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

Haematology Slides

Niroshan_loku@ yahoo.com

Anaemia

Microcytic anaemia

Sickle cell anaemia

Hereditary Spherocytosis

Hereditary spherocytosis

Autosomal dominant
Anaemia,jaundice,hepatomegaly
Increased osmotic fragility

Osm. fragility test

Macrocytic anaemia

Microangiopathic Haemolytic Anaemia

Leukaemias

ALL. Bone marrow.

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

AML

Myeloblast cells

Niroshan_loku@ yahoo.com

AML

CLL
Numerous Mature lymphocytes, few smear cells

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

Salah BMA needle

Jamshidi BM Trephine Biopsy needle

Niroshan_loku@ yahoo.com

Reed-Sternberg cell - HL

RS cells - HL

Other Slides

Niroshan_loku@ yahoo.com

A thin film from a 22-year-old male holidaying in

Anuradhapura one month previously. Intermittent fevers
since returning.

Developing and thick (signet) ring forms

Enlarged red cells Pv malaria

Numerous fine ring forms

Pf malaria ring forms & sausage shaped gametocytes

Malaria

Uncomplicated

Oral Chloroquine

Complicated

IV quinine

Instruments

Niroshan_loku@ yahoo.com

Abrahams Pleural Biopsy needle

PD catheter

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

umbilically

ECG
Niroshan_loku@ yahoo.com

ECG

RATE
RHYTHM REGULAR / IRREGULAR
CARDIAC AXIS
CONDUCTION INTERVALS PR,QRS
ABNORMALITY IN P,QRS,ST,T

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

VT & SVT

55

QRS complx > 0.12 s VT

QRS complx < 0.12 s SVT

VT
57

VT

60

Atrial fibrillation causes:- MV disease , IHD & cardiomyopathy, Thyrotoxicosis, LA fibrillation

Rx:- Digoxin to control Ventri rate, Warfarin to prevent thromboembolism

Atrial flutter

HEART BLOCK

64

Ist degree HB

Mobitz I (Wenkebach)

Mobitz II
67

2:1
block
68

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

AXIS DEVIATION

RAD

LAD

79

LIII > L II > LI

RVH,RBBB

LI > LII > LIII

LVH,LBBB

RAD
80

LAD
81

LAD

RAD

84

86

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

Leads & ischaemic area

Anterior MI

Lateral MI

98

V2-V6, L1, aVL

Extensive anterior

LII,LIII.aVF

Anterolateral

V4 to V6 & aVL, LI

Inferior MI

V1 to V4

V1-V6, L1, aVL,

Posterior MI

Anterior MI

Anterior MI

Inferior MI

OTHER CHANGES IN ECG

107

Hyperkalaemia

Hyperkalaemia

Chest X-Rays
Niroshan_loku@ yahoo.com

112

L/pleural effusion/haemothorax

R/Pneumothorax

R/Tension pneumothrax

L/ pyopneumothorax

R/upper lobe consolidation

Fibrosis.

Bronchiectasis

Some consolidation in the right upper lobe

with a cavity (arrowed), typical of
secondary tuberculosis

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,
differentlysized, mostly
round shadows
with the
intensity of soft
tissue in both
lungs. Most of
them are in the
lower lobes

Milliary shadows

Milliary shadows

Hilar lyphadenopathy

Lymphoma

Pericardial calcification
Read: causes for cardiomegaly

C T SCANS
Niroshan_loku@ yahoo.com

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

Other Investigations

Niroshan_loku@ yahoo.com

Rugger Jersy Spine

IVU - Hydronephrosis

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

ABG Reference Values

pH
HCO3
pCO2
pO2

7.35 - 7.45
22-26 mmol/L
35-45 mmHg
80-110 mmHg

SaO2 97-100%
BE 2 to +2
AG <12-18
157

(24)
(40)

4.7-6kPa
11-15kPa

1. Know the pH; (pH determines whether the

primary disorder is an acidosis or an alkalosis)

2. What is the primary problem metabolic or

respiratory
3. 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

8. 13yr boy, vomiting and diarrhea for 3

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

9. 23yr student ?drug overdose. He suffers

a significant depression of mental status and
respiration. RR 6. pH = 7.16, pCO2 = 70,
HCO3 = 22

Uncompensated respiratory acidosis

There has not been time for metabolic compensation to
occur.

160

26yr male abd. pain & SOB

pH=7.2, PaCO2=22, HCO3=12,
PaO2 = 99. CBS= 590mg/dl
Met acidosis with partial resp. compensation

161

45yr female developed hypoventilation & slight

disorientation after D2 of peptic ulcer Sx
O/E NG in situ
BP, pulse & ECG NAD
Resp. shallow & RR=10
pH=7.54, PaCO2=46, HCO3=32, PaO2 = 99. BE +9
Partially compensated met alkalosis

162

Few causes.

163

Resp Acidosis
Type II Resp failure

Resp Alkalosis
Hyperventilation
(CNS stroke,
meningitis, anxiety,
fever, drugssalicilates.)

Few causes.

Met. Acidosis
Renal failure
Keto-acidosis
Lactic acidosis
Diarrhea
Illeostomy
Renal TA

164

Met. Alkalosis
Vomiting
Freq. NG suction
Hyperaldosteronism
Diuretics

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

DM retinopathy (Proliferative)

LEFT: Moderate hypertensive retinopathy with hemorrhages and exudates.

RIGHT: This patient developed central retinal vein occlusion as a result of
uncontrolled hypertension angry looking eye

Ht retinopathy( grade IV) / Papilloedema Ill defined disk margin, enlarge disk, cup
cant see, vessel markings are reduce. Pulsations invisible

Macular star in Ht

Optic atrophy

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

Question 2

In a patient with jaundice

188

Bilirubin -12 mg/dl ( < 1.5mg/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 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

Thyrotoxic facies

L / 3rd CN palsy

Facial N palsy

Niroshan_loku@ yahoo.com

Addison disease oral pigmentation

Oral candidasis

RA - Hand

Niroshan_loku@ yahoo.com

Ulnar nerve palsy

Duputrens contracture

Tendon Xanthoma

Scabies hands & legs

NF

Plaque Psoriasis

E. nodosum

Niroshan_loku@ yahoo.com

E. multiforme

Typhus

Snakes
Niroshan_loku@ yahoo.com

Miscellaneous

Niroshan_loku@ yahoo.com

Fatty liver

Macronodular cirrhosis

HCC/ Liver IIry

Niyangala

Good Luck!
Feedbacks to
niroshan_loku@yahoo.com