1. OSCE Raika Jamali M.D. Gastroenterologist and hepatologist Sina hospital Tehran University of Medical Sciences

2. Case 56 A middle age woman with mild abdominal pain that tolerate food intake. A middle age woman with mild abdominal pain that tolerate food intake. You see the CT scan of patient in next slides. You see the CT scan of patient in next slides.

3. Physical examination: Conscious, cooperative Vital signs are stable. No Icteric sclera, She was not pale, No peripheral LNP, Heart and lung are normal. Abdomen: Epigastric tenderness, No Morphy sign, Liver span=12 cm, No shifting dullness,

4. Lab findings Hb = 13.4 gr/dl, RBC = 5.1x10 6, MCV=102, MCH & MCHC = normal PLT = 217000 WBC = 9100, poly = 68% lymph = 27% ESR = 22, PT = 12.5 sec. INR = 1.1, Albumin = 4.4 g/dl / total protein = 5.7g/dl BUN, Creatinine= normal 24 hour urinary protein= normal

5. AST = 79 U/L ALT = 62 U/L Alkaline phosphatase = 769 U/L Viral markers = negative Amylase = 100 T= 1.2 Bilirubin mg/dl D=0.8

7. What is your diagnosis? A)Pancreatic abscess B)Acute mild pancreatitis C)Pancreatic pseudocyst D)Chronic pancreatitis E)Necrotizing pancreatitis F)Focal nodular hyperplasia

8. What is the best treatment? A) Prompt surgical consult for resection B) Intraveous antibiotic plus appropriate hydration C) CT guided percutaneous aspiration D) Angiographic chemoembolization E) Follow up visits

9. Case 57 A middle age man with RUQ pain and vomiting. You see the CT scan of patient in 48 hours after the onset of pain.

10. Physical examination: Conscious, cooperative T (oral) = 37.5° c Icteric sclera, He was pale, No peripheral LNP, Heart and lung are normal. Abdomen: Epigastric tenderness, No Morphy sign, Liver span=12 cm, Shifting dullness,

11. Lab findings Hb = 9.4 gr/dl, RBC = 5.1x10 6, MCV=102, MCH & MCHC = normal PLT = 217000 WBC = 12100, poly = 88% lymph = 12% ESR = 22, PT = 12.5 sec. INR = 1.1, Albumin = 4.4 g/dl / total protein = 5.7g/dl BUN, Creatinine= normal 24 hour urinary protein= normal

12. AST = 119 U/L ALT = 122 U/L Alkaline phosphatase = 769 U/L Viral markers = negative Amylase = 1000 T= 3.2 Bilirubin mg/dl D=1.8

15. What is your diagnosis? A)Pancreatic abscess B)Acute mild pancreatitis C)Pancreatic pseudocyst D)Chronic pancreatitis E)Necrotizing pancreatitis F)Intra peritoneal metastasis

16. What is the best treatment? A) Prompt surgical consult for resection B) Intraveous antibiotic plus appropriate hydration C) A & B D) CT guided percutaneous aspiration E) Angiographic chemoembolization

17. Case 58 A middle age woman with chronic abdominal pain. You see the CT scan of patient in next slides.

18. Physical examination: Conscious, cooperative Vital signs are stable. No Icteric sclera, She was not pale, No peripheral LNP, Heart and lung are normal. Abdomen: Epigastric tenderness, No Morphy sign, Liver span=12 cm, No shifting dullness,

19. Lab findings Hb = 13.4 gr/dl, RBC = 5.1x10 6, MCV=102, MCH & MCHC = normal PLT = 217000 WBC = 9100, poly = 68% lymph = 27% ESR = 22, PT = 12.5 sec. INR = 1.1, Albumin = 4.4 g/dl / total protein = 5.7g/dl BUN, Creatinine= normal 24 hour urinary protein= normal

