OSCE 2008

Post Graduate CME – Spots List of contributors: 

Post Graduate CME – Spots List of contributors N. C. Joshi. Shakuntala Prabhu. Sumitra Venkatesh Shilpa Kamat. Sudha Rao. Parmanand.A. Ira Shah. Rajesh Joshi. Alpana Ohri Ruchira Pahare.

All vaccines are susceptible to loss of potency when exposed to warm temperatures [4 marks]: 

All vaccines are susceptible to loss of potency when exposed to warm temperatures [4 marks] What is a cold chain? [1] What is a vaccine carrier? [1] How long can you keep vaccines in a vaccine carrier? [1] What are the other factors which damage vaccines? [1]

Answers: 

Answers 1. The system of transporting, distributing and storing vaccines under refrigeration using any convenient methods, from the manufacturer right up to the point of use is referred to as the cold chain. 2. A vaccine carrier is a thick walled, insulated box with a tight lid, used for carrying small quantities of vaccines to the peripheral clinics & fields for use. 3. Vaccines can be kept safely in the desired temperature, generally for 1 working day in vaccine carriers. 4. Heat, sunlight and freezing are other factors which damage vaccines.

A child presents with history of questionable bite by a stray animal. [4 marks]: 

A child presents with history of questionable bite by a stray animal. [4 marks] Is rabies prophylaxis indicated? [1] What is Essen protocol? [1] Can a vaccinated dog transmit rabies? [1] What are the dog vaccines available against rabies & what is the commonly used schedule? [1]

Answers: 

Answers Yes, even questionable bites by any stray animal does require rabies prophylaxis as risk of rabies overrides all other considerations. Essen protocol is the WHO standard schedule which comprises of 5 injections of rabies vaccine on days 0, 3, 7, 14 & 28 or 30 Yes, even vaccinated dogs can transmit rabies especially if they have not received booster doses regularly & also if there was inadequate potency of the vaccine in the first place Dog vaccines available are: Live attenuated vaccine, Nerve tissue vaccine & tissue culture vaccine. Dose: 3 ml single dose followed by booster every 3 years.

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Diagnose 3 salient features Maternal illness responsible

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Septo optic dysplasia Optic nerve hypoplasia, absent septum pellucidum, endocrine abn Maternal diabetes

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Diagnose Inheritance 2 associated abnormalities

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Apert syndrome Autosomal dominant Proptosis, syndactyly, MR

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23) This child came with neuroregression from 7 months of age with abn hand movts Diagnose/DD 3 salient features Which milestones are delayed?

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Retts syndrome / Autism Autism, stereotypies, microcephaly,loss of fine movts, Social, language

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3 yrs old girl comes with drooping of both the eyelids noticed since 15 days which increases in evening. There is no limb weakness. Diagnose How do you confirm? Drug of choice.

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Ocular myasthenia Anticholinesterase antibody, EMG , Edrophonium test Pyridostigmine

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4 Yrs old boy with normal motor and mental development becomes aphasic for last 15 days.He had a single GTC at 3.6 yrs.CNS examination is normal. Investigation of choice Diagnosis Treatment options

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EEG Landau Kleffner syndrome IV Ig ,Steroids

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6 yrs old girl with neonatal hypoglycemia and infantile spasms at 6 months now develops tonic seizures, atypical absences, myoclonic seizures and drop attacks. Diagnose Drugs used AEDs to be avoided Non pharmacological treatment modalities

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Lennox Gastaut syndrome Valproate, Lamotrigine, Topiramate,clobazam Carbamazepine, phenobarbitone Corpus callosotomy, Ketogenic diet, vagal nerve stimulation

Lamotrigine : 

Lamotrigine Indication, Dose Synergistic with? What dosage modification done? Life threatening side effect?

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Partial, generalied, LGS, JME; 3-7 mg/kg/d Valproate, Halve the dose Steven johnson syndrome

This child came with epilepsy. What is the diagnosis? What are the findings seen? What is the inheritance? What will neuro imaging show?: 

This child came with epilepsy. What is the diagnosis? What are the findings seen? What is the inheritance? What will neuro imaging show?

