IMED OSCE Guide

Nephrology: Nephritic Syndrome (allergic interstitial nephritis, lupus nephritis), Nephrotic

Syndrome (Diabetic Nephropathy (Diffuse glomerulosclerosis)), Lupus and Chronic kidney
disease, hypo/hypernatremia, hypo/hyperkalemia, AKI, Acid Base disorders
Questions to ask:
● İdrar yaparken yanma yada ağrı oluyor mu? Günde kaç kez tuvalette gidersiniz?
İdrar miktarında azalma fark ettiniz mi? Gecede idrar yapmak icin kalkıyor
musunuz? İdrarda çıkarmaya zorlanıyor musunuz? Tek seferde yapabilir misiniz
yoksa kesik kesik mi geliyor? İdrar kaçırıyorsunuz hiç? İdrar rengi veya koku
değişiklik var mı? Ne rengiydi? Kanlı mıydı?
● Karın ağrın var mı? Yan ağrın var mı? Yandan gelen aşağıya inen ağrın var mı?
● Ateş çıktı mı? Olçtunuz mu? Kaçtı?
● Bulantı ve kusma oldu mu?
● Üremik semptomlar: mide bulantısı, kusma, yorgunluk, anoreksi, kilo kaybı, kas
krampları, kaşıntı ve bilinç kaybı.
● Geldikten önce kan yada idrar testi yaptırdınız mı?
● Herhangi bir hastalığınız var mı?
● İlaç kullanıyor musunuz? Ağrı kesici kullanıyor musunuz? Ne sıklıkla? En son ne
zaman antibiyotik kullandiniz? Yeni kullanmaya başladığınız bir ilaç var mı?
● Ailenizde herhangi bir hastalık var mı? Özellikle böbrek hastalıkları?
● Daha önce kan veya idrar testi yaptırdınız mı? Creatinine değeri için
● Ayak kalkınca başınız dönüyor mu?
● Başka şikayetiniz var mi?
● Şimdi muayene için uzanabilir misiniz?
Treatment of nephrotic and nephritic syndrome with ACEi or ARBs + loop diuretic
+ statin and blood pressure control
Tests: USG w/o contrast, urine analysis, microscopy, CBC, albumin, lipid panel,
complete metabolic panel, liver function tests, renal function tests (creatinine, BUN),
eGFR, albumin-to-creatinine ratio, thyroid function, HbA1c, protein/creatinine ratio or 24
hour urine for protein, contrastless abdominal CT for nephrolithiasis
Physical Exam: hypertension, costovertebral angle, renal artery auscultation, pretibial
edema, suprapubic tenderness, skin turgor, neck veins, rash

Think about whether to send the patient home!

