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MNJ06-001
Identify the audiogram patterns shown in Image A and Image B:

MNJ-P-OSCE 06. Audiometry, capnogram, spirometry_page_4_Figure_5.jpeg
MNJ-P-OSCE 06. Audiometry, capnogram, spirometry_page_5_Figure_2.jpeg

  1. Identify the hearing defect shown in Image A.
  2. Identify the hearing defect shown in Image B.

Answer

  1. Image A: Conductive Hearing Loss (Left Ear) — Air-bone gap present (bone conduction normal, air conduction impaired).
  2. Image B: Bilateral Sensorineural Hearing Loss (SNHL) — Both air and bone conduction thresholds depressed equally without air-bone gap.

MNJ06-002
Review the instrument shown below:

MNJ-P-OSCE 06. Audiometry, capnogram, spirometry_page_5_Picture_7.jpeg
MNJ-P-OSCE 06. Audiometry, capnogram, spirometry_page_5_Picture_8.jpeg
MNJ-P-OSCE 06. Audiometry, capnogram, spirometry_page_6_Picture_2.jpeg

  1. Identify the instrument.
  2. Which respiratory illness is it primarily used for home monitoring?
  3. What are the three color-coded zones and their corresponding Peak Expiratory Flow (PEF) percentages?

Answer

  1. Peak Expiratory Flow Meter (PEFR meter / Wright peak flow meter).
  2. Bronchial Asthma (monitoring airflow obstruction, response to bronchodilators, and asthma action plan).
  3. Three Zones (Asthma Action Plan):
    • Green Zone: >80% of personal best PEF (Good control; continue baseline controller medications).
    • Yellow Zone: 50–80% of personal best PEF (Caution; worsening symptoms/exacerbation; step up reliever therapy).
    • Red Zone: <50% of personal best PEF (Medical emergency; immediate short-acting bronchodilators and seek urgent hospital care).

MNJ06-003
Review the waveform tracings below:

MNJ-P-OSCE 06. Audiometry, capnogram, spirometry_page_6_Figure_6.jpeg

  1. What is this monitoring modality / graphical technique?
  2. What are the interpretations for wave patterns A, B, and C?

Answer

  1. Capnography / Capnogram (end-tidal carbon dioxide [EtCO2] monitoring).
  2. Interpretations:
    • A (Shark-fin waveform): Bronchospasm / Airway obstruction (e.g., Bronchial Asthma, COPD, prolonged expiratory upstroke).
    • B (Loss of waveform / Flatline): Endotracheal tube (ET) displacement / accidental extubation, esophageal intubation, or complete airway obstruction / circuit disconnection.
    • C (Progressive rise in EtCO2 baseline during CPR): Return of Spontaneous Circulation (ROSC) / effective cardiac output during CPR.

MNJ06-004
Identify the arterial pulse waveforms shown below and give one clinical condition for each:

MNJ-P-OSCE 06. Audiometry, capnogram, spirometry_page_6_Figure_8.jpeg

  1. Waveform 1
  2. Waveform 2
  3. Waveform 3
  4. Waveform 4
  5. Waveform 5
  6. Waveform 6

Answer

  1. Collapsing Pulse (Water-hammer / Corrigan pulse): Aortic Regurgitation (AR), Patent Ductus Arteriosus (PDA), Large arteriovenous fistula, Thyrotoxicosis.
  2. Pulsus Bisferiens (Biphasic pulse with two systolic peaks): Combined Aortic Stenosis + Aortic Regurgitation (AS + AR), Hypertrophic Obstructive Cardiomyopathy (HOCM).
  3. Dicrotic Pulse (Two peaks, one in systole and one in diastole): Typhoid fever, Severe dilated cardiomyopathy, Septic shock.
  4. Small Volume Collapsing / Weak Pulse (Pulsus Parvus et Tardus): Severe Aortic Stenosis (AS), Mitral Regurgitation (MR).
  5. Pulsus Alternans (Alternating strong and weak beats): Severe Left Ventricular Systolic Failure (severe CHF).
  6. Pulsus Paradoxus (Exaggerated drop in systolic BP > 10 mm Hg during inspiration): Cardiac Tamponade, Severe acute asthma (status asthmaticus), Constrictive pericarditis, Superior Vena Cava (SVC) obstruction.

MNJ06-005
Give the type of visual field defect according to the anatomical lesion at sites 1 to 6 on the visual pathway:

MNJ-P-OSCE 06. Audiometry, capnogram, spirometry_page_7_Picture_3.jpeg
MNJ-P-OSCE 06. Audiometry, capnogram, spirometry_page_11_Figure_2.jpeg

  1. Lesion at Site 1 (Optic nerve)
  2. Lesion at Site 2 (Optic chiasm - midline)
  3. Lesion at Site 3 (Optic chiasm - lateral margin / uncrossed fibers)
  4. Lesion at Site 4 (Optic tract)
  5. Lesion at Site 5 (Meyer loop / Temporal optic radiation)
  6. Lesion at Site 6 (Visual / Occipital cortex with macular sparing)