20. AST = 49 U/L ALT = 42 U/L Alkaline phosphatase = 769 U/L Tumor markers = negative Amylase = 100 T= 1.2 Bilirubin mg/dl D=0.8

23. What is your diagnosis? A)Pancreatic abscess B)Acute mild pancreatitis C)Pancreatic pseudocyst D)Chronic pancreatitis E)Necrotizing pancreatitis F)Intra peritoneal metastasis

24. What is the best treatment? A) Prompt surgical consult for resection B) Intraveous antibiotic plus appropriate hydration C) ERCP for drainage and pancreatic stent placement D) CT guided percutaneous aspiration E) Angiographic chemoembolization

25. Case 60 A middle age woman with chronic abdominal pain and weight loss. You see the CT scan of patient in next slides.

26. Physical examination: Conscious, cooperative Vital signs are stable. No Icteric sclera, She was not pale, No peripheral LNP, Heart and lung are normal. Abdomen: Epigastric tenderness, No Morphy sign, Liver span=12 cm, No shifting dullness,

27. Lab findings Hb = 13.4 gr/dl, RBC = 5.1x10 6, MCV=102, MCH & MCHC = normal PLT = 217000 WBC = 9100, poly = 68% lymph = 27% ESR = 22, PT = 12.5 sec. INR = 1.1, Albumin = 4.4 g/dl / total protein = 5.7g/dl BUN, Creatinine= normal 24 hour urinary protein= normal

28. AST = 49 U/L ALT = 42 U/L Alkaline phosphatase = 769 U/L CEA & CA 19-9 > 3 Upper limit normal range Amylase = 100 T= 1.2 Bilirubin mg/dl D=0.8

30. What is your diagnosis? A)Pancreatic abscess B)Acute mild pancreatitis C)Pancreatic pseudocyst D)Chronic pancreatitis E)Necrotizing pancreatitis F)Pancreatic cyst adenocarcinoma

31. What is the best treatment? A) Prompt surgical consult for resection B) Intraveous antibiotic plus appropriate hydration C) ERCP for drainage and pancreatic stent placement D) CT guided percutaneous aspiration E) Angiographic chemoembolization

32. Case 61 A middle age woman with epigastric pain. You see the CT scan of patient in next slides.

33. Physical examination: Conscious, cooperative T (oral) = 39.5° c Icteric sclera, She was not pale, No peripheral LNP, Heart and lung are normal. Abdomen: Epigastric tenderness, No Morphy sign, Liver span=12 cm, Shifting dullness,

34. Lab findings Hb = 11.4 gr/dl, RBC = 5.1x10 6, MCV=102, MCH & MCHC = normal PLT = 217000 WBC = 12100, poly = 88% lymph = 12% ESR = 22, PT = 12.5 sec. INR = 1.1, Albumin = 3.4 g/dl / total protein = 5.7g/dl BUN, Creatinine= normal 24 hour urinary protein= normal

35. AST = 119 U/L ALT = 122 U/L Alkaline phosphatase = 969 U/L Tumor markers = negative Amylase = 1000 T= 3.2 Bilirubin mg/dl D=1.8

38. What is your diagnosis? A)Pancreatic abscess B)Acute mild pancreatitis C)Pancreatic pseudocyst D)Chronic pancreatitis E)Necrotizing pancreatitis F)Pancreatic cyst adenocarcinoma

39. What is the best treatment? A) Prompt surgical consult for resection B) Intraveous antibiotic plus appropriate hydration C) A & B D) ERCP for drainage and pancreatic stent placement E) CT guided percutaneous aspiration F) Angiographic chemoembolization

40. Case 62 A middle age woman with epigastric pain and shock. You see the CT scan of patient in next slides.

41. Physical examination: Conscious, cooperative T (oral) = 37.5° c Icteric sclera, She was pale, No peripheral LNP, Heart and lung are normal. Abdomen: Epigastric tenderness, No Morphy sign, Liver span=12 cm, Shifting dullness,

