OSCE
Introduction: This online E-log Entry Blog is an objectively structured clinical examination method to assess the clinical competence during the course of my General Medicine Internship rotation (June'2023-August'2023) by reviewing the case reports shared below and to discuss, understand and review the clinical scenarios and data analysis of patients so as to develop my clinical competency in comprehending clinical cases, and providing evidence-based inputs for questions surrounding the clinical vignettes borrowed from the E Log Book.
Note: The cases have been shared after taking consent from the patient/guardian. All names and other identifiers have been removed to secure and respect the privacy of the patient and the family
Case 1
Patient is a 70 year old female resident of West Bengal, Home Maker by Occupation came with Chief Complaints of Pain in Abdomen Since 2 Years, and Loose Stools and Burning pain While passing Stools Since 2 Years.
Timeline of Events :
2019 : She was diagnosed with Cholelithiasis, and underwent Cholecystectomy
2021 : She Started having Complaints of pain Abdomen.
Loose stools, and Burning Type of Pain while Passing stools.
Losse stools were Non blood stained, Pale in Colour, Slimy in Consistency.
And Decreased Appetite
She went to a local doctor. No record of it.
December 2021 : Later that year she went to visit her relatives in Mumbai where she went to see a doctor in the hospital for her symptoms on advice of their relatives,
Endoscopy was advised for the Patient.
CT SCAN Abdomen was done :
Impression: Diffuse Long segment Mural Thickening along the terminal Ileum
Fatty liver , Borderline Spleenomegaly, Mildly Prominent Common Bile Duct - Post Operative Satus.
Bilateral simple cortical cysts
Few Small Subcentimeter mesenteric lymph nodes.
ILIOCAECAL - LYMPH NODE Biopsy was done :
Impression: Reactive Hyperplasia of Lymph node
Rx Given :
Tab Veloz D
Unienzyme Tablet
Cremaffin syrup
2023 : She was Apparently alright until 6 months ago where she started having similar complaints.
She went to see a local Doctor who prescribed her the following medication :
Rx ;
Rifaximin 400
Pre and Probiotic capsules
Raciper D
Vibact DS capsules
Libratex (Chlordiazepoxide and Clidinium)
Cremaffin Syrup
But her symptoms did not improve and She came to this Hospital.
Dec 2023 :
Patient Came to the OPD with chief Complaints of Pain in Abdomen( Just before Passing stools)Since 2 Years
Loose Stools 2-3 episodes per day, Non Blood Stained, Pale in Colour, Watery In Consistency Since 2 Years
Her Abdominal Pain relieved after passing Stools
Case Report Link : https://ankurkumar14.blogspot.com/2023/12/70y-female-with-complaints-of-loose.html
OSCE Questions :
1. What is the Epidemiology of the IBD.
The North American incidence of inflammatory bowel disease (IBD) ranges from 2.2 to 19.2 cases per 100,000 person-years for ulcerative colitis and 3.1 to 20.2 cases per 200,000 person-years for CD. Prevalence in the United States of adult ulcerative colitis was 238 per 100,000 population and 201 per 100,000 population from data in a large study based on insurance claims. IBD is much more prevalent in North America and Europe than in Asia or Africa. Although most IBD occurs in people aged 15 to 30 years, up to 25% of patients will develop IBD by adolescence.
There appears to be a bimodal distribution with a second peak of 10% to 15% developing IBD after age 60.
Crohn disease is slightly more common in females compared to males, but ulcerative colitis appears to be equally present in both genders. IBD is generally a disorder in developed countries and colder climates.
2. Hygiene Hypothesis And Inflammatory Bowel Disease .
According to the hygiene hypothesis, individuals raised in a sanitary environment have a higher risk of developing inflammatory bowel diseases (IBD). However, results have been inconsistent. We conducted this systematic review of factors related to environmental hygiene and risk of IBD, Crohn's disease (CD) and ulcerative colitis (UC).
3. What Could Be The Differential Diagnosis With A Patient With Above Symptoms ?
Irritable Bowel Syndrome (IBS):
Characterized by abdominal pain, bloating, and changes in bowel habits.
Inflammatory Bowel Disease (IBD):
Conditions like Crohn's disease or ulcerative colitis can cause chronic inflammation in the digestive tract.
4. How can Radiologic Imaging Help in the Diagnosis of CROHN'S Disease.
Showing Thickening of the Wall of Terminal Ileum in our Patient.
Radiologic imaging plays a crucial role in the diagnosis and management of Crohn’s disease (CD). With cross-sectional imaging techniques in particular, the bowel lumen, wall, and extraintestinal manifestations of the disease can be visualized efficiently and noninvasively. Computed tomography enterography (CTE) and magnetic resonance enterography (MRE) are the new gold standards of imaging inflammatory bowel disease, replacing the small-bowel follow-through as the first-line imaging test of choice.
5. What is The Treatment ?
The first step in pharmacologic therapy for IBD is aminosalicylates. If the patient does not respond to an appropriate dose of aminosalicylates, the second step is the addition of corticosteroids, which tend to result in a significant decrease in inflammation. Once the response is seen, the dose can be tapered.
6. Rationale Behind Using Rifaximin in IBD.
Rifaximin is a non-systemic antibiotic, since it is essentially non-absorbable from the gut. It has particular indications for traveller’s diarrhoea. There has been interest in recent years in the potential roles of rifaximin in CD.
[21/12, 8:04 am] Rakesh Biswas Sir GM HOD:
Well done. Get this reviewed by radiology and put a pointer in the long segment terminal ileum thickening and reshare only that image for the DP and the case report.
Prepare this entire case as your farewell osce toward 31st December successful exit
[21/12, 8:13 am] ANKUR KUMAR: Ok sir
[21/12, 10:36 am] ANKUR KUMAR: This Image Shows Thickening of Small bowel Wall sir
[24/12, 12:59 pm] Rakesh Biswas Sir GM HOD: @Dr.Bharath kumar GM PG III @ANKUR KUMAR Updated discharge summary? They are leaving tomorrow?
[24/12, 7:51 pm] ANKUR KUMAR: http://ankurkumar14.blogspot.com/2023/12/70y-female-with-complaints-of-loose.html
[24/12, 8:37 pm] Rakesh Biswas Sir GM HOD: Prepare it as your exit osce with questions as done by other 2018-2019 batches archived here :
https://medicinedepartment.blogspot.com/2023/12/ongoing-project-draft-optimizing.html?m=0
[24/12, 8:49 pm] ANKUR KUMAR: Yes sir
Some Procedures I did or assisted in
Ryles tube insertion :
Collected some ABG samples.
Ultrasound Sound Guided Ascitic Tap :
Other Procedures Include Foleys Catherization.
And also Learned about the 2 D echo Equipment.
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