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OSPE DU Medicine
OSPE DU Medicine
Curriculum
OSPE
1. Fifty (50) marks will be allocated for OSPE.
2. There will be ten (10) stations in OSPE.
3. Each station shall carry five (5) marks.
4. Topic of OSPE station number one to eight (no.1-8) will be given from Internal
Medicine.
Four (4) examiners (Board I & II) of Internal Medicine & allied subjects will examine the
answer scripts of these (1-8) OSPE stations.
5. Topic of OSPE station number nine & ten (no.9&10) will be given from
Paediatrics.
Two (2) examiners (Board III) of Paediatrics will examine the answer scripts of these
(9&10) OSPE stations.
6. Time allocation for each station shall be five (5) minutes.
Probable stations:
1. ECG.
2. X-ray/ Radiology.
3. Instruments.
4. Data interpretation/ Scenario.
5. Pictorial diagnosis/ Picture scenario.
6. Pediatrics (Instruments).
7. Pediatrics (Data/ Photograph).
8. Skin-VD (Photograph/ Data).
9. Psychiatry (Data/ Scenario).
10. Pedigree/ Family tree.
Prescriptions.
Procedures.
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Medicine OSPE
Bonus
(Click to see/download)
Figure 1
Hair-on-end appearance—lateral view.
Figure 2
Hair-on-end appearance—frontal view.
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Medicine OSPE
Description
The hair-on-end sign is a finding seen in the diploic space on skull radiographs and has the appearance of long,
thin vertical striations of calcified spicules perpendicular to bone surface that look like hair standing on end. It
is classically seen in children/adolescents with haemolytic anaemias, in particular, thalassemia major.
A 24-year-oldman, born out of consanguinous marriage with history of splenectomy done at the age of four
and history of requiring frequent blood transfusions, that is, every 5–6 months, came with complaints of
breathlessness on exertion, generalised fatiguability and weakness. On examination the patient had frontal
bossing, haemolytic facies and hepatomegaly. His haemoglobin (Hb) was 5.6 g/dl and peripheral smear
revealed hypochromic, microcytic red blood cells with target cells. Serum iron studies revealed serum iron of
300 mg/dl (200–400 mg/dl) and serum ferritin of 1500 ng/ml (20–300 ng/ml). Haemoglobin electrophoresis
showed fetal haemoglobin F of 7 g/dl and adult haemoglobin A of 8.8 g/dl. A skeletal survey was done which
revealed evidence of extra medullary haematopoiesis with a classical hair–on-end appearance seen on x-ray
skull (Figures 1 and 2). The patient was given three packed cell transfusions. The patient was advised tablet
folic acid daily and iron chelation therapy. The patient was discharged on a Hb of 9 g/dl.
Cooley and Lee described skeletal changes associated with haemolytic anaemias, more than 80 years
ago.1 Hair–on-end appearance refers to the skull abnormalities seen predominantly in patients with
haemolytic anaemias that is, thalassemia, major, sickle cell anaemia, pyruvate kinase deficiency—hereditary
elliptocytosis and spherocytosis.2 It is due to periosteal reaction with neo-osteogenesis of the outer cranial
table which results in marked calvarial thickening, external displacement and thinning of the inner table. The
changes are due to marrow hyperplasia. Hair–on-end appearance is also seen in congenital syphilis—syphilitic
periostitis of tibia, metastatic neuroblastoma, iron-deficiency anaemia, cyanotic—right-to-left shunt—
congenital heart disease, osteomyelitis, polycythaemia vera, thyroid acropachy and haemangiomas. 3 ,4
It is debatable whether the hair-on-end sign may be reversed following treatment of anaemia. The classical
presentation is rarely seen these days. Hair-on-end is uncommon in the milder thalassemia intermedia. Similar
appearance in facial bones is rare and suggests an extreme degree of medullary erythropoiesis. Our patient
had facial involvement as well.
Normal X-ray
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Medicine OSPE
Cardiac Silhouette
On an antero-posterior (AP) or postero-anterior (PA) view of the chest, the borders of the heart have
common landmarks:
• Right Border: Formed by the right atrium which is in between the SVC and IVC
• Left Border: Formed by the left ventricle & portion of the left auricle
• Anterior Surface or Sternocostal Surface: Mainly the right ventricle (not seen on AP view)
• Inferior Border: Combination of the right & left ventricles
Aortic Knob
The aortic knob should be visualized in the normal chest radiograph around the level of T3 to T4 or
just lateral to the carina. In patients with aortic aneurysm, this can be the area contributing to the
"widened mediastinum".
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Medicine OSPE
Carina
The carina is the point or level at which the trachea divides into the right and left main bronchi. This
is usually midline with the spinous process being behind it. The carina is also the location that is
used by healthcare providers when assessing the proper position of an endotracheal tube (ET) after
intubation. Typically, the tip of the ET tube should be 3-4 centimeters above the carina so that both
lungs are properly oxygenated.
