INBDE CONQUER CASE BASED QUESTIONS PATIENT BOX QUESTIONS ORAL MEDICINE

hi everyone this is dr saiti team inbd conquer so today's discussion is on patient box okay so wherein in your imbd exam we have come across the clinical scenarios or case based questions are being presented in a form of a patient box okay so in that in that box they give the details of the patient they give the background history they give the chief complaint as well as the clinical findings so at times they also post the picture clinically or radiographically which will help us to arrive at the diagnosis okay so how these questions are being asked is as i said it's in the form of a case that is presented in the form of a box followed by the question and the options and you have to go for the correct answer so today i'm going to discuss few important cases from your oral medicine oral pathology and wherever required the radiograph is also included because at times radiographic features actually help us to arrive at the correct diagnosis right so radiograph is also required wherever the question has its need okay so like that few questions i'm going to discuss so that you'll have an idea and also you'll have the practice before arriving for your exam okay so coming to the very first question so as if here you can see here so it's a patient that of a 14 year old female so this girl is a 14 year old female so now you have to be very sure of each and every line that is presented in this box okay so the chief complaint here is that she has to correct her crooked teeth okay so next the background history it's quite important because here the history says that the family has uh the mom and dad had a consequence marriage okay so wherever i mean it's not always but kansas marriage cases might have a genetic like like genetic abnormality in the offspring might have chances might be there so that's the reason here the background history definitely has its importance and a very very important which actually help us to arrive at the diagnosis are the three points that are being given here so these are the clinical findings or the key points which will actually exactly arrive as at the diagnosis right so here what are those clinical findings that has been given in the question is a micrognathic left palate and the glossopterosis so here if you see the girl obviously you can appreciate the micrognathia right so and in the question it's clearly mentioned the triad that is microgravity cleft palate and glossoprosis so i think by now the answer must have been clicked but let's see the option so what is the syndrome that you can diagnose in this patient is the question so there are four options that the stretcher collin p robin who is juggle and parry romberg so we know in um p d robin syndrome you see the sequence you see this triad right so happily you can go for the answer of peri robin syndrome and you can eliminate the others if you know the findings of the other options also but here it is a straightforward question that's a period robin syndrome so what exactly happens in a period orbiting cinema is actually the sequence okay so patient will be having in a hypoplastic mandible because of which a secondary enamel like the tongue will fall backwards and gloss optics is occur and the tongue will also obstruct the palatal fusion and there will be a u-shaped pallet and a cleft palate occurs okay so these are the very important sequence so that is micrognathia glossoptosis and cleft palate so this is a sequence or this is important triad of a peri robin syndrome okay so i hope you got an idea of how the question can be asked in respect to the important diseases or the important syndromes from your subjects in your exam okay so this is the very first question now let's go to the next question so here again you have seen a data it's a 53 year old female and the chief complaint is she has a swelling of the upper lip as you can see that's since a very long time that's a chief complaint and the patient has developed swelling of the upper lip and also there's a ruling of saliva in the corner of the mouth so that is a history now coming to the clinical findings where we have to check further key points okay so she's unable to smile on the same side there's absent of wrinkles on the forehead and intraorally fissured tongue is there as you can see so in the background history also you have seen that there is a drooling of saliva from the right corner of the mouth and in the clinical findings we have seen that she is unable to smile on the same side absence of wrinkles so all these will help us to arrive at a one of the component of a syndrome which is nothing but the facial palsy right so there is a paralysis of the facial knob so this is that next fissure tank is clearly given and there is a picture showing the fissure tongue this is the second component third component if you see the swelling right so what exact swelling of the upper lip so there are three components now the swelling of the upper lip the facial palsy and fissure tongue so we know we out of this we have got the three important key points right now let's see the options so what is the condition so peri romberg methods and ross of the killer analyst and ramsay hunter the options given so where do you see these three components that is fissure tongue the facial palsy and the upper lip swelling which is nothing but key light is granulomatosa so where do you see that so if you go through a developmental disturbances chapter from your oral pathology in your schaefer these three components are seen in our mechancel rosenthal syndrome okay so you see fish your tongue you see facial palsy so here the patient had that all the features of the facial palsy like absence of wrinkles unable to smile ruling of saliva so these are like