Endocrinology: pituitary, diabetes and its complications, thyroid, goiter, osteoporosis,
adrenal, parathyroid, hypoglycemia and diabetes, DKA
For Diabetes:
● Symptoms: Polyuria, polydipsia, weight loss, dehydration, and fatigue; Blurred
vision and recurrent infections with progression (type 1 diabetes)
● Tests: random glucose if symptomatic, HbA1c, fasting glucose if asymptomatic,
OGTT
○ For Ketoacidosis: hyperglycemia, anion gap metabolic acidosis, and
blood and urine ketones, Don’t forget hyperglycemic hyperosmolar
syndrome
● Treatment for Type 1: daily regular insulin and finger stick glucose
measurement 4-6 times a day
● Treatment for Type 2: Diet, exercise, seek medical attention if you have side
effects of medication, proper foot care, ophthalmology visits, and symptoms of
hypo/hyperglycemia.
○ Metformin given initially,
○ SGLT2i and GLP-1 analogues for weight loss, ASCVD, HF, CKD
○ And insulin therapy if HbA1c is above target
● Treatment for DKA: intravenous 0.9 saline, regular insulin bolus followed by
continuous insulin infusion, replace potassium, correct acidosis with HCO3
For Diabetes Insipidus:
● Symptoms: polyuria, thirst and polydipsia, dilute urine
● Tests: serum and urine osmolality, water deprivation test
For Pituitary Adenomas and Craniopharyngeomas:
● Symptoms: women with galactorrhea, infertility, or oligomenorrhea; men with
hypogonadism or infertility (for prolactinomas most common), Headache, visual
changes, signs of ICP (for craniopharyngiomas)
● Tests: Hormone studies then MRI
● Treatment for prolactinomas: dopamine agonists and hormone replacement for
hypopituitarism. Surgery for neurologic complications. Adjunct radiotherapy.
For Acromegaly:
● Symptoms: Progressive enlargement of peripheral body parts, joint pains,
hyperhidrosis, organomegaly, hyperphosphatemia, gigantism in children
● Tests: serum IGF-I levels, GH levels, Oral glucose suppression test, MR of
pituitary
● For Hypopituitarism: ACTH, GH, Prolactin, TSH and T4, LH and FSH, ADH
○ thyroid function tests, ACTH, late night salivary cortisol
● Treatment for Acromegaly: transsphenoidal adenectomy, radiation, dopamine
agonist or somatostatin analogues if mild disease.
For SIADH:
● Symptoms: Hyponatremia symptoms: nausea, vomiting, lethargy, fatigue,
dizziness, headache, malaise, muscle weakness, gait disturbances, forgetfulness
○ If severe, confusion, stupor, coma, seizure, ataxia, respiratory failure
● Tests: hyponatremia, high urinary sodium, low serum osmolality, euvolemic, and
urine osmolality > serum, normal Adrenal and thyroid functions
● Treatment of SIADH: fluid restriction, hypertonic saline in severe hyponatremia
For Hyperthyroidism:
● Symptoms: heat intolerance, sweating, palpitations, weight loss, tremor,
nervousness, anxiety, weakness, fatigue, diarrhea, and hyperdefecation
● Tests: TFT, TRABs, TSI, radioactive iodine uptake scans
● Treatment of hyperthyroidism: methimazole, beta blocker, radioactive iodine
ablation therapy or thyroidectomy
For Hypothyroidism:
● Symptoms: cold intolerance, fatigue, lethargy, weakness, and weight gain,