Clavicle
The head of the clavicle is attached to the lateral surface of the sternum. The location of the
clavicular heads in relation to the trachea can help determine proper positioning of the patient at
the time the chest radiograph was taken. The two clavicular heads should be on either side of the
trachea and with the spinous processes being in the middle.
Hemidiaphragms
The right hemidiaphragm normally sits slightly higher than the left due to the presence of the liver
under the diaphragm which prevents the right hemidiaphragm from going down further with
inspiration. Important clinical pearls include:
Each dome of the diaphragm is innervated by its own nerve supply from the phrenic
nerve. Therefore, damage to the nerves for one side will not affect the other. On chest
radiograph you would see the the paralyzed hemidiaphragm as being higher than the other
hemidiaphragm during inspiration (creating a paradoxical pattern of movement with
respiration).
You should also not see free air under the hemidiaphragm. If free air is found you will see a
black line under the hemidiaphragm which would be concerning for a bowel perforation. This
requires emergent evaluation with a CT scan and surgical consult. Do not confuse the normal
gastric bubble seem on many chest radiographs with free air.
Trachea
The trachea should sit midline and be in between the right and left clavicular heads. Any deviation
from the midline could suggest that the patient was either rotated at the time of the chest
radiograph, the presence of a mediastinal mass, or presence of a tension pneumothorax.
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Medicine OSPE
Pulmonary TB
Figure: Chest x-ray demonstrates extensive patchy reticulonodular opacities particularly on the left. Peripherally at
the junction of mid and upper zones a parenchymal cavity can be identified.
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Both lungs are markedly hyper-inflated with 11 posterior ribs easily visible above the diaphragmatic
domes (yellow dotted lines). The diaphragms are depressed and flattened (best seen on lateral
projection, with loss of the normal acute angle formed by the costophrenic pleural reflection (dotted
blue line).The lungs appear very radiolucent with some areas devoid of lung markings ( * ) suggesting
bullous formation.On lateral projection the retrosternal air space (RS) is markedly widened (aorta
outlined in red).
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Bronchial carcinoma
Case Discussion
Moderate to severe pulmonary fibrosis. The 'shaggy' appearance to the heart results from adjacenet
lung fibrosis so the outline of the heart is less well delineated.
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Medicine OSPE
Acne vulgaris
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These photographs are from a pregnant patient with lower motor neuron facial palsy and syndrome of hemolysis,
elevated liver enzyme levels, and low platelet levels [HELLP].
Top left image: The nasolabial fold is flat on the right side of the face. At the same time, the patient was also
unable to wrinkle her forehead on the same side (not shown).
Top right image: She was unable to show all her teeth on the right side.
Bottom left image: The patient could not purse her lips on the right side.
Bottom right image: She exhibited Bell phenomenon (upward rolling of the eye on the affected side with partial
closure of the eyelid when asked to close both eyes).
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November, 2019
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May, 2019
Time: 05 minutes
case.
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July,2019
Question 1: Write down the 2 (two) important abnormal ECG findings. (MI)
Question 2: Write 5 (five) investigations necessary for this patient.
Question 3: Mention 4 (four) immediate complications of this condition.
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Medicine OSPE
Station: 3
Instructions: A 35 year old male (weight-45 kg) diagnosed as a case of smear +ve
pulmonary tuberculosis. You are asked to prescribe Category-1 anti tubercular
therapy. Write down a prescription for him.
Time: 05 minutes
Station: 4
Station: 5
Instruction: A 45 year old female presented with fever for 2 months and
abdominal examination revealed hepatosplenomegaly.
Station: 6
Station: 7
Station: 8
Instructions: A 35 year old male presented with fever for 1 week and
disorientation for 2 days. His CSF study is as follows:
Cytology-
Total leukocyte- 2000/Cu mm, neutrophil- 90%, lymphocyte- 10%
Biochemistry- protein-150mg/dl, sugar-25mg/dl
Station: 9
Station: 10
Instructions: A 10 months old child, weighing 7 kg has been suffering from acute
watery diarrhea for 3 days. On examination, the baby is lethargic and drinking poorly.
January,2019
Station list
1. Instrument: Lumbar puncture needle,
2. Instrument: Bone marrow aspiration needle,
3. Prescription: Enteric fever,
4. X-Ray: Pleural effusion,
5. ECG: LVH ē strain,
6. Data: Rheumatoid arthritis,
7. Photograph: Psoriasis,
8. Photograph: AGN,
9. Data: Hypoglycaemic coma,
10. Case: Acute viral hepatitis.
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Station: 2
Station: 3
Station: 4
Instruction: Please see the supplied instrument and answer the following
questions-
Station: 5
Station: 6
Instructions: A 20-year-old male, known diabetic, presented to emergency
department in semiconscious state. On query his attendant told that he is having
fever for 1 week and stopped insulin doses. Now his blood sugar is 32 mmol/L and
urine for ketone body is present.