arriving us for the facial palsy obviously fissure tongue is also the clinical picture of the fissure tongue is also posted next the swelling of the upper lip which is nothing but key light is granulomatosa so these three are the components of the mechancyl or simple syndrome that's all okay so we know that disease we know the components but how it is being presented in the exam and how we need to get exposed is the main thing that we have to do now that's all okay so next coming to the next question so here is a 65 year old man who is living in so and so plays in south east of iran okay and the chief complaint is he has fever cough chill shortness of breath so these are like respiratory symptoms as you can see and then the background history like has history of keeping animals okay so that is why they have given industry maybe it has some importance and also like sheep and goats but animals were not infected and has a long issue of copd also and the symptoms didn't like improve despite of antibiotics and the patient was referred to the hospital okay and here is a radiograph that is there okay now we'll see the current findings of the clinical findings so here the chest x-ray has shown a mediastinal widening it's clearly shown plural effusions are there parenchymal infiltrations and lymphadenopathy is there and the blood samples has revealed gram positive strepto basilic the bamboo stick appearance so that appearance might have an importance again so that's a key point again and the black culture has shown a creamy grow coarse grayish texture with irregular border lines with hemolysis looking like a jellyfish so all these now if you see so how to think those now after seeing this question one thing is clear that this is an infectious disease for sure okay because there are fever and there is lymphadenopathy and all those pulmonary symptoms are there so it's infectious that is understood right next in the background he is having a history of animals and all that okay and in the current findings that is the chest x-ray if you see or the chest radiograph what what you have observed is a mediastinal widening which is a very important key point okay and then a culture is taken and there's a bamboo stick appearance so this is a combination of oral path as well as a microbiology okay so this bamboo stick appearance you see in a bacteria okay already it is given the gram positive streptobacillus so already it is very clear that it's a bacterial infection again okay so now let's go for the options and let's arrive at the answer okay so identify the disease so it is wool sort of pulmonary anthrax tetanus is the options that is given and fourth option is both a and b so now it can't be tetanus because in tetanus we definitely see that you know rigidity the log jaw rigid muscles and all that right so this can't be tetanus so other option could be since it's a gram positive bacilli showing it you know the bamboo stick appearance it's nothing but a bacillus anthracis caused disease which is our anthrax so it is a pulmonary anthrax so there's a mediastinal widening is a very very important radiographic feature it's gene seen in the chest radiograph of whoever is suffering from pulmonary anthrax okay so it is caused by this bacteria that is bachelor's and crisis and in a microbiological view it is showing the bamboo stick appearance so all these are the key points to arrive at the pulmonary anthrax option but there is one more thing that is being given that is a wool sorter's disease right so wool sorter is other name for pulmonary anthrax okay so wool sorted this is other name for pulmonary anthrax so here both a and b are your answers okay yes now coming to the next a 25 year old female has come for the regular dental checkup there is no particular history over there but as you can see there is a serpentis pattern in the observed on the tongue now what is that simple it is showing a serpentis pattern of decapitated tongue so it's a case of a geographic tongue that solves a case of geographic tongue which is also called as benign migratory glossitis or erythema migraines so answer here it is both a and b so for the previous question also the wool shortest disease which is other name for pulmonary anthrax so even there it is both a and b and even here also it is geographic tongue because you have seen the serpentis borders on the tongue and erythema migrants so both the and b is answer simple this is a very simple question right next here a patient has like it's a 20 year old female regular dental checkup and hyperplasia of the cingulum of the anterior teeth is seen so it's a developmental anomaly of the tooth simple question i think you can guess this it's just a cingulum that is hyperplastic and you can see that cone shape so what is that so identify whether it's talents cause when and why publisher attorneys are options among the options it's a straightforward question it's a beautiful picture is also posted so it is hyperplasia scene on the cingulum of the teeth so it's nothing but the talents cusp so now my question is neymar syndrome which is related to the talents cusp so from your shaffer if you see the syndrome which is associated or where you see the talents cusp is a rhubarb steam taste syndrome okay it's a rubestine taste syndrome okay good so yes let's go with the next question here so here it is a male of a 10 year old okay and he has cavities in the mouth and reddish rashes on the hands and feet that's his chief complaint and he was born to a mother who has poor prenatal care and belong to a less socioeconomic group okay and then the clinical findings so what are the clinical findings so is it refused arithmatus palmer plantar keratoderma along with these commission fissures and intraorally we have seen dwarfed molars as you can see in the