muscle weakness, cramps, arthralgias, constipation, dry coarse thick cool skin and
nonpitting edema, loss of outer ⅓ of eyebrows, pericardial effusion, delayed
relaxation phase of deep tendon reflexes, slow speech w/ hoarse voice
● Tests: TFT, anti-TPO and antithyroglobulin antibody
● Treatment of hypothyroidism: levothyroxine and monitoring
For Hyperparathyroidism:
● Symptoms: asymptomatic until hypercalcemia develops with symptoms of
fatigue, polyuria, weakness, nausea, vomiting, abdominal pain, and change in
mental status
● Tests: elevated serum calcium, low serum phosphate, and high serum PTH
● Treatment: surgery. Emergency measures: normal saline, calcitonin,
bisphosphonates to block bone resorption
For Hypoparathyroidism:
● Symptoms: seizures, perioral paresthesia, fasciculations, tetany, and muscle
weakness, CNS irritability
● Tests: low serum calcium, high serum phosphorus, normal or low PTH with
normal 25-OH vitamin D and low 1,25-(OH)2 vitamin D, QT prolongation on
ECG in severe cases
● Treatment of hypoparathyroidism: IV calcium for severe hypocalcemia,
maintenance therapy with calcitriol and oral calcium supplementation
For Adrenal insufficiency:
● Primary adrenal insufficiency (Addison Disease): fatigue, weight loss, muscle
and joint pain, nausea, vomiting, and abdominal pain, hyperpigmentation,
hypoglycemia
 ● Secondary adrenal insufficiency (due to lack of ACTH from pituitary): same
as primary but without hyperpigmentation and more common hypoglycemia
● Tests: morning cortisol, ACTH stimulation test
● Treatment: glucocorticoid. Add mineralocorticoid if Addison Disease
For Cushing disease:
● Symptoms: hypertension, central obesity, buffalo hump, facial plethora, hair loss,
fragile easily-bruised skin, purplish abdominal striae, proximal muscle weakness,
hirsutism
● Tests: late night salivary cortisol, 24 hour urine free cortisol, lose-dose
dexamethasone suppression test, ACTH
● Treatment: transsphenoidal surgery, cabergoline, pasireotide …
For Primary Hyperaldosteronism:
● Symptoms: asymptomatic, hypertension, possible signs of hypokalemia like
muscle cramps and palpitations
● Tests: plasma aldosterone-renin activity ratio, hypokalemia and metabolic
alkalosis, CT scan
● Treatment: adrenalectomy, spironolactone, low sodium diet, lifestyle changes
For Pheochromocytoma:
● Symptoms: paroxysmal attacks of high blood pressure, tremor, anxiety, weight
loss
● Tests: 24 hour urine catecholamines and metanephrines, plasma fractionated free
metanephrines then CT or MRI to look for adrenal mass
● Treatment: alpha adrenergic blockade, BP control, and volume expansion then
surgical resection
For Osteoporosis:
● Symptoms: fragility fracture at the spine, humerus, rib or pelvis, colles fracture
of the distal radius
● Tests: DEXA scan, FRAX calculation, screening
● Treatment: calcium and vitamin D supplementation, lifestyle measures, and oral
bisphosphonates (alendronate)
● Differential Diagnosis of osteoporosis: malignancy (multiple myeloma,
lymphoma, leukemia, and metastatic carcinoma), hyperparathyroidism,
osteomalacia, paget disease of bone

