small non drainable inflammatory mass measuring 1 x 2.7 om. likely related to penetrating disease. Colonoscopy: segmental colitis with normal intervening mucosa throughout the colon. Sever inflammation in terminal ileum with ulceration.SCE Qassim OSCE Course For Internal Medicine QOSCE 1 course Name Date P= delsester inca © 050 690 5091Qassim OSCE Course For Internal Medicine @ 050 690 5031 SCE] @ gosces@gmail.com OSCE STATION DURATION : 10 MIN SCENE : OUTPATIENT SETTING Mrs. Asma is 21 years old . Presented to Rheumatology clinic with History of Fever and Joint pain. A- Obtain focused History. B- Discuss a focused physical examination C-Discuss the investigations required D-Interpret the results E- Discuss the possible diagnosis F- Discuss the management planQassim OSCE Course For Internal Medicine Sc Examiner E] 2 050 690 S081 © QoscEs@gmail.com Coe Please take focused Hx and do focused physical exam Candidate History: - introduce yourself and take permission detailed history of Fever ( Onset , duration , documented or not , relieving factors like analgesic , contact with sick patients , associated symptoms like fatigue , night sweating , wight loss , SOB, cough , Diarrhea , dysuria , skin rash , URTI like runny nose, history of raw milk ingestion) Detailed history of joint pain ( Onset , duration , pattern , Distribution , aggravating or reliving factors , morning stiffness , severity assess by affecting daily activity , associated with swelling ) Symptoms of CTD (Sicca symptoms , Oral/genital ulcers , malar rash , photosensitivity , hair loss , brightness of skin , serositis Rynoud , abortion if married , thrombosis) Hx of systemic involvement: CNS symptoms( change in LOC or mood , seizure, weakness, headache) Respiratory( SOB, cough, hemoptysis) cardio(chest pain, palpitation, LL edema) GIT( N,V, Abd pain, diarrhea, dysphagia , GERD, steatorrhea), Urinary( dysuria, change in amount, hematuria, frothy) recent iliness or previous similar episodes Past medical history of autoimmune disease like SLE, RA, APS SS , psoriasis, DM, HTN, CKD Past surgical and blood transfusion history Family history of autoimmune disease like SLE, RA, APS, SS, psoriasis History of neonatal lupus Medication history : analgesic , immunosuppressive medication , prednisone ‘social Hx — smoking, alcohol , socioeconomic state , marital status Physical Exa Vital sign P, HR, RR, Temp, O2- BMI, built Head and neck ( palllor , oral ulcers , cervical LN) Axillary LN Signs of active arthritis ( swelling , redness , hotness , tenderness , deformity , limitation of movement) ‘Skin rash :- described by candidate in the photo Examine for signs of CNS involvement; LOC, sensory or motor defect, Meningeal signsQassim OSCE Course For Internal Medicine E] 2 050 690 S081 © QoscEs@gmail.com Sc Response Chest for type of breathing , crackles, pleuritic ( effusion, rub) ‘CVS: murmur, HF signs, raised JVP, lower limb edema, GIT; tenderness or Hepatomegaly , splenomegaly , ascites -GTU; flank tenderness, uremic signs, overload , inguinal LN urine dipstick Total out of 40 Examiner Mrs . Asma id 21 years old , female patient , medically free Presented with 2 weeks history of fever which is documented 39 C, in afternoon time , not respond to antipyretic , associated with fatigue and sweating , no history of contact with sick patient No history of cough of sputum production , SOB , abdominal pain , diarrhea or dysuria , raw milk ingestion Associated with joint pain of wrists , 1° and 2° PIP bilateral with no morning stiffness which started with fever No sicca symptoms , oral/genital ulcers , hair loss , abortion or thrombosis On examination Temp = 40, HR=110 , RR-24 ,O2 sat = 96% RA ‘Swelling of Lt axillary LN Rash as in PHOTO Active arthritis of wrist bilateral Normal vesicular breathing with no crackles CVS :- $1+S2+0 , no murmur or LL edema Abdomine :- soft and lax with no tenderness but there is hepato-splenomegaly Urine dipstick :- negative for protein and blood Give the possible differential diagnosis based on her presentation? ‘Candidate -AOSD “SLE -early RA -PSA -viral infection like hepatitis and HIV Examiner What workup you are going to ask for her? Candidate = CBC with Diff 2,1 [9 =__ Chemistry including creatinine and GFR 2[1][ 0 ~__LFTS, ALP and bilirubin and albumin 2{[1 | 0 = Inflammatory markers, ESR, CRP 2[1 | 0 - Autoimmune markers ( ANA, RF, CCP, Anti DsDNA) a a) - €3,c4 <_ Ferritin, LDH = TOScOPY 2[1 | 0 == 24hr urine prot, or prot/er ratio ieQassim OSCE Course For Internal Medicine Sc E] 2 050 690 S081 © QoscEs@gmail.com - CXR, echo , CT CAP 2ya - Coagulation profile , APS serology 1 - HCV, HBV, HIV, EBV, quantiferon , Brucella titer To Total out of 20 20 Examiner WBC = 13 , Hb=10 , MCV=90,, Platelet = 400 Normal U/E AST=120 , ALT = 150 , normal albumin and bilirubin ESR=90 , CRP=50 Negative ANA , RF, CCP, Anti DSDNA Normal C3 , C4 Ferritin =2000 , normal LDH Normal urine analysis CXR normal CT CAP show hepato-splenomegaly with no para aortic and inguinal lymphadenopathy PT, PTT is normal Viral serology Quantiferon and Brucella titer are negative What is your diagnosis now? Candidate ‘AOSD Total out of 15 15 Examiner ‘Mention the steps of management for this Conditions Candidate ‘Admit the patient to regular ward Rheumatology consultation Prednisone Img / kg / day Methotrexate IL-6 inhibitor (Tocilizumab) \Linhibitor (Anakinra) fs Examiner 270 clear pass Final mark out of 100 Final mark out of 10 60-69 borderline pass 50-59 borderline fail 100 10 <50 clear failQassim OSCE Course For Internal Medicine @ 050 690 5091 SCE] © gosces@gmail.com —— east AesSCE Qassim OSCE Course For Internal Medicine QOSCE 1 course Name Date P= delsester inca © 050 690 5091Qassim OSCE Course For Internal Medicine @ 050 690 5091 SCE] @ gosces@gmail.com OSCE STATION DURATION : 10 MIN SCENE: ER 32-year-old female, presented to ER with Hx of SOB for 3 days Pt inform you that she delivered a baby 2 weeks ago Please take: Focused history and do focused physical exam. Give 5 differential diagnoses Suggest the workup Give the most likely diagnosis with line of management What is the prognosis of this case?Qassim OSCE Course For Internal Medicine E] 2 050 690 S081 SCE] @ gosces@gmail.com Coe Examiner Please take focused Hx and do focused physical exam Candidate History: ~ introduce yourself and take permission = Dyspnea: exertional (NYHA Classification), orthopnea, PND chest pain or discomfort palpitations, sweating, syncope cough weight gain ankle swelling, peripheral edema, RUQ discomfort fatigue, exercise intolerance Previous pregnancy, recent delivery and if so: preeclampsia Risk factors Hx: DM, HTN, Smoking, recent infections any chronic illnesses or recent infections Past Hx of cardiac illness Family Hx. Specially Cardiomyopathies, IHD, congenital heart diseases = Medications: Hx Physical Exam: -__ General appearance, position = Any connection to the patient: Oxygen, IV line, Monitor =__ Vital signs: BP, HR, O2sat on room air = General exam: JVP, lower limb edema, pallor, jaundiced ‘Abdomen: hepatomegaly, ascites Chest: basal Crepitation, pleural effusion eo} of of ofololo = Local Exam: CVS --> Auscultatio pericardial rub -> inspection, palpation a [2 : heart sound, added sound $3, $4. Murmur, - Candidate able to differentiate between congested or 2 [alo hypoperfused heart failure state. Total out of 40 40 Examiner Pt. gave hx of SOB NYHA class 2 to 3, lower limb swelling, she had DM and HTN No chest pain, cough or recent infection No past hx of similar complain On exam: vital signs HR: 102, BP 110/70, 02 sat 99% on RA, JVP raised, pil Limb ing edema of Lower Chest: basal crepitation, CVS: $1 452+ $3 no murmur,Qassim OSCE Course For Internal Medicine © 050 690 5081 SCE] © gosces@gmail.com Response Examiner What is your deferential Diagnosis? Mention 5 DDX ‘Candidate 1- Dilated CMP 5- valvular CMP (MS, AS, MR) ISCHEMIC CMP 6- infectious CMP (viral) Hypertrophic CMP 7- metabolic causes of CMP (hyperthyroid) Hypertensive CMP 8 systemic causes of CMP (SLE, Toxin, muscular dystrophy) Soe What workup are going to ask for her ? Candidate = CBC, = renal function test and LFT - BNP. ~TSH and FT4 - CXR, - ECG ~ Echo -Rt. Heart cath., coronary CT or angiography, Cardiac MRI, Endomyocardial biopsy Hb: 9. electrolyte WNL, cardiac enzyme trop 0.02. TSH, Renal and LFT WNL BNP: 900 ECG: sinus tachycardia, Left axis deviation CXR: enlarged heart shadow, congested lung Echo: EF 30% global hypokinesia, LV diameter enlarged, normal RV size and function, trace MR, no pericardial effusion What is your most likely diagnosis? Candidate Peripartum Cardiomyopathy 5 2] 0 5 Total out of 5 1s eee What is the outline management for this pt.? Candidate _| - life style modification ~ exercise training -low Na Intak -fluid restriction aQassim OSCE Course For Internal Medicine Sc | 2 050 690 5091 © QoscEs@gmail.com cen Mark Medication: 1- ACEI / ARBs 4- diuretics 7- hydralazine + nitrate 2- Beta blocker 5- Entresto (ARNI) 8- Empagliflozin 5 (SGLT2) 3- Aldactone 6- digoxin 2 Implantable Device: ICD / CRT-D 5 2 Cardiology Consultation 5 Total out of 15 js a vaminer What is the prognosis for this case? Candidate | 50% of women completely recovered 5 Persistent LV dysfunction or Poor LV (EF <25%) at initial presentation will be very high risk for 5 complication at next pregnancy Examiner Final mark out of 100 100 270 clear pass 60-69 borderline pass 50-59 borderline fail < 50 clear fail