picture and also their screwdriver shaped incisors all these can be nicely appreciated in the picture that is given right so very nice question to be honest because you have seen a direct uh the important or characteristic feature of a disease where you see the mulberry molars and the screwdrivers shaped in sizes these are nothing but hatchings teeth okay so there is a trial which is called as in hutchins triad where you see the screwdriver shape incisors mulberry molars interstitial keratitis and eighth nerve deafness right so all these are the features or the triad that our chinchin striat is seen with very good it's congenital syphilis right so it's nothing but a case of congenital syphilis so as you can also see a rash besides that the intraoral findings are these so obviously the question is helping us to think of congenital syphilis but yes before going for the other thing we have to definitely read all the options and what is exactly the question being asked we have to think right so what is the question now so what are the other findings that can be expected in this child so here they are not asking us to diagnose they are asking what are the other findings that can be seen in this disease or in this condition so obviously we have arrived at a diagnosis that it could be like it is definitely because there's attention's teeth there so it is in hatching since triad is i mean it is component of fascination's triad that is screwdriver shape and sizes and mulberry moles so obviously we know that it is a case of congenital syphilis right so it is a very clear-cut case of congenital syphilis now what are the other findings that will be expected in this child so a scapula in the vertebral border below the level of the spine is having concavity instead of convexity yes this can be expected because this is nothing but scaphoid scapulae scaphoid scapula so this is a finding that is seen in congenital syphilis gets or children affected with congenital syphilis so this is a scaffold scapula next anterior bowing of the mid portion of the tibia yes this is nothing but shaver shin okay this is nothing but shape or shin even this you can expect in this chill child okay next thickening of sternoclavicular portion of the clavicle yes this is he go saddle knows okay regades of flip all these are the very very important features of congenital syphilis besides that hutchington's triad these are the very important features of congenital syphilis obviously our answer is any of the above right so this is how the questions can be put forward either they'll ask you to arrive at a diagnosis or they will ask you to find give you give other findings or they'll ask you to give an investigation the question can be asked here this way or that way the only thing is you need to get exposed to those type of questions and you need practice that's all okay so next the other question now here is a 30 year old female pregnant patient so she was having fever dry irritating cough and growth on the tongue this is a growth on the tongue as you can observe and the patient was having a bacterial pneumonia few weeks back so this is also an important point now coming to the clinical findings so there is a nodular ulcer with undermining edges so this is our key point always focus on the key points given so there is an ulcer with undermining edges so that is a key point and a dorsum of the tongue and cancer sauce and intra release was there and cardo pulmonary examination has shown these with scattered crackles as you can see here and there especially in the upper two thirds of the tongue and a radiograph has shown radio opacities throughout the lung fields in the upper two thirds of the tongue and there was a granulomatous inflammatory process so this is a granulomatous infection obviously undermining edges involvement of the lungs this is nothing but a case of just think before that will arrive at the answers or i mean the options so what is the diagnosis now so there's squamous cell carcinoma no it will have inverted edges so no canker it will be painless and it is seen in syphilis and lung involvement may not be much tuberculosis also with pulmonary involvement yes yes the pulmonary involvement is there you have seen radio opacity is a gone focus that you see in the tuberculosis besides that the very important key point in properly is the undermining edges of the ulcer so these two are the thing and granulomatous obviously so all these are the key points which are helping us to give a provisional diagnosis of tuberculosis also with a pulmonary involvement why is it not final diagnosis because before doing i mean you have to go for the acid fast bacilla you have to do a montox test to go for the final diagnosis this is just a provisional diagnosis based on the key points of the clinical or the current findings and the history that is given by this patient in the box that i have presented okay so geotrichos is no because it will be like a patch so obviously the straightforward answer for the options given in this particular question where you can think of a provisional diagnosis of tuberculosis ulcer obviously there's a pulmonary involvement there is fever there is all these creatures that is there is helping us to arrive at the answer there is a bacterial pneumonia right so it's a straightforward answer that is tuberculosis ulcer with pulmonary involved good next question now so is a 11 year old girl she wants a correct alignment of her teeth considers marriage of the parents so whenever there is consequence marriage you can think of some genetic abnormality in that offspring next what are the clinical findings so there's a mandible of facial disorders white face hypoplastic maxilla hypertelorism bulging of eyes as you can see prognathism of the mandible as you can see and