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MEDICINE OSCE

AL 2003 Batch

2008

Common areas

Haematology


CVS

Anaemia
Clotting disoders
Blood grouping
ECG
Mx of MI

RS


CXR
LFT
ABG

Common areas

CNS
CSF report
 CT

GUT
UFR
 Imaging
 RFT

Common areas

Clinical signs




Photo graphs-patients ,fundus,hand,eye,nail,
Characteristic facies
Dermatological conditions
Clinical features in text
True / False

Others


Specimen collection – bottles
equipments
Clinical stations / clinical interview

com .Haematology Slides Niroshan_loku@ yahoo.

Anaemia .

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Microcytic anaemia .

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Sickle cell anaemia .

Hereditary Spherocytosis .

Hereditary spherocytosis    Autosomal dominant Anaemia.hepatomegaly Increased osmotic fragility .jaundice.

Osm. fragility test .

Macrocytic anaemia .

Microangiopathic Haemolytic Anaemia .

Leukaemias .

com . Bone marrow.ALL. Complete replacement by small/medium sized blasts with scanty cytoplasm Niroshan_loku@ yahoo.

com .AML Myeloblast cells Niroshan_loku@ yahoo.

AML .

few smear cells .CLL Numerous Mature lymphocytes.

CLL .

CML Niroshan_loku@ yahoo.com .

.  Numerous granulocytic cells At different stages of differentiation.

MM – Plasma cells .

MM – Skull / bones .

Serum Protein Electrophoresis .monoclonal gammopathy .

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Salah BMA needle .

Jamshidi BM Trephine Biopsy needle .

HL .Niroshan_loku@ yahoo.com Reed-Sternberg cell .

RS cells .HL .

com .Other Slides Niroshan_loku@ yahoo.

Developing and thick (signet) ring forms Enlarged red cells  Pv malaria . Intermittent fevers since returning.A thin film from a 22-year-old male holidaying in Anuradhapura one month previously.

Numerous fine ring forms .

Pf malaria ring forms & sausage shaped gametocytes .

Malaria  Uncomplicated   Oral Chloroquine Complicated  IV quinine .

com .Instruments Niroshan_loku@ yahoo.

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Abraham’s Pleural Biopsy needle .

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PD catheter .

Desferrioxamine Infusion Pump40mg / kg/d over 8hrs per day para umbilically .

com .ECG Niroshan_loku@ yahoo.

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T .ST.QRS.QRS ABNORMALITY IN – P.ECG      RATE RHYTHM – REGULAR / IRREGULAR CARDIAC AXIS CONDUCTION INTERVALS – PR.

RATE  Heart rate = 300/R-R interval .

Heart rate   R-R INTERVAL = 8 large square So HR =300/8 = 38/min .

Normal ECG .

Rhythm abnormalities .

12 s  SVT .VT & SVT   55 QRS complx > 0.12 s  VT QRS complx < 0.

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VT 57 .

VT .

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60 .

Warfarin to prevent thromboembolism . LA fibrillation Rx:. IHD & cardiomyopathy. Atrial fibrillation – causes:. Thyrotoxicosis.MV disease .Digoxin to control Ventri rate.

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Atrial flutter .

HEART BLOCK 64 .

Ist degree HB .

Mobitz I (Wenkebach) .

Mobitz II 67 .

2:1 block 68 .

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3rd degree heart block / complete heart block .

3rd degree heart block / complete heart block Atrio ventricular dissociation. Atrium & ventricle have separate rhythms .

Bundle branch block 72 .

RBBB   73 V1  M wave / RSR’ V6  deep S wave .

LBBB   74 V6  M wave / RSR’ V1  deep S wave .

RBBB .

LBBB .

AMI in the setting of LBBB .

AXIS DEVIATION 78 .

LBBB .AXIS DEVIATION  RAD    LAD   79 LIII > L II > LI RVH.RBBB LI > LII > LIII LVH.

RAD 80 .

LAD 81 .

LAD .

RAD .

84 .

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86 .

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LAD .

HYPERTROPHY OF HEART 89 .

HEART CHAMBERS .HYPERTROPHY  LVH     90 Tall R wave in V6 & deep S wave in V1 V6 R wave > 25mm V1 S + V6 R > 35mm LAD .