Physical Exam: thyroid examination, listen to renal arteries

Cardiology: Hypertension and hypertensive emergencies, Acute coronary syndromes, chronic
coronary syndromes, heart failure, valvular heart disease, supraventricular arrhythmia (SVT),
ventricular arrhythmias, syncope bradyarrhythmias & syncope, hyper/hypothyroidism, sick
sinus syndrome, hyperthyroidism and AFib, diabetes with CAD atherosclerosis, RD and
pancarditis, systemic sclerosis and pulmonary hypertension, hypertrophy in muscular
dystrophies, myocardial toxicity with oncological drugs, valvular toxicity after radiation to the
thorax years after the procedure, pregnancy and heart, hypertrophic cardiomyopathy (ddx:
aortic stenosis, hypertension, exercise induced LVH), vaccination and myocarditis, long QT
syndrome (burgada (full, after alcohol), WPW), and hypertrophic cardiomyopathy causes of
sudden death, causes of orthostatic hypotension and fatigue in older patient (aortic stenosis,
autonomic neuropathy, dehydration, malignancy/anemia), amyloidosis (LV wall thickness),
Fabry disease
Probably more chronic, tests to order, what you do for treatment
Questions to ask:
● Maneuvers

● Chest pain
○ Where is the pain? Can you point to where you experience the pain?
○ Did the pain come suddenly or gradually? When did it first start? What were you
doing when the pain started? How long have you been experiencing the pain?
○ How would you describe the pain? (dull ache, throbbing, sharp, pressure)? Is the
pain constant or does it come and go?
○ Does the pain spread anywhere else? Have you noticed the chest pain spreading
towards your arm, back, or neck?
○ Are there any symptoms that seem associated with the pain?
○ How has the pain changed over time?
○ Does anything make the pain worse? better?
 ■ On a scale of 1-10, how severe is the pain, if 0 is no pain and 10 is the
worst pain you’ve ever experienced?
■ Stable vs Unstable Angina
● Is the pain precipitated by physical exertion or emotional stress
● 2-5 min stable angina; >15-20 min unstable angina
● Do you think the chest pain is predictable
● Palpitations: do you sometimes feel like your heart is fast-beating, fluttering or
pounding? How often?
○ “How fast do the palpitations feel?”
○ “Have you ever recorded your pulse rate during an episode of palpitations?”
○ “Does your heart feel like it’s beating in a regular or irregular rhythm during
palpitations?”
○ “Do you sometimes feel like you’re missing a heartbeat, or having an extra
heartbeat?”
○ “Could you tap out the pattern of the palpitations?”
○ “How long have you been experiencing palpitations?”
○ “How often do you experience palpitations?”
○ “How long does each episode of palpitations last on average?”
○ “Can you describe the worst episode of palpitations you have had so far?”
○ “Are you able to stop the palpitations by straining or holding your breath?”
● Shortness of breath: exertional (progressive intolerance)? Related to lying down (how
many pillows)? Wakes patients from sleep?
● Syncope: did you lose consciousness or faint? Is it associated with changes in posture?
Exertion? Or does it occur randomly?
● Intermittent claudication: Muscle pain, typically in the calf, that develops during
exertion and resolves upon resting. Intermittent claudication may be due to inadequate
arterial supply due to peripheral vascular disease.
● Systemic symptoms: fatigue (congestive heart failure), fever (pericarditis/endocarditis),
weight loss (endocarditis/atrial myxoma), weight gain (congestive heart failure),
sweating, nausea, vomiting
● Hypertension: How long did you have it? Ask about medications (diuretics and
dehydration, ACEi and renal injury, etc.)? Did you start any new meds recently?
● Other Symptoms:
○ Chest pain (occurring separately from the palpitations): consider myocardial
infarction.
○ Low mood: consider anxiety-related palpitations.
○ Tremor: consider anxiety or hyperthyroidism.
○ Sweating: consider myocardial infarction, hyperthyroidism and anxiety.
○ Heat intolerance: consider hyperthyroidism.
○ Weight loss: consider hyperthyroidism or malignancy (e.g. atrial myxoma).
 ○ Productive cough: consider pneumonia.
○ Fatigue: consider sleep deprivation and alcohol misuse.
○ Vomiting or diarrhea: consider hypovolemia and electrolyte disturbances.
● Relevant medical conditions: Hypertension, Hyperlipidaemia, Angina, Myocardial
infarction, Obesity, Chronic kidney disease, Atrial fibrillation, Stroke, Peripheral vascular
disease, Rheumatic fever
● Family history of cardiac disease, Sudden unexplained death in family
○ Do any of your parents or siblings have any heart problems? At what age did your
father suffer his first heart attack? When was your mother first diagnosed with
high blood pressure? I’m really sorry to hear that, do you mind me asking how old
your dad was when he died? Do you remember what medical condition was felt to
have caused his death?

Tests: ECG, ECHO, CXR, CBC, CRP, ESR, complete metabolic panel, NT-proBNP if
heart failure, troponin I and T, CK-MB, LDH lipid panel, liver function, kidney function,
thyroid function
● For acute coronary syndromes: if suspicion of NSTE-ACS is low do stress
testing before discharging (optional), if in the ward do angiography or stress
testing or CCTA, if in CCU do angiography and echo
● Management: Nitroglycerine and if pain continues Morphine Sulphate, UFH,
Aspirin, Clopidrogel → Aspirin+Clopidogrel for 12 months after ACS → Aspirin
beyond the first 12 months of ACS
○ Beta blocker or CCB (if BB is contraindicated), ACE inhibitor if
hypertension, LV dysfunction, HF, or diabetes
Physical Exam: Measure BP in both arms, and standing, peripheral pulse, listening to the
lungs and heart sounds
Pulmonology: Apnea, Obesity hypoventilation syndrome, COPD exacerbation,
bronchiectasis, asthma attack/exacerbation, drug anaphylaxis, pulmonary hypertension,
pulmonary embolism, pulmonary & extrapulmonary tuberculosis, interstitial lung disease,
sarcoidosis, pneumonia, plural diseases
Notes are in the notebook
Ask if they took a CXR before and if they have it
Tests: CXR, Pulmonary function tests (DLCO and spirometry), right heart catheterization
for pulmonary hypertension, thoracentesis, PPD or IGRA and AFB stain of sputum for
tuberculosis,
Physical Exam: more emphasis on lung but otherwise complete head to toe PE