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Tuberous sclerosis Adenoma sebaceum, shagreen patch, ash leaf macules. Autosomal dominant. CT scan shows calcified tubers in the periventricular area.

What is the sign shown below? Give differentials.: 

What is the sign shown below? Give differentials.

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Leucokoria Cataract. Primary hyperplastic primary vitreous. Retinoblastoma.

This 10 year old boy came with first episode of non febrile left focal seizures. What is the diagnosis? What is the etiology? What is the treatment? What should you ensure before starting treatment?: 

This 10 year old boy came with first episode of non febrile left focal seizures. What is the diagnosis? What is the etiology? What is the treatment? What should you ensure before starting treatment?

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Neurocysticercosis Pork tape worm/ taenia solium Albendazole (15 mg/kg/day, BID) for 28 days with steroids for 2-3 days before and immediately after initiating therapy. Anticonvulsant- carbamazepine or phenytoin Fundus examination to look for ocular cysticercus, should be done before initiating therapy.

This 18 months old boy is brought with low grade fever and increasing drowsiness. He was diagnosed to have tuberculous meningitis and was getting treated for past 3months. What is the finding? And its explanation? What surgical intervention is warranted immediately? : 

This 18 months old boy is brought with low grade fever and increasing drowsiness. He was diagnosed to have tuberculous meningitis and was getting treated for past 3months. What is the finding? And its explanation? What surgical intervention is warranted immediately?

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Multiple ring enhancing lesions – tuberculomas. Therapeutic paradox due to increased immunity to tubercular protein / MDR tuberculosis V-P shunt .

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A 13year old girl presents with menorrhagia with no significant history in the past. There is a similar history in her mother.Her CBC and platelet count is normal,PT is normal and PTT deranged. The diagnosis is____________ What is the mode of inheritance What is the treatment of this condition?

a) Von Willebrand disease b)Autosomal dominant c) Desmopressin (DDAVP),: 

a) Von Willebrand disease b)Autosomal dominant c) Desmopressin (DDAVP),

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9yr male with h/o sudden onset giddiness and fall. Identify this ECG. Mgt of this condition. Counselling.

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Long QT – Syndrome. Beta-Blockers.Avoid drugs known to prolong QT-interval, electrolyte imbalance.SOS pacemaker.R/o Syndromes associated with Long QT-interval. Avoid competitive sports and swimming,teach CPR to the caretakers.Inform about SIDS.

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A newborn presented with severe respiratory distress. Describe the X-Ray findings. What other anomalies are associated with this condition?

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A)There is a cystic mass( ? Bowel loops) on the left side displacing the heart to the opposite side.Diagnosis: Congenital Diaphragmatic hernia. B) Pulmonary Hypoplasia/aplasia with congenital heart disease

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A 15 days old newborn was noticed to have sweating and poor feeding. On examination HR was >240/min with signs of poor perfusion. What are the diagnostic possibilities? What is the immediate management? Detail the emergency drug treatment ?

ANSWER: 

ANSWER Supra-ventricular tachycardia. Vagal stimulation folowed by I.V.Adenosine. I.V. Adenosine 0.05mg/kg rapid bolus followed by increased bolus by 0.05mg/kg every 2 minutes until clinical response occurs or a max dose of 0.25mg/kg or 12mg is reached.

20 year old primigravida mother presents in the ER with crowning. As per NRP: 

20 year old primigravida mother presents in the ER with crowning. As per NRP What relevant history will guide your steps of resuscitation? What are the initial steps of assessment? How will you manage a baby with mecoinum stained amniotic fluid?

ANSWER: 

ANSWER Gestational age,Single/multiple pregnancy,h/o any drug administration,h/o bleeding PV,color of liquor. Assess the heart rate, respiration, meconium staining and gestational age. Suctioning of the oropharynx after the head shows at the perinium,and after delivery endotracheal intubation and direct suctioning.

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A 5 years old girl is admitted with H/o fever, polyuria, polydipsia,abdominal pain .Her RBS-480 mg%. O/E: she is dehydrated and tachypnoeic. a) What is the likely diagnosis? b) The immediate treatment would be: 1. IV Normal Saline 2. 0.2% DNS 3. 1/3 NS 4. 1/3 NS with potassium c) Which investigations will guide in immediate treatment? 1.Blood gas 2.C-peptide 3.Sr. Insulin 4. S. Electrolytes d) What CNS complication can you encounter during the treatment?