Station: 7
Instructions: Look at the picture and answer the following questions-
Scabies-of-the-hand-with-secondary-infection
Station: 8
Instructions: A 35 year-old woman presented with progressive generalized
weakness and palpitation for 3 months. She had H/O menorrhagia for 5 months.
On examination, she had koilonychia, anaemia and no organomegaly.
Station: 9
July,2017
Station: 1 (Q+Answer key)
Instructions: Look at the X-ray and answer the following questions-
Chest X-ray showing the features of pneumothorax on the left side of the person
(right in image)
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Medicine OSPE
Station: 2
(ECG tracing)
Question 1: Write down the 3 important abnormal ECG findings.
Question 2: What is your ECG diagnosis?
Question 3: Mention 4 important causes of this ECG change.
Question 4: What are the clinical findings as palpation of precordium?
Instructions: Write down a prescription for a 30 year old pregnant female who
has been suffering from uncomplicated Urinary tract infection.
(Only one drug is to be prescribed)
(See above)
Station: 10
Ans:
1. Bacterial meningitis/Pyogenic meningitis.
2. Group B streptococcus, Neisseria meningitidis.
3. Hydrocephalus, Death.
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January,2017
Station: 1 (Q+Answer key)
Instructions: A 25 year old male presents with fever and cough for 5 days.
Study at the X-ray and answer following questions-
(see above)
Question 1: Write down the three (3) important abnormal ECG findings.
a. ST segment elevation in II, III, aVF (0.5) and V1 to V6 (0.5) 1
b. Pathological Q wave in II, III, aVF (0.5) and V1 to V6 (0.5) 1
c. T inversion in V1 to V6 (0.5) 0.5
Question 2: What is your ECG diagnosis? 2
a. Acute (0.5)
b. Anterior (0.5) & Inferior (0.5) MI (0.5)
Question 3: Write five (5) investigations necessary for this patient.
(Any five) 0.5x5=2.5
a. Cardiac enzyme- Troponin I/CPK MB/CPK
b. Echocardiogram
c. CAG (Coronary Angiogram)
d. Blood sugar
e. Lipid profile
f. S. creatinine (0.5)
g. S. electrolyte
h. CBC with ESR
Question 4: Mention three (3) immediate complication of this patient.
Max-3
a. Cardiogenic shock (1)
b. Acute circulatory failure (1)
c. Arrhythmia/Heart block/AF/VF/Bradycardia (1)
d. Mechanical-rupture of Papillary muscle/rupture of inter-ventricular
septum (0.5)
e. Thromboembolism/embolism (0.5)
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Answer of Q 1: (1x4=4)
a. Kala-azar,
b. Chronic myeloid myeloma,
c. Malaria,
d. Lymphoma.
Answer of Q 2: (0.75x4=3)
a. Bleeding manifestation/purpura/gum bleeding,
b. Anaemia,
c. Jaundice,
d. Lymphadenopathy,
e. Bony tenderness.
Answer of Q 3: (Max-4)
a. CBC with ESR (1)
b. PBF (1)
c. Bone marrow (1)
d. Rk39/DAT/Serology for kala-azar (0.5)
e. Splenic puncture/Splenic puncture for LD bodies (0.5)
f. CXR (0.5)
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Medicine OSPE
Question 1: What is the name of the condition of the eye visible in the
photograph? 2
Bitot’s spot/Xerophthalmia/ocular manifestation of Vit-A deficiency
Question 2: Write down the WHO Staging of this condition. 5
WHO staging are:
XN- Night blindness
XIA- Bitot’s spot
XIB- Conjunctival Xerosis
XII- Corneal Xerosis
XIIIA- Keratomalacia ˂1/3rd of the corneal surface
XIIIB- Keratomalacia ˃1/3rd of the corneal surface
XS- Corneal scar
XF- Xerophthalmic fundus
(Examinee will get full marks even if they write the name of the stages)
Question 3: Mention the specific treatment. 3
Vit-A (1) three doses (1) on day 1, day 2 and day 14 (1)
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Medicine OSPE
January,2016
Station: 6 (Q+Answer key)
(See above)
July,2010
Station: 3 (Q+Answer key)
Instructions: Write down a prescription for a patient who has been
suffering from typhoid fever.
…Answer Key….
1. Name of the patient 0.5
2. Age 0.5
3. Date 0.5
4. Name of the drug - 2
Quinolone/Azithromycin/Cefixim/Co-trimoxazole/Ceftriaxone
5. Route of administration- oraly 1
6. Dose of drug- 1
7. Frequency of administration- 1
8. Duration of treatment- 7 days 1
9. Advice to the patient 1
10.The doctor’s name, registration number and signature 0.5x3=1.5