Infectious: STIs, Acute viral hepatitis, parasitic diseases, HIV/AIDS, Covid-19, viral
pneumonia, zoonotic, brucellosis, tularemia, traveler infections, infective endocarditis,
dermatological lesions, etc. + vaccinations
Tests: CBC, CRP/ESR, Blood culture, Urine/stool/sputum culture and analysis, CXR if
pulmonary, PPD or IGRA testing for tuberculosis,
Physical Exam: normal full PE
Hematology/Oncology: Anemia, leukemia, bleeding disorders, lymphoma, multiple
myeloma, tumor lysis syndrome, hypercalcemia
Questions to ask:
● B symptoms: weight loss, fever, night sweats, fatigue
● Abdominal discomfort - LUQ splenomegaly
● Lymphadenopathy
● anemia , neutropenia (recurrent infection and fever)
● GI Bleeding
● History of easily bruising, prolonged bleeding after laceration, hemarthrosis,
bleeding from the gums (after brushing teeth)
● Diet
● Malabsorption (atrophic gastritis, gastrectomy, alcohol use disorder, IBD,
pancreatic insufficiency, …)
Tests: CBC, CRP/ESR, complete metabolic panel, liver and kidney function tests,
iron studies, folate and vitamin B12 levels, coagulation studies, peripheral blood
smear
● For Leukemia: LAP (leukocyte alkaline phosphatase), bone marrow aspiration
and biopsies
● For Lymphomas: LDH, HIV screening, US or CT scan in individuals with
palpable lymphadenopathy or hepatosplenomegaly and CXR with generalized or
mediastinal lymphadenopathy, excisional biopsy of involved lymph node
● For Multiple Myeloma: urine analysis, serum and urine protein electrophoresis,
free light chain assay, LDH, whole body low dose CT scan, bone marrow biopsy ,
high calcium level, skeletal survey (osteolytic bone lesions and fractures)
Physical Exam: According to associated symptoms
Gastroenterology: Acute liver failure, peptic ulcer disease, chronic diarrhea, constipation
and hypothyroidism, cirrhosis, IDA with GI bleeding, IB, abdominal pain
Questions to ask:
● Herbal medicine, alcohol, iv drug, relation of pain with food and food intake prior to
onset, B symptoms, orthostasis (if volume loss), when was the last colonoscopy, how
many times a day do you defecate, do you have to wake up to defecate at night, sick
contacts, travel history, NSAIDs, laxatives, recent antibiotic use, admissions, operations
(GI related surgery, bariatric surgery), ectopic pregnancy and menstruation
Upper gastrointestinal symptoms include:
● Jaundice: yellowing of the skin/sclera and dark urine. Causes include hepatitis, liver
cirrhosis and biliary obstruction (e.g. gallstone, pancreatic cancer).
● Aphthous ulceration: round or oval ulcers occurring on the mucous membranes inside
the mouth. Aphthous ulcers are typically benign (e.g. due to stress or mechanical trauma),
however, they can be associated with iron, B12 and folate deficiency as well as Crohn’s
disease.
● Vomiting: a common symptom of many gastrointestinal disorders including infections
(e.g. gastroenteritis), gastro-oesophageal reflux disease (GORD), pyloric stenosis
(projectile nonbilious vomiting), bowel obstruction (typically bilious), gastroparesis (e.g.
secondary to diabetes), pharyngeal pouch and esophageal stricture (vomit containing
undigested food).
● Haematemesis: the vomiting of blood which can be fresh red in color (e.g.
Mallory-Weiss tear, esophageal variceal rupture) or coffee ground in appearance (e.g.
gastric or duodenal ulcer).
● Gastroesophageal reflux: backflow of the stomach’s contents into the esophagus
secondary to lower oesophageal sphincter incompetence. Patients typically describe
epigastric discomfort which is burning in nature.
● Dysphagia: difficulty swallowing which may affect solid food, liquids or both depending
