Pre final OSCE and Learning points

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The case allotted to me one day before the exam is presented in the following log which can be found here







OSCE



1) Can diabetes cause Fatty liver, if yes how?

     Yes, Diabetes can cause fatty liver. 

  • Non-alcoholic fatty liver disease (NAFLD) is highly prevalent in type 2 diabetes mellitus.
  •  The pathogenesis of NAFLD is not yet fully understood, but insulin resistance appears to be a critical contributing factor with obesity as the most common cause of the insulin resistant.
  • As body fat stores expand with  excess calories and progressive obesity, alterations in lipid metabolism along with inflammation in adipose tissue and ectopic sites of fat deposition lead to insulin resistance.
  • Insulin resistance leads to increased its accumulation in body. This excess insulin increases lipolysis and increases the production of free fatty acids.
  • The surplus amount of fatty acids cause an excess production of triglycerides in the liver.
  • This accumulation of excess liver fat is further exacerbated by impaired hepatic fatty acid oxidation secondary to insulin resistance.
  • The elevated glucose levels in context of diabetes, further provide substrate for triglyceride synthesis. 
  • Additionally, impaired VLDL secretion, which commonly occurs with insulin resistance, further contributes to hepatic fat accumulation
All the above factors cumulatively cause fatty liver in a diabetic.



2) Is the pre renal AKI due to DKA or vice versa?

  • I think the pre renal AKI is due to DKA and not vice versa. 
  • In DKA osmotic diuresis occurs and it may even be accompanied by emesis, which causes dehydration





3) How much of a role does a renal cyst play in causing AKI?

  • Enclosed liquid or semisolid fluid is called a cyst and are commonly identified on imaging.
  • The currently accepted hypothesis is that renal ischaemia or injury prompts an aberrant hypertrophic response leading to cyst growth and leads to further nephron loss due to compensatory hyperfiltration.
  • So thus, a renal cyst can occur as a consequence of ischaemia which is actually a cause of AKI




4) What is phantom lung tumor?

  • Phantom or vanishing tumor stands for a localized transudative interlobar pleural fluid collection in congestive heart failure.
  • It appears as a tumor on chest Xray and disappears after appropriate management of heart failure.


5) How to differentiate between pneumonia and phantom lung tumor?

  • While both pneumonia and phantom tumor may present with SOB, cough and have similar chest Xray findings, cough due to pneumonia is mostly associated with expectoration and fever may also be present, which not the case for phantom tumor. 
  • Heart failure symptoms like orthopnea, dysnea are seen in phantom tumor where as infection symptoms are seen in pneumonia like fever, cold and cough with expectoration.
  • More over Phantom tumor resolves once appropriate treatment for heart failure is started.


LEARNING POINTS

  • I learnt about the seriousness of uncontrolled diabetes.
  • How important is it under go regular screening for diabetes
  • I learnt about treatment of DKA and various complications of DKA
  • Phantom tumor and how to differentiate it from pneumonia



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