OSCE

1. OSCE
Dr Subhasish Deb
Burdwan Medical College & Hospital
Dept of General Medicine
Dr Subhasish Deb, BMC

2. CASE 1
Dr Subhasish Deb, BMC

3. • A 65yr old woman present to the med opd
with low back pain and stiffness on forward
flexion. HLA B-27 positive.
• X Ray of the pelvis and spine were ordered
and showed:
Dr Subhasish Deb, BMC

4. Dr Subhasish Deb, BMC

5. Dr Subhasish Deb, BMC

6. Diffuse Idiopathic Skeletal
Hyperostosis (DISH)
• Aka Forestier’s disaese
• Non inflammatory spondyloarthopathy of
spine
• Characterized by spiny ankylosis and
enthesopathy (ossification of ligaments and
enthese)
• Commonly affects elderly – 6th to 7th decade.
Dr Subhasish Deb, BMC

7. Pathology
• focal and diffuse calcification and ossification
of the anterior longitudinal ligament
• paraspinal connective tissue and annulus
fibrosis
• degeneration in the peripheral annulus
fibrosis fibers
• hypervascularity
• periosteal new bone formation on the anterior
surface of the vertebral bodies
Dr Subhasish Deb, BMC

8. Radiographic features
• florid, flowing ossification is noted along the
anterior or right anterolateral aspects of at
least four contiguous vertebrae, so-called
flowing ossifications.
• disc spaces are usually well preserved
• ankylosis is more commonly seen in the
thoracic than in the cervical or lumbar spine.
• no sacroiliitis or facet joint ankylosis
Dr Subhasish Deb, BMC

9. Dr Subhasish Deb, BMC

10. Dr Subhasish Deb, BMC

11. Treatment
• Physiotherapy
• NSAIDS
Dr Subhasish Deb, BMC

12. CASE 2
Dr Subhasish Deb, BMC

13. • A 62 year old woman presented with low back
pain for the past 6 months and shooting pain
around the thighs.
• X ray LS spine showed:
Dr Subhasish Deb, BMC

14. Dr Subhasish Deb, BMC

15. Spondylolysthesis
• Forward displacement of a vertebrae esp the
5th lumbar vert
• m/c/c- spondylolysis (a defect or fracture of
the pars interarticularis of the vertebral arch)
• should not be confused with a slipped disc, in
which one of the spinal discs in between the
vertebrae has ruptured.
• Backward displacement = retrolysthesis
Dr Subhasish Deb, BMC

16. Dr Subhasish Deb, BMC

17. Treatment
• Conservative : Nsaids + physiotherapy
• Surgery if canal stenosis present
Dr Subhasish Deb, BMC

18. Scotty dog sign with collar
• The scotty dog sign refers to the normal appearance of the
lumbar spine when seen on oblique radiographic
projection. On oblique views, the posterior elements of
vertebra form the figure of a Scotty dog with:
• the transverse process being the nose
• the pedicle forming the eye
• the inferior articular facet being the front leg
• the superior articular facet representing the ear
• the pars interarticularis (the portion of the lamina that lies
between the facets) equivalent to the neck of the dog.
• If spondylolysis is present, the pars interarticularis, or the
neck of the dog, will have a defect or break. It often looks
as if the dog has a collar around the neck
Dr Subhasish Deb, BMC

19. Dr Subhasish Deb, BMC

20. CASE 3
Dr Subhasish Deb, BMC

21. • A 70yr old man presented with low back pain.
He had moderate pallor and complaint of
loose fitting of his clothes since the past 5
months.
• X ray LS spine showed
Dr Subhasish Deb, BMC

22. Dr Subhasish Deb, BMC

23. Prostate CA
• Osteoblastic lesion in vertebrae/ bone
• Screening- Digital rectal exam, PSA
• Diagnosis- Biopsy
• Gleason score
• t/t- depends on stage
– Low grade in a elderly (>60yr) no t/t as it grows
very slowly
– Advanced dis- radical prostatectomy +
radiotherapy
Dr Subhasish Deb, BMC

24. CASE 4
Dr Subhasish Deb, BMC

25. • A 73 year old woman being treated for Rhumatoid
Arthritis for several years with methotrexate and
sulphasalazine complaint of puffiness of her face and
legs for the past 1 month. Routine urine showed
albumin ++ and a 24 hr unrine protein was ordered.
What will you expect in renal biopsy?
1. Normal glomeruli
2. IG A deposits
3. Apple green fluorescence with birefringent deposits
on polarized microscopy
4. Thickening of GBM
Dr Subhasish Deb, BMC

26. • Ans: 3 apple green staining with birefingent
deposits
AMYLOIDOSIS
Dr Subhasish Deb, BMC

27. Dr Subhasish Deb, BMC

28. AMYLOIDOSIS
• disease resulting from extracellular
accumulation of inappropriately folded
proteins
• These misfolded proteins = amyloids
• In 1854, Rudolph Virchow named it amyloid
based on the colour after staining them iodine
and sulphuric acid.
• Means cellulose or strach
Dr Subhasish Deb, BMC

29. Some common amyloid proteins
Dr Subhasish Deb, BMC

30. Diagnosis
• By tissue biopsy
• Congo red stain + polarized light = apple green
fluorecence
• Site of tissue: any involved organ but in
systemic disease subcut abdominal fat biopsy
done, is less invasive than rectal, salivary
gland and organ biopsy
Dr Subhasish Deb, BMC

31. Treatment
• Limited and research is still in progress
• Treatment depends on the subtype
• AL and AH:
– High dose mephalan +
dexamethasone/prednosolone
– In selected canditates, autologus stem cell
transplant
– The goal with t/t is to get rid of clonal plasma cells
that lead to immunoglobulin protein
Dr Subhasish Deb, BMC

32. • AA: treat the chronic inflammatory condition
or infection
• Familial Mediterranean fever : cholchicine
• Prognosis is poor
Dr Subhasish Deb, BMC

33. Case 5
Dr Subhasish Deb, BMC

34. Dr Subhasish Deb, BMC

35. HANG NAIL / AGNAIL
• torn piece of skin next to fingernail or toenail
• usually caused by dry skin or (in the case of
fingernails) nail biting, and may be prevented with
proper moisturization of the skin.
• When attempting to remove a hangnail, additional skin
may be painfully ripped off of its attachment if not
broken properly. This may lead to a painful infection
called paronychia. Therefore, hangnails should usually
be cut using nail scissors or a nail clipper; biting or
pulling them frequently makes them worse. People
with a hangnail should be careful to cut it all off and
rub hand lotion into the cuticles two to three times a
day. Dr Subhasish Deb, BMC

36. THANK YOU
Dr Subhasish Deb, BMC