on its severity (e.g. oesophageal cancer).
● Odynophagia: pain during swallowing which may be associated with esophageal
obstruction (e.g. stricture) or infection (e.g. esophageal candidiasis).
Lower gastrointestinal symptoms include:
● Abdominal pain: may be localized (e.g. right iliac fossa in appendicitis) or generalized
(e.g. spontaneous bacterial peritonitis).
● Abdominal distension: associated with a wide range of gastrointestinal pathology
including ascites, constipation, bowel obstruction, organomegaly and malignancy.
● Constipation: causes include dehydration, reduced bowel motility (e.g. autonomic
neuropathy) and medications (e.g. opiates, ondansetron, iron supplements).
● Diarrhea: causes include infection (e.g. C.difficile), irritable bowel syndrome,
inflammatory bowel disease, medications (e.g. laxatives), constipation (with overflow)
and malignancy.
● Steatorrhoea: the presence of excess fat in stool causing them to appear pale and be
difficult to flush. Causes of steatorrhoea include pancreatitis, pancreatic cancer, biliary
obstruction, coeliac disease and medications (e.g. Orlistat).
● Melaena: dark, tar-like sticky stools containing digested blood secondary to upper
gastrointestinal bleeding (e.g. peptic ulcer).
● Hematochezia: fresh red blood passed per rectum which may be caused by hemorrhoids,
anal fissures and lower gastrointestinal malignancy.
● Systemic symptoms include: anorexia, weight loss (e.g. malabsorption, malignancy),
nausea, fatigue, fever (e.g. intrabdominal infection), pruritus (e.g. cholestasis), confusion
(e.g. hepatic encephalopathy).
Associated Symptoms:
● Gastrointestinal:fever/chills/rigors (infective), nausea/vomiting, change in bowel
habits, rectal bleeding, mucus in stool, mouth ulcers (Crohn's disease), reduced
appetite, weight loss, jaundice
● Urological: dysuria, urinary frequency, flank pain, hematuria
● Gynecological: vaginal discharge, pelvic pain, dyspareunia (genital pain with
intercourse)
● GI bleeding differentials: esophageal/gastric varices, peptic ulcer disease,
diverticulosis, IBD, NSAID induced ulcer, hemorrhoids, rectal varices, anal
fissures …
Tests: CBC, CRP/ESR, complete metabolic panel, lipid panel, direct and indirect
bilirubin, liver and kidney function tests, amylase lipase, PT, PTT, albumin, digital rectal
examination, abdominal USG, CT, stool tests, vitamin levels for malabsorption, upper
endoscopy and colonoscopy, open two IV lines in cases of bleeding, consider HIV
testing
● For Pancreatitis: HgA1c for recent onset atypical diabetes, CT
cholangiopancreatography with contrast
○ Start pancreatic enzyme supplementation in chronic pancreatitis
● For Acute liver failure: Acetaminophen/NSAID levels, alcohol level, viral
hepatitis serology, RUQ doppler ultrasonography
● For Cirrhosis: SAAG with ascites sample
● For H.pylori ulcer: urea breath test, stool antigen, endoscopic biopsy
○ Start amoxicillin, clarithromycin and PPI
● For Dysphagia due to esophageal cancer, achalasia, or ring: barium swallow,
esophagoduodenoscopy, esophageal manometry
● For Gallstones: ERCP (endoscopic retrograde cholangiopancreatography)
● For Chronic Diarrhea: stool electrolytes, fecal fat measurement, endoscopic
biopsy
Physical Exam: More detailed abdominal examination, check for ascites, percutate the
liver and traube space, palpate deeply, assess Murphy's sign…
Previous Questions and Notes
First
● STEMI
● DKA
● AKI(nsaid ve hipovolemi oykusu vardi metformin ve ACEI kesiyosun)
● Tuberkulosis
● Peripheral arthritis (lupus ve OA on tanisi)
● Covid
● SVC (superior vena cava)
● Anemia (iron deficiency due to heavy menstruation)
● Ibd (oral aftlardan dolayi crohn on planda)

