OSCE Answers

📋 D-1 (B) — Emaciated Patient, Examiner Gripping Chin/Trachea

a) Name the clinical test performed

b) Conditions in which this test is alone positive

• Thoracic aortic aneurysm (classically — downward pulsatile tug transmitted via compressed trachea)
• Also positive in: large mediastinal masses compressing the trachea, carcinoma of the bronchus

c) Interpretation of this test

• Positive: downward pulsatile tug synchronous with heartbeat felt on the trachea/larynx when gently grasped → indicates a pulsating mass behind the trachea (typically thoracic aortic aneurysm) transmitting its pulsation
• Negative: no tug felt

d) Same common clinical condition in which this test is positive

📋 OSCE-2 — Two Patients with Generalized Swelling (One Obese, One Cachectic)

1) Diagnose the clinical condition

• Upper patient: gross swelling of the body/limbs with pitting edema
• Lower patient: wasting with dependent pitting edema and swollen legs Both represent stages of lymphatic filariasis with secondary lymphedema

2) Enumerate the various causes

• Milroy disease (congenital)
• Meige disease (lymphedema praecox)
• Lymphedema tarda

• Lymphatic filariasis (Wuchereria bancrofti, Brugia malayi, Brugia timori) — #1 cause worldwide
• Post-malignancy (surgical lymph node dissection, e.g., axillary or inguinal clearance)
• Post-radiation therapy
• Recurrent bacterial lymphangitis (streptococcal)
• Tuberculosis (involving lymph nodes)
• Malignant infiltration of lymphatics
• Chronic venous insufficiency

3) Treatment

• Antiparasitic: Diethylcarbamazine (DEC) ± Albendazole ± Ivermectin (MDA — mass drug administration)
• Morbidity management (lymphedema not reversed by DEC):
  • Limb hygiene (daily washing with soap and water)
  • Elevation of limb
  • Compression bandaging/stockings
  • Physiotherapy / manual lymphatic drainage
  • Treatment and prevention of secondary bacterial/fungal infections (antibiotics, antifungals)
  • Surgery in selected cases (debulking, lymphovenous anastomosis)

4) Complications

• Elephantiasis (massive irreversible limb swelling with fibrosis and hyperkeratosis)
• Recurrent bacterial lymphangitis (acute attacks — "ADL attacks")
• Secondary infections (cellulitis, erysipelas, fungal)
• Hydrocele and chyluria (in scrotal/genital filariasis)
• Lymphoscrotum and scrotal elephantiasis
• Pulmonary eosinophilia (tropical eosinophilia syndrome)
• Psychological/social disability
• Immune suppression and secondary sepsis

📋 D-1 (A) — Foot with Swelling, Hyperkeratosis, and Fissuring

1) Identify the condition

2) Two most common causes

1. Podoconiosis — absorption of soil microparticles (silica/aluminosilicate) through bare feet → inflammatory lymphatic obliteration
2. Lymphatic filariasis (Wuchereria bancrofti) — #1 infectious cause of lymphedema of the lower limbs

3) Predisposing conditions (3)

1. Barefoot walking on volcanic red clay soil (podoconiosis-specific)
2. Poor foot hygiene and skin integrity
3. Living in endemic tropical regions (Sub-Saharan Africa, Central America, North India for podoconiosis; tropical regions for filariasis)

4) Investigations

• Microfilariae in peripheral blood smear (nocturnal timing) — for filariasis
• Filarial antigen detection (immunochromatographic card test — ICT) for W. bancrofti
• Ultrasound of lymphatics (filarial dance sign)
• Doppler study of lower limb vessels
• Skin biopsy — shows silica particles in lymphatics (podoconiosis)
• Lymphoscintigraphy — to assess lymphatic function
• Wound swab culture — for secondary infections

5) Treatment

• Footwear provision (primary prevention in podoconiosis — wearing shoes stops progression)
• Foot hygiene protocol: daily washing with soap, moisturizing, bandaging
• Compression therapy: stockings, bandaging, manual lymphatic drainage
• DEC + Albendazole (if filarial etiology)
• Antibiotic/antifungal treatment of secondary infections
• Surgical: debulking in severe cases

📋 Question 1 (G) — Dental Caries + Knee X-ray with Chondrocalcinosis

Diagnose the condition

• Left image: Dental/oral tophi or urate deposition — tophi can deposit in gums/oral mucosa
• Right image (knee X-ray): Shows chondrocalcinosis (calcification within cartilage — arrow and asterisks) — urate crystals depositing in cartilage

Cause of this condition

• Primary gout: Overproduction or underexcretion of uric acid
  • Enzyme defects (HGPRT deficiency — Lesch-Nyhan syndrome; PRPP synthase overactivity)
  • Idiopathic (90% of primary gout)
• Secondary gout:
  • Myeloproliferative/lymphoproliferative disorders (increased cell turnover)
  • Chronic kidney disease (reduced uric acid excretion)
  • Diuretics (especially thiazides)
  • Alcohol excess
  • Psoriasis
  • Lead nephropathy

Any 3 radiological signs seen in this patient

1. Chondrocalcinosis — calcification of articular cartilage (menisci in knee)
2. Juxta-articular punched-out erosions with overhanging edges ("rat-bite" erosions) — hallmark of gout
3. Soft tissue tophi — asymmetric soft tissue densities around the joint
4. (Also may see): Joint space narrowing (late), subchondral sclerosis

Treatment options

• NSAIDs (Indomethacin, Naproxen) — first line
• Colchicine — early acute attack
• Corticosteroids (oral/intraarticular) — if NSAIDs/colchicine contraindicated

• Allopurinol (xanthine oxidase inhibitor) — first line; target uric acid < 6 mg/dL
• Febuxostat — alternative XO inhibitor
• Probenecid (uricosuric) — for underexcretors with good renal function
• Pegloticase (recombinant uricase) — refractory tophaceous gout
• Dietary modification: avoid red meat, organ meats, shellfish, alcohol, fructose; increase hydration