HEART CHAMBERS .HYPERTROPHY  RVH    RAH    P wave > 3mm P pulmonale LAH  91 Tall R wave in V1 & deep S wave in V6 RAD P mitrale .

92

LVH

LVH

RA HYPERTROPHY – P PULMONALE

RAH .

ISCHAEMIC CHANGES IN ECG 97 .

Posterior MI .aVF Anterolateral   V4 to V6 & aVL. LI Inferior MI   V1 to V4 V1-V6. aVL. L1. L1. aVL Extensive anterior   LII.Leads & ischaemic area  Anterior MI   Lateral MI   98 V2-V6.LIII.

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Anterior MI .

Anterior MI .

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Inferior MI .

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OTHER CHANGES IN ECG 107 .

Hyperkalaemia .

Hyperkalaemia .

Chest X-Rays Niroshan_loku@ yahoo.com .

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112 .

L/pleural effusion/haemothorax .

R/Pneumothorax .

R/Tension pneumothrax .

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L/ pyopneumothorax .

R/upper lobe consolidation .

.Fibrosis.

Bronchiectasis .

typical of secondary tuberculosis .Some consolidation in the right upper lobe with a cavity (arrowed).

Cavity (Lung abscess) A welldefined rounded in L upper lobe (white arrow). .>1/2 of the cavity is filled with fluid and air (black arrow).

.Cavity (Lung abscess) Lateral view: The cavity in the left upper lobe is depicted. with the air-fluid interface (arrow).

Well-defined soft tissue mass in the right upper zone and a smaller mass medial to it. There is no bone destruction and no mediastinal lymphadenopathy. coin / cannon ball shadows .

Multiple lung mets Several. Most of them are in the lower lobes . differentlysized. mostly round shadows with the intensity of soft tissue in both lungs.

Milliary shadows .

Milliary shadows .

Hilar lyphadenopathy .

Lymphoma .

Pericardial calcification Read: causes for cardiomegaly .

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com .C T SCANS Niroshan_loku@ yahoo.

EDH .

Acute SDH .

B/L chronic SDH .

ICH .

SAH .

MCA infarct .

R/Anterior & middle cerebral infarct .

140 .

Cerebral abscess Ring enhancement in capsule of a bacterial abscess .

.Intracranial other SOLs eg: R/ Acoustic Neuroma A round mass of mixed signal in R/CP angle. It causes slight displacement of the brain stem medially. and extends into the auditory canal on the right. The edge of the mass makes an acute angle with the petrous bone.

MENINGIOMA in Contrast-enhanced CT .

com .Other Investigations Niroshan_loku@ yahoo.

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Rugger Jersy Spine .

IVU .Hydronephrosis .

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Bone Scans .

MRI scan – brain… .

Carotid angiogram .

V/Q scan .PE .

DTPA scan
(Diethelene-Triamine-Penta-Acetic acid)
Although the kidneys are the same size,
the center of the R/ kidney has areas of
decreased radioactivity; the hilum of the
R/kidney is lighter grey. This indicates that
the kidney has hydronephrosis; the pelvis
is so large that the renal parenchyma is
stretched over it.
Left kidneys show peak concentration
(computer generated curve) at about 57min. L/kidney promptly drains (curve
drops rapidly). The computer curve of the
right kidney shows a much more gradual
rise and it continues to rise almost to the
end of the study. This shows that the right
kidney doesn't drain; it is obstructed.
Additional studies demonstrated R/PUJO.

Normal DMSA renal study.

Normal right kidney with possible scar in
upper pole and scarred left kidney at upper
pole, middle and lower pole.

DMSA - HSK

Arterial Blood
Gas analysis

156

7-6kPa 11-15kPa .7.ABG Reference Values · · · · pH HCO3 pCO2 pO2 7.35 .45 22-26 mmol/L 35-45 mmHg 80-110 mmHg · SaO2 97-100% · BE –2 to +2 · AG <12-18 157 (24) (40) 4.

What is the primary problem – metabolic or respiratory 3. (pH determines whether the primary disorder is an acidosis or an alkalosis) 2.1. Know the pH. Any compensation? Compensation tries to normalize the pH Both CO2 & HCO3 goes to same direction Unusual to overcompensate Respiratory compensation is immediate while renal compensation takes time 158 .