Final OSCE:
Cardiology: Congestive heart failure
Infection: Hepatit A (sewage worker)
Pulmonary: DVT sonrası takipne öyküsü → PE
Gastro: nsaid kullanimi sonrasi ülser kanamasi ortostatik hipotansif hasta, cikista testleri
doldururken rektal tuşe bekleniyo. hastayi kesinlikle yatirip sivi baslanmali
Hemato: LAP(bulgular lenfoma lehine, hastaya durumun ciddiyetini belli etmek gerekiyor)
Endocrinology: hypothyroidism
Romato:?
Nefro: Post streptococcal/ IgA

Second
● Hypertension management
● Hypercalcemia
● Hyperthyroidism (subacute thyroiditis)
● Covid-19
● Chronic diarrhea
● Gout attack (including the treatment)
● Iron deficiency anemia
● Pulmonary embolism

Final OSCE:
Pulmonary: Copd Exacerbation
Cardiology: STEMI
Gastroenteritis: Patient with jaundice-hepatitis
Endocrinology: Diabetes mellitus management
Infectious: Urinary tract infection (pyelonephritis)
Hematology/Oncology:LAP (Hodgkin lymphoma)
Rheumatology: SLE & RA karisik semptomları olan hasta
Nephrology: Nephritic syndrome (IgA nephropathy)
Third
● Contrast AKI
● Thyrotoxicosis/Sinus Tachycardia
● Pyelonephritis
● Pneumonia
● Jaundice - Hepatitis (viral, toxic, autoimmune unclear)
● Megaloblastic anemia (probably Vit B12)

Final OSCE:
Nephrology: Hyperkalemia (due to ACEi dose increase)
Rheumatology: Gout (treatment is wanted)
Infection: Gastroenteritis/Food poisoning
Cardiology: Congestive heart failure and management
Pulmonology: COPD Exacerbation
Endocrinology: (Lower Back Pain ile geliyor) Hypercalcemia and Possible Osteoarthritis

Full Questions

Pulmonology OSCE: Tuberculosis

⁃ Doornote: 22 y/o cough with phlegm ve fever
⁃ 2 aydir artmış sari koyu balgam ve kanli
⁃ 10 gundur atesi var, beraberinde night sweats ve unintentional weight loss var
⁃ Annesi 5 yil once Tb gecirmis
⁃ 4 yıldır gunde yarim paket sigara iciyor ve cxr’de cavitary lesion var
⁃ Disarda cxr bulgularini, diff diagnosislerini ve en son treatmenti yaziyorsun
⁃ Icerde isticegin testleri soylesen iyi olur yoktu disarida :( PPD sputum culture vs onemli

Cardio OSCE: Stable Angina

⁃ 62 y/o chest pain
⁃ Burning, diffuse
⁃ Increases with exercise - 3 sets of stairs
⁃ For 3 months
⁃ Did not happen before
⁃ Stent 15 mo ago (MI)
⁃ Stressed out about son’s divorce that happened 3 months ago as well
⁃ HTN, DM - do not use drugs regularly
⁃ BP: 120/70
⁃ ECG: normal
⁃ Blood tests: glucose just above the limit, LDL 202
⁃ Stable angina
Enfeksiyon OSCE: Complicated Pyelonephritis
⁃ 52 y/o fever, left flank pain, urinary frequency, dysuria
⁃ 3 day fever, ibuprofen did not work
⁃ Nausea & vomiting this morning - what he ate
⁃ He had blood in his urine this morning - scared about bladder cancer when googled :)
⁃ DM, HTN, regular medications
⁃ 25 pack/year smoking
⁃ Mother: died from breast ca
⁃ Muayenede costovertebral angle +
⁃ Complicated pyelonephritis
⁃ Differential diagnosis
⁃ tests: CBC w/diff, electrolytes, renal function, liver function, blood glucose, urinanalysis,
urine dipstick, urine culture, 2 sets of blood culture
⁃ hospitalization: IV ciprofloxacin or ceftriaxone or carbapenem + IV fluids

Gastroenterology OSCE: …
⁃ Doornote: 56 y/o, abdominal pain
⁃ Started 6 months ago, usually after meals, but not with fatty food specifically
⁃ Diffuse, specifically on epigastric area, radiates to back and left shoulder
⁃ Tried gaviscon and lansor upon friends’ recommendation — did not work
⁃ Vomiting also accompanies, just what he ate
⁃ 8 kg weight loss in past 2 months unintentionally
⁃ Stressful about job
⁃ 2/3 glasses of wine daily, 10 pack/year cigarette smoking
⁃ Insulin resistance - no drug
⁃ Mother: pancreas cancer - dead, dad: stroke - alive
⁃ Differential diagnoses: PUD, pancreatitis, cholecytitis, pancreas cancer vs vs