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Diabetic Keto Acidosis IV NS Blood gas ,S.electrolytes Cerebral edema

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To reduce transfusion reaction due to blood in Thalassemia all except can be used a) Pre storage filtration of blood b) Washed RBC c) Bedside filtration of blood d)Neocyte or young red cell transfusion Packed blood to be given for transfusion in thalassemia major a) 15 ml/kg b) 5ml/kg c) 7.5 ml/kg d) 10 ml/kg Desferroxime toxicity all except a) Arthritis b) growth retardation c) visual & auditory impairment d) Pancreatitis Vit B12 absorbed from a) Duodenum b) jejunum c) ileum d) cecum

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1 C 2 A 3 D 4 c

HISTORY TAKING: 

HISTORY TAKING A 2 yr old child presents to emergency department with severe pallor. Take the history of the child from mother.

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Introduces himself and tries to make the mother comfortable 0.5 marks Asks onset sudden or gradual 1 mark history of bleeding or bluish spots 1 mark History of associated symptoms : fever, failure to thrive 1 mark Recurrent blood transfusions 1 mark history of associated jaundice 1 mark history of worm infestation 0.5 mark birth history 0.5 mark community and religion and history of consanguinity 1 mark dietary history 1 mark family history 0.5 mark drug history 1 mark

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Q 1. What type of anemia is seen in the Peripheral smear ? 1 mark Q2. Name four causes of this type of anemia? 2marks Q3. Name one drug which can cause this type of anemia ? 2 marks

Macrocytic Anemia : 

Macrocytic Anemia Answer 1 Macrocytic anemia Answer 2 Folic acid defiency ( nutritional), Vitamin B12 deficiency ( nutritional) , Pernicious Anemia, Malabsorption disorders , Surgical resection of bowel Answer 3 Anticonvulsants – Phenytoin, phenobarb , antifolate – Methorexate,pryrimethamine,

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1 Identify the x-ray ? – 1 mark Ans : Rt sided diaphragmatic hernia. 2. Expand EXIT and give its two components – 2 marks Ans : EXIT ( Ex Utero Intrapartum Treatment): Intubation and ECMO during delivery 3.Name the commonest pulmonary complication associated with this condition? – 1 mark Ans : PPHN/Pulmonary hypoplasia 4. Commonly this condition occurs from which defect? 1 mark Ans : Bochdalek : 70%

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Mark the vaccines as live attenuated or killed or recombinant as L, K, R respectively. OPV-L IPV-K BCG-L Rabies-K DPT-K Measles-L MMR-L

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What is the concentration of IVIG availble in India 5% 10% 20% ans:1

ABG report – Ph – 7.343 / PaCo2 – 60/ PaO2 – 47.6 mmHg / Bicarb 32 : 

ABG report – Ph – 7.343 / PaCo2 – 60/ PaO2 – 47.6 mmHg / Bicarb 32 Ques 1 - Interpret this blood gas ( 1 mark) Ques 2 – What is normal PaO2 level expected if a child is breathing at room air with normal lungs ? ( 1 mark) Ques 3 - Above mentioned ABG was taken when patient was inspiring 60% Fio2 . Choose the correct option to describe oxygen status of the patient ( 1 mark) Corrected hypoxemia Under corrected Hypoxemia Normoxemia Over corrected hypoxemia Ques 4 What is normal bicarbonate level in a normal blood gas write unit also . ( 1 mark) Ques 5 What is normal PaCo2 in normal blood gas – write unit also . ( 1 mark)

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Ans 1 ) Respiratory acidosis with metabolic compensation Ans2 ) 80-100 mmHg Ans 3 ) b Ans 4 ) 24mmol/L

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a) What is Sandifer Syndrome? Name the disorder in which it is seen. b) Name the surgical procedure which is done to treat it. c) Name an antibiotic used in the treatment of this condition and what is its mechanism of action.

