OSCE of 5 cases

1. DR SUBHASISH DEB
Burdwan Medical College and Hospital
Department of General Medicine
OSCE
DR SUBHASISH DEB 09/12/2014
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2. DR SUBHASISH DEB 09/12/2014
CASE 1
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3. DR SUBHASISH DEB 09/12/2014
 A 72 year old man presented with
generalized erythroderma with palmer and
planter hyperkeatosis and enlarged Lymph
nodes.
 WBC= 24,000/ul (mico lit)
 Peripheral smear shows the following
atypical cell.
 Skin biposy showed epidermotropism of the
atypical cells
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4. (A)Typical erythroderma of Sézary syndrome, and
(B) solitary mycosis fungoides plaque,
(C) tumour nodule of large cell lymphoma (LCL). Histology reveals
(D) an upper band-like infiltrate with epidermotropism of atypical
lymphocytes and
DR SUBHASISH DEB 09/12/2014
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5. SEZARY SYNDROME
 An aggressive form of CTCL (cutaneous T
cell Lymphoma)
 Triad:
1. Erythroderma (diffuse)
2. Lymphadenopathy
3. Circulating atypical lymphocytes (Sezary
cells)
DR SUBHASISH DEB 09/12/2014
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6. DR SUBHASISH DEB 09/12/2014
DIAGNOSTIC CRITERIA
 1 or more of the following should be present:
1. An absolute Sézary cell count of least 1000
cells/μL
2. Demonstration of an expanded CD4+ T-cell
population CD4/CD8 > 10; loss of any or all
of the T-cell antigens CD2, CD3, CD4, and
CD5; or loss of both CD4 and CD5)
3. Identical T-cell clone in blood and skin. (by
molecular assay like pcr)
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7. DR SUBHASISH DEB 09/12/2014
 Mycosis fungoides and SS are the m/c
CTCLs
 Lineage: Mature (peripheral) T cells
 SS differentiated from MF by presence of
atypical lymphocytes in blood.
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8. DR SUBHASISH DEB 09/12/2014
CASE 2
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9.  A 70 year old woman came with a c/o of
chest pain with radiation to left shoulder. She
has a medical h/o of hypercholesterolemia.
Her ECG showed the following.
 Trop T – positive
 CXR- NAD
 Ur-30, Cr-1.0
DR SUBHASISH DEB 09/12/2014
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10. DR SUBHASISH DEB 09/12/2014
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11. POSTERIOR WALL MI
DR SUBHASISH DEB 09/12/2014
 PMI also called ‘dead angle infarction’
 One of the m/c missed types of AMI
 The term PMI is used for necrosis of the
dorsal infraatrial part of the left ventricle
located between the atrioventricular sulcus
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12. DR SUBHASISH DEB 09/12/2014
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13. DR SUBHASISH DEB 09/12/2014
 Occurs due to stenosis/ occlusion of RCX
 Often accompanied by inferior and/or lateral
wall MI
 Pts with ecg of isolated PMI often do not
receive the appropriate reperfusion t/t due to
lack of classical ST-segment elevation in
normal 12 lead ecg
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14. ECG FINDINGS
DR SUBHASISH DEB 09/12/2014
 V1 and V2 are mirror images of V1 and V2 of
anterior wall MI
 Vector cardiogram points ventrally due to
loss of the electrical forces normally aimed
dorsally, resulting in a prolonged R wave –
R/S >1 in V1 and V2
 ST depression in precordial leads in acute
phase + tall upright T waves
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15. USE OF DORSAL LEADS
 Mortality reduction is max when reperfused
within 6hrs if pain onset
 POSTERIOR LEADS:
 V7 – at the level of V6 at post Axillary line
 V8 – left side of back at the tip of scapula
 V9 – half way between V8 and the left
paraspinal muscles
ST elevation >1mm in post leads is suggestive
of PMI
DR SUBHASISH DEB 09/12/2014
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16. DR SUBHASISH DEB 09/12/2014
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17. DR SUBHASISH DEB 09/12/2014
 Sensitivity increases from 32% to 57% and
specificity 98% for RCX on the 15 lead ecg
instead of the normal 12 lead ecg
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18. DR SUBHASISH DEB 09/12/2014
CASE 3
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19. DR SUBHASISH DEB 09/12/2014
 A 83 year old man with h/o heart disease
with repeated symptomatic episodes of CHF
presented with c/o cough and progessive
orthopnea and 3 weeks of PND. CXR
showed A
 Pt was treated with iv furosemide, t. digoxin,
iv nitroglycerine and captopril. He improved
in 3 days and 6 days later, repeat CXR
showed B
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20. DR SUBHASISH DEB 09/12/2014
A B
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21. PHANTOM TUMOUR
DR SUBHASISH DEB 09/12/2014
 The term phantom tumour is applied to a
transudative interlobar pleural fluid collection
in CHF which disappears spontaneously with
compensation and may reappear on
decompensation
 USUALLY SEEN IN:
 CHF
 Renal Failure
 Hypoalbuminemia
Due to transudation from pulmonary
vasculature
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22. PATHOGENESIS
DR SUBHASISH DEB 09/12/2014
 Involves the adhesion and obliteration of the
pleural space due to pleuritis that may be
transient, thereby preventing the free
accumulation of fluid.
