OSCE STATION

DURATION:10 MIN
SCENE: ER

Scenario:
28 Years Old Female Presented to ER With History of Muscle Twitching and
Carpopedal Spasm.

Please Do the Following and Listen to The Examiner Questions:

- Describe the Findings.
- Focused History & Physical Examination.
- Work Up
- Diagnosis and Management.
 Response Mark
Examiner Describe findings? 5 2.5 0
Total out of 5 /5
Examiner Please take a focused history?

Candidate Introduce yourself and take permission. 2 1 0

Neuromuscular excitability: circumoral paresthesia, acral numbness
and tingling, carpopedal 3 1.5 0
spasm, laryngospasm or bronchospasm
CNS: seizures, confusion, memory impairment 3 1.5 0
Cardiac: syncope, arrythmia and angina. 3 1.5 0
Gastrointestinal: Abdominal pain, dysphagia. 2 1 0
Others:
Skin: Dry skin, coarse hair, brittle nails, psoriasis. 2 1 0
Eyes: cataract
Past medical history includes pancreatitis, renal or liver failure,
gastrointestinal disorders, hyperthyroidism or hyperparathyroidism, 2 1 0
and other autoimmune diseases.
Past surgical history includes thyroid, parathyroid, or bowel
3 1.5 0
surgeries, or recent neck trauma.
Drug history: Diuretics, bisphosphonates, denosumab, calcium
3 1.5 0
supplements, antibiotics, antiepileptics.
Family history of hypocalcemia may aid in the diagnosis of inherited
2 1.5 0
conditions.
Total out of 25 /25
Examiner Take a focused physical examination?

Candidate Vital signs 5 2.5 0

Features of acute hypocalcemia:
• Arrhythmias—check pulse and ECG
• Tetany 10 5 0
• Chvostek’s sign—less specific (present in 25% normocalcemic
subjects)
 • Trousseau’s sign—more specific (present in 1% normo-calcemic
subjects)
• Shortness of breath/stridor
• Seizure (partial or generalized)
• Acute confusion
• Cardiac failure
Features of chronic hypocalcemia:
• Features of parkinsonism/other movement disorders
• Dementia
• Nail dystrophy
5 2.5 0
• Hair loss
• Dry skin
• Papilledema
• Cataract
Features of underlying cause:
• Evidence of neck surgery—suggestive of primary
hypoparathyroidism
• Abdominal tenderness (pancreatitis); previous surgery
(malabsorption); hepatic failure (hemochromatosis)
• Proximal muscle weakness—suggestive of osteomalacia
• Syndromic features (eg, moon facies, short fourth/fifth
5 2.5 0
metacarpals)—suggestive of genetic cause
• Evidence of malignancy such as breast or prostate
• Features of infiltrative diseases, such as skin discoloration
(hemochromatosis) or Kayser-Fleischer rings (Wilson’s
disease)
• Features of Addison’s disease, mucocutaneous candidiasis—
autoimmune polyglandular syndrome type 1\
Total out of 25 /25
Response a 28 Years old female presented to ER With history of muscle
twitching and carpopedal spasm for the last 2 days. She had history of
Total thyroidectomy 2 weeks back for large obstructive goiter.
• Physical exam:
• Looks ill, dehydrated.
• Average body built.
• Carpopedal spasm.
• -ve Chvostek's sign
• -ve Trousseau's sign
Examiner
What workup are you going to ask for?
Candidate • Corrected calcium 1 0.5 0
• Phosphate 1 0.5 0
• Parathyroid hormone 1 0.5 0
• Alkaline phosphatase 1 0.5 0
• Magnesium 1 0.5 0
• Vitamin D level 1 0.5 0
• BUN (urea)/creatinine 1 0.5 0
• Liver function tests 1 0.5 0
• ECG—looking for prolonged QTc or arrhythmia 1 0.5 0
Other investigations
• Amylase/lipase—if pancreatitis suspected
• Fecal elastase/bowel investigation—if malabsorption suspected
• Urinary magnesium—if urinary magnesium loss is suspected. 6 3 0
• x-rays—to look for osteomalacia due to vitamin D deficiency
• Bone scan and other imaging—for malignancy related hypocalcemia
• Genetic tests—if genetic causes of hypocalcemia suspected
Total out of 15 /15
Response Lab results:
• C.calcium:1.43 repeated 1.41
• Po4:1.77 (0.81-1.45)
• Albumin :43
• ALP:57
• MG:0.56
• Intact PTH:11 (15-65 ng/l)
• Vitamin D level :31 ( low)
Renal and liver function: WNL
Examiner What is the most likely diagnosis? Mention 4 differential diagnosis?
Candidate Post-surgical hypoparathyroidism + low vitamin D
7 3.5 0
Differential diagnosis:
1-Hypoparathyroidism: autoimmune destruction, genetic (DiGeorge
2 1 0
syndrome, infiltrative, post radiation.
2-PTH resistance: Pseudohypoparathyroidism, Magnesium deficiency 2 1 0
3-Inadequate vitamin D: nutritional, malabsorption, ESRD, cirrhosis. 2 1 0
 4- Miscellaneous: IV bisphosphonate, acute pancreatitis. 2 1 0
Total out of 15 /15

Examiner What are the lines of Management for this condition?

Candidate Sx pt with Tetany, seizures, laryngospasm, or cardiac dysfunction with
proven or strong suspicion of low calcium:
-10–20 mL of 10% calcium gluconate in 50–100 Ml 5% dextrose (or
3 1.5 0
0.9% saline) given over 10 min with ECG monitoring.
- Repeat above treatment until symptom-free. 3 1.5 0
-Treat hypomagnesemia (if present) with IV magnesium sulfate. 3 1.5 0
-Start IV infusion of 100 mL of 10% calcium gluconate in 1 L of normal
(0.9%) saline (or 5% dextrose) at a rate of 50–100 mL/hr Adjust rate 3 1.5 0
to normalize calcium.
-Start oral calcium and vitamin D (e.g., calcitriol or alfacalcidol) as
3 1.5 0
soon as possible.
Total out of 15 /15

Examiner Final mark out of 100 100

Final mark out of 100 10
≥70 clear pass 60-69 borderline pass 50-59 borderline fail < 50 clear fail