13yr boy. 159 .8. pCO2=26. HCO3=12 Partially compensated metabolic acidosis The prolong history of fluid loss through diarrhea has caused a metabolic acidosis. The body has compensated by hyperventilation. ABG: pH=7.34. He appears lethargic and cool to touch with a prolonged capillary refill time. vomiting and diarrhea for 3 days. (lactic acid production from the hypovolemia and tissue hypoperfusion + bicarbonate losses in the stool).

HCO3 = 22 Uncompensated respiratory acidosis There has not been time for metabolic compensation to occur.16. RR 6. pCO2 = 70. He suffers a significant depression of mental status and respiration.9. 160 . pH = 7. 23yr student ?drug overdose.

HCO3=12.2.26yr male abd. pain & SOB pH=7. CBS= 590mg/dl Met acidosis with partial resp. PaO2 = 99. compensation 161 . PaCO2=22.

HCO3=32. PaO2 = 99. BE +9 Partially compensated met alkalosis 162 . PaCO2=46.54. shallow & RR=10 pH=7.45yr female developed hypoventilation & slight disorientation after D2 of peptic ulcer Sx O/E NG in situ BP. pulse & ECG – NAD Resp.

fever. meningitis. drugssalicilates….) .Few causes…. anxiety.  163 Resp Acidosis Type II Resp failure  Resp Alkalosis Hyperventilation (CNS – stroke.

Alkalosis Vomiting Freq. NG suction Hyperaldosteronism Diuretics . Acidosis Renal failure Keto-acidosis Lactic acidosis Diarrhea Illeostomy Renal TA 164  Met.Few causes….  Met.

Respiratory Failure  Hypoxia (PaO2 < 8 kPa or <60 mmHg) with normocapnia (PaCO2< 6.5kPa) Type I Resp Failure with hypercapnia (PaCO2> 6.5kPa) Type II Resp Failure 165 .

Resp. Function Tests 166 .

167 .

168 .

Fundoscopy Niroshan_loku@ yahoo.com .

DM retinopathy .

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DM retinopathy (Proliferative) .

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RIGHT: This patient developed central retinal vein occlusion as a result of uncontrolled hypertension – angry looking eye .LEFT: Moderate hypertensive retinopathy with hemorrhages and exudates.

vessel markings are reduce. enlarge disk. cup can’t see.Ht retinopathy( grade IV) / Papilloedema – Ill defined disk margin. Pulsations invisible .

Macular star in Ht .

Optic atrophy .

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ALT > 6 Times & ALP < 2.5 times

ALT < 6 Times & ALP > 2.5 times

184

Hepatocellular jaundice

Obstructive jaundice

TRUE / FALSE 185 .

QUESTION 1     186 Urine Ix of a man during test for insurance is given below BU & S.Cr  NAD UFR  pus cells 40/hpf protein + appearance – clear urine culture .negative .

 List 3 causes?     187 Urinary calculi TB Urinary tract malignancy cystitis .

5mg/dl ) AST -100 IU ( < 35 IU ) ALT – 90 IU ALP – 800 I WHAT IS THE DIAGNOSIS? NAME 1 Ix TO CONFIRM THE DIAGNOSIS LIST 2 AETIOLOGICAL FACTORS .Question 2  In a patient with jaundice        188 Bilirubin -12 mg/dl ( < 1.

Question 3 189 .

TRUE / FALSE      190 It is an EDH Due to bleeding from middle meningeal artery CSF will be xanthochromic Alcoholism is a risk factor Patient may have confusion .

Physical Signs Niroshan_loku@ yahoo.com .

Acromegaly face .

Hypothyroid facies .

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Thyrotoxic facies .

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L / 3rd CN palsy .

Facial N palsy .

com .Niroshan_loku@ yahoo.

Addison disease – oral pigmentation .

Oral candidasis .

RA .Hand Niroshan_loku@ yahoo.com .

Ulnar nerve palsy .

Duputren’s contracture .

Tendon Xanthoma .

Scabies hands & legs

NF

Plaque Psoriasis

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E. nodosum .

multiforme .Niroshan_loku@ yahoo.com E.

Typhus .

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com .Snakes Niroshan_loku@ yahoo.

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Miscellaneous Niroshan_loku@ yahoo.com .

Fatty liver .

Macronodular cirrhosis .

HCC/ Liver IIry .

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Niyangala .

com .Good Luck! Feedbacks to niroshan_loku@yahoo.