Answer

  1. Site 1 (Optic Nerve): Ipsilateral Monocular Anopia / Complete Blindness in that eye.
  2. Site 2 (Optic Chiasm - central): Bitemporal Hemianopia (e.g., Pituitary adenoma, Craniopharyngioma compressing decussating nasal fibers).
  3. Site 3 (Optic Chiasm - lateral): Binasal Hemianopia (calcified carotid arteries compressing uncrossed temporal fibers).
  4. Site 4 (Optic Tract): Contralateral Homonymous Hemianopia.
  5. Site 5 (Meyer Loop / Temporal Optic Radiation): Contralateral Superior Homonymous Quadrantanopia ("Pie-in-the-sky" defect).
  6. Site 6 (Occipital Visual Cortex / Calcarine Sulcus): Contralateral Homonymous Hemianopia with Macular Sparing (due to dual blood supply from MCA and PCA).

MNJ06-006
Review the electrophysiological test tracing below:

MNJ-P-OSCE 06. Audiometry, capnogram, spirometry_page_7_Figure_7.jpeg

  1. What is this test?
  2. Identify the anatomical generators for Waves I through VII (using the mnemonic E. COLI).

Answer

  1. Brainstem Evoked Response Audiometry (BERA / ABR - Auditory Brainstem Response).
  2. Anatomical Generators (Mnemonic: E. COLI):
    • Wave I & II: Cochlear nerve / distal and proximal cranial nerve VIII (Eighth nerve)
    • Wave III: Cochlear nucleus (pons)
    • Wave IV: Superior Olivary complex (pons)
    • Wave V: Lateral lemniscus (most prominent wave, used for threshold estimation)
    • Wave VI & VII: Inferior colliculus (midbrain)

MNJ06-007
Review the pulmonary function flow-volume loop below:

MNJ-P-OSCE 06. Audiometry, capnogram, spirometry_page_8_Picture_2.jpeg

  1. Identify the graphical plot and state its clinical utility.
  2. Differentiate the Red loop and Green loop patterns with an example of each.

Answer

  1. Flow-Volume Loop (Spirometry): Used to differentiate obstructive vs. restrictive ventilatory defects, evaluate upper airway obstruction (fixed vs. variable intra-/extra-thoracic), and monitor response to bronchodilators.
  2. Patterns:
    • Green Loop (Obstructive pattern): Scooped-out expiratory curve ("coving") with reduced peak expiratory flow and concave descending limb (e.g., Bronchial Asthma, Cystic Fibrosis, Bronchiectasis).
    • Red Loop (Restrictive pattern): Miniature / narrow "witch's hat" appearance with preserved shape but symmetrically reduced lung volumes (FVC and TLC reduced with normal/high FEV1/FVC ratio) (e.g., Interstitial lung disease, Kyphoscoliosis, Neuromuscular weakness).

MNJ06-008
Audiogram from a 7-year-old boy Ronit. His mother was worried about his hearing in the left ear. He had passed his routine audiometry screening at 5 years and there was no family history of deafness. On physical and otoscopic examination, no abnormalities were found:

MNJ-P-OSCE 06. Audiometry, capnogram, spirometry_page_8_Figure_6.jpeg

  1. Diagnose the audiogram findings.
  2. List 4 possible acquired causes of this hearing loss in childhood.

Answer

  1. Diagnosis: Profound Unilateral Sensorineural Hearing Loss (SNHL) affecting the left ear (both air and bone conduction thresholds severely elevated > 90 dB on the left, with normal hearing in the right ear).
  2. Causes:
    • Viral labyrinthitis (e.g., Mumps [most common acquired cause of unilateral profound SNHL], Measles, Rubella)
    • Post-meningitic labyrinthitis / bacterial meningitis
    • Temporal bone trauma / skull base fracture
    • Ototoxic drug exposure (Aminoglycosides, Cisplatin)
    • Acoustic neuroma / Vestibular schwannoma
    • Autoimmune inner ear disease / Sudden sensorineural hearing loss

MNJ06-009
This is the pure-tone audiogram of a 4-year-old girl who was referred because of severe speech delay:

MNJ-P-OSCE 06. Audiometry, capnogram, spirometry_page_9_Figure_5.jpeg
MNJ-P-OSCE 06. Audiometry, capnogram, spirometry_page_10_Picture_2.jpeg

  1. What does this audiogram show?
  2. What is the most likely cause of her speech delay?
  3. What is the next step in auditory habilitation for this child?

Answer

  1. Diagnosis: Bilateral Moderate-to-Severe Sensorineural Hearing Loss (SNHL) across all speech frequencies (500–4000 Hz) with superimposed threshold loss.
  2. Cause of Speech Delay: Congenital or early-onset bilateral sensorineural hearing impairment impairing auditory input during critical periods of speech and language acquisition.
  3. Auditory Habilitation:
    • Prompt fitting of bilateral digital hearing aids.
    • Comprehensive speech and language therapy.
    • Evaluation for Cochlear Implantation if hearing aids provide inadequate benefit.
    • Genetic and etiology workup (Connexin 26/GJB2 mutation testing, CMV screening, CT/MRI temporal bone for inner ear anomalies).