the radiograph here it is showing something which is very important okay so there is a radiographic picture obviously the syndrome that we know all the syndromic features are there right the radiograph is showing some very good characteristic feature here so what is that now so it is nothing but a copper beaten skull or a hammer beaten or a metal beaten skull okay so this is a syndrome where you see the copper beaten skull is the let's see the options now it's not upper syndrome because in a person the most very important feature is the socket feet and the mitten hands that is synthetic tightly obviously the other features could be there but that is not presented here so it is not that p robin as we have already discussed that it will be have micrognathia glossoptosis and cleft palate so it is not that retrocalling syndrome the patients will have hyperplasia of the malar bones it is not that the copper beaten skull along with the characteristic features that is given here it is nothing but a krausen syndrome so the copper beaten skull the radiographic feature the radiographic picture that is given it is a straightforward case of crows and syndrome no need to think of other options also the copper beaten skull hammer bitten skull netting beaten skull is clearly seen in this syndrome that is krausen syndrome okay so that here in this particular question though the clinical findings history everything is important but the most important thing is our radiographic picture that is posted okay so this is a case of krausen symbol next question i mean the main thing of the crowson syndrome so here it is characterized by primarily closure of the fibrous joints and the cranial sutures between the certain portions of the bone so there is craniosynostosis and distinctive facial abnormalities is also there so that is the primary characteristic of the krausen syndrome okay so next question now so here it is a three-year-old girl regular pediatric checkup second segments marriage so genetic abnormality so there's a depressed nasal bridge so the nasal bridge is gone hypothesis of eye hypertelorism maxillary hyperplasia mitten hands and socket feet just just now i have told the options in the previous question okay so this is our key point obviously the depress nasal which is also a key point so now what's the condition here so let's eliminate browsing syndrome no because the nasal bridge will not be that depressed it will have a good nasal bridge only and obviously syndactyly won't be there hypertelorism all the other features could be there okay so it's not that cherubism it will be like chubby cheeks so it's not that make utilitarian you have the kefla spots and all that and you know precocious puberty so it's not that so obviously it is upper syndrome so in upper syndrome you see that syndactyly okay so where you see the midterm hands and the socket feet so it's a very very very important feature of the kids or the children suffering with upper syndrome okay so what does that similarity with the krausen's is so brachiocephaly hypoplastic mid phase hypertalorism proptosis all this could be there and common radiographic is impacted teeth delayed eruption and ectopic you know eruption supernumerity calcification of styloid process could be there and distinguishing from krausen is neurological deficits syndactyly as you can see here the fusion and also the fusion of cervical vertebrae so all these are the differentiating features so here in this particular baby since we have seen the midterm hands and socket feed so that is a very important key point for us to arrive at the epper syndrome similarly the previous question the very important feature was the radiographic feature of a copper bit and skull which is arriving at the krausen syndrome okay so just know the differences between the crows and versus epper syndrome okay so now here you can see an 18 year old male what is the chief complaint so it's a complaining of discolored teeth since his childhood the background history that he shares that is was like bluish discoloration of the milk teeth okay and he underwent crowding of the upper scissors two years back and what are the clinical features so there's a bluish amber colored teeth with a translucent hue okay very important finding blueish hue translucent hue so that is a key point and opg revealed obliterated pulp chambers as you can see so here you can see that translucent hue in the teeth and you can also see that pulp chamber obliteration okay so what it could be let's see for the question now so this is our patient box what are the key points blue is through bluish amber color translucent hue and obliterated pipe chambers so which type of collagen is affected in this disease so now first where do you see the bluish hue on the teeth and the pipe chambers is obliterated so which disease that you can think of okay so this is a case of obviously the dentinogenesis imperfecta so if associated with osteogenesis you can also see the blue issue in this clearer okay and in osteogenesis imperfecta you can see that fragile bones and all that why because there is a defect in type 1 collagen so this type 1 collagen is present in the sclera is present in the dentin is present in the bone so obviously if osteogenesis imperfecta along with antinogenesis or just a dentogen densities imperfecta can occur obviously the defect is seen with the type 1 collagen so wherever the typhoon collagen is affected obviously the patient will show the respective clinical features so here the patient show bluish that translucent shoe of the teeth and if the same patient also had bone fragility and you know brittle bones and the bluish hue of this clearer so you can also think of osteogenesis imperfecta so in that disease the type one collagen is affected okay so this is nothing