42. Lab findings Hb = 6.4 gr/dl, RBC = 5.1x10 6, MCV=102, MCH & MCHC = normal PLT = 217000 WBC = 12100, poly = 88% lymph = 12% ESR = 22, PT = 12.5 sec. INR = 1.1, Albumin = 3.4 g/dl / total protein = 5.7g/dl

43. AST = 119 U/L ALT = 122 U/L Alkaline phosphatase = 969 U/L Tumor markers = negative Amylase = 1000 T= 3.2 Bilirubin mg/dl D=1.8

45. What is your diagnosis? A)Pancreatic abscess B)Hemorrhagic pancreatic pseudocyst C)Pancreatic pseudocyst D)Chronic pancreatitis E)Necrotizing pancreatitis F)Pancreatic cyst adenocarcinoma

46. What is the best treatment? A) Prompt surgical consult for hemostasis B) Blood transfusion plus appropriate hydration C) A & B D) ERCP for drainage and pancreatic stent placement E) CT guided percutaneous aspiration F) Angiographic chemoembolization

47. Case 63 A middle age man with abdominal distention. He had hepatosplenomegaly without shifting dullness in physical exam. You see the CT scan of patient in next slides.

48. Physical examination: Conscious, cooperative Blood pressure: 180/ 110 mm Hg. No Icteric sclera, She was not pale, No peripheral LNP, Heart and lung are normal. Abdomen: Hepatosplenomegaly was detected, No Morphy sign, No sign of portal hypertension, No shifting dullness,

49. Lab findings Hb = 14 gr/dl, RBC = 5.1x10 6, MCV=102, MCH & MCHC = normal PLT = 217000 WBC = 6100, poly = 45% lymph = 55% ESR = 22, PT = 12.5 sec. INR = 1.1, Albumin = 3.4 g/dl / total protein = 5.7g/dl Creatinine = 2.5 mg/dl U/A = normal

50. AST = 119 U/L ALT = 122 U/L Alkaline phosphatase = 969 U/L Tumor markers = negative Na = 145 mEq/l K= 4.5 mEq/L T= 3.2 Bilirubin mg/dl D=1.8

52. What is your diagnosis? A)Primary amyloidosis B)Primary liver lymphoma C)Liver metastasis D)AD Polycystic kidney disease E)Intra peritoneal carcinomatosis F)Storage diseases

53. What is the best treatment? A) Prompt surgical consult for resection B) Diagnostic laparoscopy C) Control of hypertension and low salt diet D) liver and kidney transplantation on E) CT guided percutaneous aspiration

54. Case 64 An old man with lower abdominal pain. He had tenderness in LLQ. You see the abdominal sonography and CT scan of patient in the next slides.

57. What is your diagnosis? A)Pancreatic abscess B)Hemorrhagic pancreatic pseudocyst C)Pancreatic pseudocyst D)Chronic pancreatitis E)Necrotizing pancreatitis F)Pancreatic cyst adenocarcinoma

58. What is the best treatment? A) Prompt surgical consult for hemostasis B) Blood transfusion plus appropriate hydration C) A & B D) ERCP for drainage and pancreatic stent placement E) CT guided percutaneous aspiration F) Angiographic chemoembolization

59. Case 65 A young man with epigastric pain. She had hepatomegaly in physical exam. You see the CT scan of the patient in next slide.

61. What is your diagnosis? A)Pancreatic abscess B)Hemorrhagic pancreatic pseudocyst C)Pancreatic pseudocyst D)Chronic pancreatitis E)Necrotizing pancreatitis F)Pancreatic cyst adenocarcinoma

62. What is the best treatment? A) Prompt surgical consult for hemostasis B) Blood transfusion plus appropriate hydration C) A & B D) ERCP for drainage and pancreatic stent placement E) CT guided percutaneous aspiration F) Angiographic chemoembolization