Endocrinology OSCE: Hyperthyroidism

⁃ Doornote: 38 y/o male (depends on sp), palpitations, tachycardia
⁃ 5 months ago, started with exercising, 3 times per week, got worse recently for the past
few weeks and happens more frequently even with resting
⁃ Sweating, fatigue, heat intolerance —> hipertiroidi disinda daha Sistemik sorgu
(anksiyete, kardiyolojik sebepler vs de sorgulanmalıydı basta)
⁃ Not a quite balance diet, but not as bad
⁃ Cut off caffeine, did not resolve
⁃ Hashimoto’s thyroiditis in sister
⁃ Has hyperlipidemia - uses atorvastatin, has insulin resistance - weight loss suggested
⁃ GP ran tests —> TSH 0.01 (low), fT3 & fT4 high
⁃ Hyperthyroidism, differential olarak Graves vs de yazilmaliydi
Rheumatology OSCE: …
⁃ Doornote: 43 y/o, joint pain
⁃ Started couple months ago, worse for the past couple of weeks, can’t jog anymore
⁃ Morning stiffness for an hour
⁃ Mainly in hands (MCP and PIP in physical exam), knees and ankles
⁃ Went to GP and got some blood tests (Hb low, renal function tests elevated, urinalysis
revealed proteinuria and hematuria)
⁃ Sinusitis like symptoms
⁃ Nocturia
⁃ Prostate hyperplasia in dad
⁃ 1) Wegener’s 2) SLE 3) RA differential diagnoses were expected (at least one of the
systemic ones - small vessel vasculitis or SLE)
⁃ Tests
⁃ No tx plan

Oncology OSCE: …
⁃ Doornote: fatigue and nausea
⁃ Came to doctor’s office for some antidepressants since her husband thought she was
depressed lately
⁃ Lab tests from 4 months ago: slightly elevated calcium (10.8 - upper range 10.5), low Hb
⁃ Side pain
⁃ Breast cancer history, successful mastectomy, still on tamoxifen
⁃ Uses vitamin D supplements
⁃ Lost mother to ovarian cancer, sister has thyroid disease
⁃ Hypercalcaemia due to vitamin d intoxication or parathyroid adenoma or bone
metastases — all as differentials
⁃ Repeat lab tests and act accordingly
⁃ Treatment plan

Hematoloji OSCE: Macrocytic Anemia

⁃ 50 y/o woman presented with extreme fatigue, dizziness and tingling
⁃ Shortness of breath while climbing stair
⁃ Tingling and numbness in feet
⁃ Forgetfulness and difficulty in concentrating
⁃ Went to GP and CBC shows Hb: 8.9 MCV: 114 (macrocytic anemia)
⁃ Some stomach pain now and then
⁃ Nothing excluded from diet
⁃ Post menopausal
⁃ No chronic disease, no medications
⁃ Painkillers frequently
⁃ Father has colon cancer
⁃ Lawyer, no smoking, alcohol, drugs
⁃ Cikista Ddx, tests, Tx: macrocytic anemia due to vit b12 deficiency, malabsorption
(celiac??) vb, bunlara gore test iste ve KESIN endoscopy colonoscopy iste!! Tedavi IM vit b12
injections

Nefroloji OSCE (Turkish): AKI

⁃ Doornote: 52 yasinda kadin halsizlik, bulanti kusma sikayetleriyle basvuruyor
⁃ 10 gun once ishalle baslamis, en son dun kusunca aile hekimine gitmis, testlerde bobrek
degerleri yuksek cikinca sen bir dahiliyeye git demis
⁃ Ishal ve kusmada kan vs yok
⁃ Bulantidan su da icememis cok
⁃ DM ve HTN hastasi - 5 yildir
⁃ Glifor ve diovan kullaniyor, kontrol altinda, duzenli takiplerine gidiyor
⁃ Ara sira arveles kullaniyormus haftada birkac gun, simdi cok agrisi falan da olunca gunde
2 falan almis bu sikayetlerle
⁃ Safra kesesi operasyonu oykusu var
⁃ Annede seker ve hipertansiyon, babayi kalp krizinden kaybetmis
⁃ Polis, ofis isi yapiyor
⁃ Sigara yok, alkol sosyal (haftada 1), madde kullanimi yok
⁃ Cikista Ddx & Tests & Tx soruyordu: 1) prerenal AKI due to dehydration 2) intrinsic
AKI due to NSAID use 3) post renal AKI due to obstruction 4) AKI on CKD due to past htn and
dm, bunlara gore test iste, IV saline bas metformini de kes