but a case of ostrogenesis or a dentinogenesis imperfecta where the type one collagen is affected okay yes now coming to the next question so here a seven year old female crowded upper front teeth so ophthalmic problems are there and we pattern uh is there travis misses their high myopia is their cardiac problems are also they're like mitral valve prolapse iotic aneurysm so underlying that and patient has genetic tests and there's a mutation of fibrillin type one okay so very very important key point within the history only we got it okay and next clinical finding so there are elongated arms legs fingers dolichocephalic head broad forehead and a maxillary retinopathy hypermobility of the joint so here elongated arms and legs and fibrillin type one genetic disorder and iotic aneurysm so what can you think of now go for the options so what is the clinical finding based on the history and the clinical findings that is given what is the diagnosis that you can think of so first mcq and albert syndrome no you see a catholic pigmentation and all that so it's not that rubinstein taking no anyways it's not that ls dawn of course here you have seen little hypermobility of joint but here in ls knowledge you see hypermobility of the skin everything the other features of elongated hands and feet and mitral valve prolapse the iot can neuralisms and definitely the gene mutation of fibulin type one so that is a very important key point of our marfan syndrome okay so there's clear-cut mutation that has been presented it's an autosomal dominant disorder where you see the type one fibrillin that is got mutated okay so it is a case of marfan syndrome so in marfan syndrome obviously you have eye problems you have heart problems okay so abnormal chest heart related problems okay and tall thin body frame and obviously the long arms and long feet and long fingers all that are the features of the marfan syndrome so this is a clear cut case of a martin syndrome okay good now here next case is 11 year old female missing teeth and swollen gums and there's premature birth delayed milestones iq certified triosome 21 irregular sequence is there triosami 21. so background history very important key point triosemi 21 and in clinical findings brachycephaly uh slanting uh trees and horse voice so of course there are many other features but very straightforward feature or the thing that we can completely focus is nothing but our triosami 21. so what is that trio 21 what syndrome is rhizome 21 simple down syndrome no need to think of other options and eliminate also triosome 21 is down syndrome that's all okay so here this is a simple case of down syndrome clear so in down syndrome you see that all the other features that were presented okay so palma crease all that very important brush field spots in the eyes so these are the very important key points but yes rhizome 21 is nothing but a genetic thing that you see with the down syndrome okay good now going to the other question this is a 16 year old female fluid secretion in the lower lipit is there history of cleft clip and cleft wallet when he was a toddler so what are the clinical findings mid phase retention is a lower lip bilateral lipids are there so if you see the picture lipids are there and the conjunctivally missing teeth are there marker hypoplasia and label abrasion are there so lip so lipids is a very important key point here so what is the syndrome that you can think of so what is the syndrome associated with the lipids vanderwood syndrome okay so the syndrome which is associated with the lipids the pits that is seen in the lower lip especially is nothing but a vanderwood syndrome that's all okay so i think it is now you are getting more adapted and you are able to think now right so next is a 16 year old boy he says discoloration of the teeth and family reveals that there's presentation of the teeth which are discolored i mean other means in the family also there were some other people who had the similar discoloration so here you have seen yellowish discoloration and radiograph so now the radiograph is showing a very important key point that is picket fence appearance so this line that is picked friend's appearance is from your white and pharaoh it is not from your oral path so this picket friend's appearance is seen from your white and pharaoh so now what can you think of so now let's go for the question so pick it friends appearance yellow is discoloration of the teeth other two important and also the family history are the important key points for us to think of now now let's see for the options so based on the clinical and radiographic findings what will you think of dentinogenesis imperfecta no there will be obliteration of the pulp chambers they will not we have never heard of this pickered friend's appearance dentin dysplasia rootless teeth no so the other two so it's hypo maturation and hypoplastic type of amylogenesis imperfecta so it is a case of amylogenesis imperfecta yellows discoloration you see so what among these two what it could be so in hyper maturation type you see snow cappity okay so you see snow capped teeth in hypo maturation type radiographically here this is a case of hypoplastic type because the anomalous laws or enamel is not there or it's very thin because of which there will be loss of contacts between the teeth and especially if the anterior teeth if you see a radiograph you get that picket fence appearance okay so radiographic finding is a very important thing for us to think of the diagnosis so here you have seen that there is no contact so there is less enamel so this is a hypoplastic type of amylogenesis imperfecta if snow capper teeth is there then you can go for hypo maturation type okay so this is from your radiology point of view good now coming to the next question