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23. DR SUBHASISH DEB 09/12/2014
CASE 4
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24. DR SUBHASISH DEB 09/12/2014
 A 56 year old woman with past h/o of HTN
presented with flue like symptoms that were
ongoing for last 3 days. While waiting in the
observation room for 6 hrs, she developed
chest pain. No family h/o of any cardiac
problems.
 ECG - showed the follwing
 TROP t – positive
 ECHO – hypokinetic walls with EF – 35%
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25. DR SUBHASISH DEB 09/12/2014
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26. MYOCARDITIS
DR SUBHASISH DEB 09/12/2014
 NON ISCHEMIC myocardial inflammation
resulting from a variety of infectious, immune
and toxic insults.
 DCM and Chronic Heart Failure are the
mojor long term sequla of myocarditis.
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27. DR SUBHASISH DEB 09/12/2014
 M/c/c in Europe and North America – VIRUS
 m/c/c Worldwide – chagas disease
 Less common non viral pathogens:
1. Borrelia Burgdorferi
2. Trypanosoma Cruzi
3. Hypersensitivity to drugs
4. Autoimmune reaction
(Streotococcal M protein and Coxsakie virus B
epitopes are similar to cardiac myosin)
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28. DR SUBHASISH DEB 09/12/2014
 As definitive diagnosis requires a heart
biopsy,which doctors are reluctant to do,
statistics on the incidence of myocarditis vary
widely.
 Among HIV patients, myocarditis is the m/c
cardiac pathological finding at autopsy.
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29. SIGNS AND SYMPTOMS
1. Chest pain (stabbing)
2. CHF
3. Palpitation
4. Sudden death
5. Fever
6. Flue like symptoms
DR SUBHASISH DEB 09/12/2014
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30. DIAGNOSIS
DR SUBHASISH DEB 09/12/2014
 ECG- diffuse t wave inversions, saddle
shaped ST-segment elevations (also in
pericarditis)
 Gold standard – biopsy of myocardium
Generally done in a setting of angiography. A
small tissue sample of te endoand
myocardium is taken
Also useful are IgM against virus, ESR, CRP
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31. TREATMENT
DR SUBHASISH DEB 09/12/2014
 Viral infections cannot be treated with direct
therapy – symptomatic
 People who do not responf to convesional
therapy are candidayes for bridge thrapy with
Left ventricular assist device
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32. DR SUBHASISH DEB 09/12/2014
CASE 5
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33. DR SUBHASISH DEB 09/12/2014
 A 20 years old man presented with this
rash and 1st degree heart block.
What is the diagnosis and what is the
treatment ?
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34. DR SUBHASISH DEB 09/12/2014
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35. LYME DISEASE
DR SUBHASISH DEB 09/12/2014
 Borrelia burgdorferi is transmitted to humans
by the bite of infected hard ticks.
 Early symptoms may include fever, headache,
fatigue, depression, and a characteristic
circular skin rash called erythema migrans
(bull's eye rash) .
 Left untreated, later symptoms may involve
the joints, heart, and central nervous system.
 Treatment: antibiotics-doxycycline, if have
later complications- cefotaxime or ceftriaxone.
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