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Ans-a) It is the neck contortions seen in children with Gastroesophageal Reflux disease. b) Fundoplication c) Erythromycin, it acts as motilin receptor agonist

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A 13 year old child came to the OPD with C/o gradual loss of vision. On Examination he had ataxia, intention tremors, loss of vibration and position sense. He had history of chronic Diarrhea with passage of bulky frothy stools. His plasma cholesterol was 28 mg/dl and his Serum triglycerides were 12 mg/dl. What is the diagnosis? What is the characterstic finding on peripheral smear of this patient? What is the visual problem?

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a) Abetalipioproteinemia b) Acanthocytes. c) Retinitis pigmentosa

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a) What is Zafirlukast used as? b) What is the mechanism of action? c) What would you like to monitor when the patient is on this drug?

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Ans-a) Antiasthamatic b) Leucotriene receptor antagonist c) Periodic assessment of liver functions.

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a) What is Pamidronate Sodium? b) Name the genetic disorder where it can be used. c) What is the mode of administration .

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Ans-a) Biphosphonate derivative b) Osteogenesis Imperfecta. c) IV

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a)What is the Indication for the use of Sodium Nitroprusside? b) How does it act? c) What two specific precaution will you take while administering it?

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Ans- a) Hypertensive Crisis. b) Vasodilator c) Protect from light and discard if colour changes from pale orange to dark brown or blue.

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a) Name an antineoplastic agent used in JRA as a a diesase modifying agent. b) Describe its Dosing schedule in JRA and route of administration and precaution to be taken. c) Name a chronic skin disorder where it is used.

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Ans a) Methotrexate b) 5-15 mg/m2/week as a single dose or three divided doses given 12 hrs apart, Oral/IM/SubQ.Folic acid 1 mg daily is given along with methotrexate to prevent Folate depletion c) Psoriasis.

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A 8 day old baby was brought to PHC with C/O difficulty in feeding , crying excessively,& seizure. Parents of baby were 2nd degree cousins & labourers by occupation. Mother had not received any ANC care. Baby was at home., had moderate cry , was well till D8 .His picture is shown HR-140/min RR-42/min AF-at level, sutures - normal Tone- Increased in all 4 limbs with neck retraction, intermittent seizures. , worsened with stimulus . Q. (a) What is the diagnosis of this baby ? What is the treatment? What is the usual cause of death in this condition?. What are the various types?

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a) Neonatal tetanus Penicillin,tetglob,Musle relaxants- Diazepam, Baclofen. (c) Recurrent seizure causing airway obstruction. (d) Neonatal, Localized , Genralised, Cephalic

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A 3kg male child was delivered at town by vaginal delivery. He had good cardiac activity but poor respiratory efforts. On examination- Cynosis present which worsened when baby was quite. Baby turned pink on crying. HR=110/min, Tone -normal,Cry + on tactile stimulation. RS=AEBE No crepts P/A no distension, no organomegaly No signs of birth trauma. Q. (a) Which condition is the baby suffered from? (b) What is it commonaly associated with? How will you confirm the diagnosis?

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Ans. (a) B/L Choanal atresia (b) CHARGE (c) Inability to pass the catheter through nose.

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1 y old child presented with fever, barking cough and breathing difficulties. Initially child was having only running nose . O/E: Tachypnoea, stridor, subcostal retractions, intercostal retractions. A] What is the diagnosis? B] What is the usual etiological agent? C] Which X ray sign is diagnostic of this condition?

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Answers: A] Croup B] Parainfluenza A C] Steeple sign

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Child has nephrotic syndrome. How world you categorise him? 1) Infrequent Relapse : Less than 2 relapses in 6 months or 3 in a year 2) Frequent Relapse: More these 2 in 6 months or 3 in a year 3) Dependent NS: Relapses on shifting steroids to alternate day or on omission within 2 weeks on at least on 2 occasions. 4) Steroid resistant NS : Does not respond to more than 4 weeks of daily 2 mg/Kg of steroids.

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12 years old girl presents with rash on both cheeks with thrombocytopenia with acute renal failure and left sided pleural effusion over a period of 1 months. 1. Likely diagnosis : SLE 2. Serological Test to confirm it : ANA, ds DNA 3. Drug of choice for treatment : Steroids 4. Can this condition have CNS involvement and if yes then as what : Yes Seizures, Vasculitic involvement of Brain Psychological disturbances