so here is a 34 year female the pain and swelling in the floor of the mouth in the right side so here the swelling is hard tender and more evident on eating and they this decrease has salivation okay so there is a decrease in the salivation also so there's a swelling here okay and the swelling is heart tender so it is something related to salivary glands that we can think of okay so what is a probable diagnosis so here it is just a swelling and on eating it is different so it is simple case of silo lithius okay so it's a simple case of silo lithius at times you can clearly appreciate the stone in the picture also okay so this is a case of cello lithius now coming to the next question here is a 45 year old male chief complaint of difficulty in opening the mouth so this is a like client with why why there is a difficulty and he has smoking and alcohol habit diff clinical findings is diffuse white lesions as you can see in the buccal mucosa little borders of the tongue and the label mucosa and decrease ballooning of the cheek so the patient is not able able to balloon so there is some fibrosis there obviously is having some habits difficulty in opening so there is something that has occurred or some condition which can decrease that uh decrease i mean this is not able to blow and decrease mouth opening is there so these are the key points that you have to put in your mind now think of the answers smokers melanosis melanosis means it will cause the dark pigmentation but such type of complete rigidity and ballooning absency or the rigidity and opening will not be there on the lateral border of the tongue so obviously because of fibrosis oral mucosal fibrosis is the case it is blanching of the oral mucosa there's whiteness there's blanching and the patient is not able to open the mouth not able to blow and if the further features like shrunken uvula rigid tongue all these are nothing but the case of oral submucosal fibrosis that's all okay so this is a case of of course a patient in the history personal history good cut showing or that arikana chewing is not given but still you can definitely think of this because of the nice creatures that has been presented the blanching of the oral mucosa and the clinical findings among the options given definitely you can go for oral submucosal fibrosis okay yes now next question severe is 11 year old male kid is a kid and severe pain in the throat and fever since five days so you can see a clinical picture some something and he didn't take any antibiotics and there's mild swelling of the neck that's an important point and there's a thick adherence pseudomembrane okay so thick catherine membrane fever a kid and swelling of the neck so these are the four key points here so what is the condition so tetanus it will have a lock jaw no hepangina is a vascular pullers it's viral it will have vesicles in the posterior turn not a membrane it will have small vesicles or ulcers in the posterior part of the palate which will not show an adherent membrane no herplex simply is definitely no so obviously it is a case of diphtheria so it is caused by corny bacterium diphtheria okay what are the important features bull's neck thick adherent pseudo membrane okay thick adherent pseudo pseudomembrane so all there is a thick adherent so it's very painful the membrane can't be removed it's very painful okay so corny bacterium diphtheria and pseudomembrane the bull's neck are very important features of corny bacterium diphtheria so here the answer is diphtheria okay yeah next a 21 year old male multiple missing teeth what are the clinical findings that is given multiple missing teeth are there scalp hair is less sparse eyebrows as you can see in prairie oral pigmentation so now think of the question and the options so what are the findings missing teeth hair is sparse so hypotrichosis hypodermicia two important points and periodical pigmentation also but these two are the key points hypertrichosis hypodontia conical shaped teeth so not in romberg not in peri robin p robin is a triad we know so it is simple case of ectodermal dysplasia hypertrichosis hypodensia okay and also note dry skin all that are the very important findings of ectodermal dysplasia so here you can see question says that is scalp hair is less eyebrows are less you know and obviously the cone shaped central incisors are missing teeth hypodensia all these are nothing but ectodermal dysplasia that's all so this is a simple case of ectodermal displacion next question so we are at almost to the last so this is 11 year old girl swelling in the right side of the face and she has said that there's a scratch by the cat okay so it's you can think now so swelling is there here as you can see and also right eyelid also there is swelling so the catch must have scratched like this so it's a simple case of what now first think of that so there is a swelling of the glands and the ocular region so it is a case of a cat scratch disease that's all okay so it is also called as oculoglandus syndrome of paranoid and obviously it is caused by bonding henselae so it is both bians it's a bacterial disease caused by botanila henselae and ocular glandular so if the scratches is you can see the swelling of the eyelid and the glands so ocular glandular syndrome of the paranoid okay so this is our case okay so like this you have to think and answer so you have to go for nice detailing what all is given in the patient box you have to see for the clinical and the radiographic picture or what all findings is given and then you have to go for the question and you have to answer if there is a straightforward thing you can directly arrive at the answer if there is a confusion you can eliminate and go okay so this is how you have to get adapted to the patient box for your imbde okay thank you