Osce

Dr Subhasish Deb, BMC

OSCEDr Subhasish Deb

Burdwan Medical College & HospitalDept of General Medicine


CASE 1


• 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:




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.


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


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




Treatment

• Physiotherapy • NSAIDS


CASE 2


• 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:



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

http://en.wikipedia.org/wiki/Pars_interarticularis

http://en.wikipedia.org/wiki/Pars_interarticularis

http://en.wikipedia.org/wiki/Vertebral_arch

http://en.wikipedia.org/wiki/Spinal_disc_herniation



Treatment

• Conservative : Nsaids + physiotherapy• Surgery if canal stenosis present


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



CASE 3


• 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



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


CASE 4


• 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 glomeruli2. IG A deposits3. Apple green fluorescence with birefringent deposits

on polarized microscopy4. Thickening of GBM


• Ans: 3 apple green staining with birefingent deposits

AMYLOIDOSIS



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


Some common amyloid proteins


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


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


• AA: treat the chronic inflammatory condition or infection

• Familial Mediterranean fever : cholchicine• Prognosis is poor


Case 5



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.


THANK YOU

Osce

Health & Medicine