VIII PG CME

NOTE: 

The OSCE Questions & Answers are prepared by the faculty of B.J.Wadia Hospital For Children , Parel , Mumbai for the benefit of Post graduate students. These Questions and answers are made for the students to understand the pattern of OSCE and not meant to completely cover the subject of Pediatrics. NOTE

Post Graduate CME –OSCE List of contributors: 

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

ABG: 

7.56 / PaCo2 – 23.7/ Pao2 157 mm Hg / Actual Hco3 – 24 Qs 1 Diagnosis ( 2 marks) Qs 2 Hb 10 gram % , Pulse ox Spo2- 100% - Calculate oxygen carrying capacity - (Write formulae only )(2 marks ) Qs 3 Calculate Aa Do2 , Fio2 30% - (write formulae only ) (1 mark) ABG

Answer: 

Answer 1 Respiratory alkalosis 2 Hb% (10) x 1.34 ml x 100/100 + 0.003 x 157 3 ( 760 ( barometric pressure ) - 47) x FIO2 - (PaCO2/0.8) - Pao2

Question: 

Question 5 Year old male child presents with fever for past 10 days. Fever is high grade, continuous in nature without chills and rigor. There is no associated loose motions, vomiting, headache, photophobia, cough, cold or rash. On examination child is conscious, febrile, normotensive , conjunctival congestion present with no apparent discharge . Two cervical lymph nodes (Right sided) palpable, 2 cm approx each. There is desquamation of skin around fingers. There is no hepatosplenomegaly . Rest of systemic examination is normal. Q 1 Your most probable diagnosis? ( 1 mark) Q 2 What characteristic feature can be found in complete blood counts? ( 1 mark) Q 3 What is the most common cause of death in above-mentioned patient? ( 1 mark) Q 4 What drug ( drug of choice ) you would like to give to this patient( 1 mark) Q 5 Meningitis can be one of complications true / false ( 1 mark)

Answers: 

Answers Kawasaki disease Thrombocytosis Congestive heart failure Intravenous immunoglobin True

Slide 7: 

2)This child has epilepsy, MR, ataxia, unprovoked laughter, severe speech delay Diagnosis? Chromosome involved Inheritance Name a syndrome with the same chromosomal abnormality

Slide 8: 

Angelman syndrome 15q11.2-12 Uniparental disomy – usually maternal (60-75%) - occ. paternal - normal chromosome ? Dominant mutations Prader Willi – 15q11-13 (paternal origin)

Slide 9: 

1 st unprovoked generalised seizure in a 2 yr old child Essential investigation Optional investigation Treatment of choice

Slide 10: 

EEG MRI, biochemistry, CSF Nil , unless specific indication

Slide 11: 

15)Name 3 newer AEDs Name a carbonic anhydrase inhibitor used as AED

Slide 12: 

Ocarbamazepine, Topiramate, Lamotrigine, Vigabatrine, Gabapentine, Zonisamide, Leviteracetam, Felbamate, Tiagabine Acetazolamide, Topiramate

Slide 13: 

9) 6 yr old male admitted with prolonged generalised seizures. Immediate AEDs –name 2 with dose 2 nd line AEDs –2 with dose 3 rd line – name 2

Answer: 

Answer Lorazepam [0.05mg/kg], Diazepam [0.3mg/kg], midazolam[ 0.2mg/kg] Phenytoin[ 20mg/kg], phenobarb[20/kg] Midazolam drip, propofol, thiopentol

Slide 16: 

What does this EEG show? What is the drug of choice? Prognosis? One OPD procedure to confirm diagnosis

Answer: 

Answer 3 Hz spike and wave activity in Absence seizure – childhood /Juvenile Valproate, Lamotrigine, clobazam Good in childhood, slightly less for juvenile Hyperventilation

Case Scenerio: 

Case Scenerio 10 year old boy was brought with the complaints of fatigue, malaise and anorexia. His parents were concerned about their boy being “too short” as compared to his colleagues. He is a known case of posterior urethral valves, fulguration done at 3 months of age and lost to follow-up thereafter. On examination, the child was 115cm in height. He had pallor and rapid deep breathing. His blood pressure was 140/90mmHg. Systemic examination was normal. Investigations revealed BUN -54 mg%, s. creatinine -5.6 mg%, Hb -6.8 g%, peripheral smear –normochromic normocytic, blood gas pH -7.25, HCO3 -13 mEq/l, s.calcium -10 mg%, s. phosphorus -8.5 mg%, USG abdomen revealed small kidneys and small capacity urinary bladder with irregular thickened bladder wall. Questions (A) Diagnosis? (B) What factors would you correct to prevent further progression of the disease? ( C)How will you treat renal osteodystrophy?

Answer: 

Answer A)Chronic renal failure following obstructive uropathy (posterior urethral valves) B)1. Diet: protein restriction to 0.8 to 1 g/kg/day, phosphorus restriction, salt restriction and avoidance of potassium containing fluids like citrus fruits, coconut water and chocolates. 2. Control of blood pressure 3. Correction of acidosis 4. Treatment of anemia. C) Phosphate binders- Calcium carbonate 100-120mg/kg bid with alkali therapy Calcitriol or 1,25(OH)2 cholecalciferol 0.5 to 1 mcg/day initially, then 0.25 to 0.5 mcg 2 to 3 times weekly till bone lesions improve.

Slide 20: 

Diagnosis Name 5 types of this condition What is the urinary test for diagnosis Name 3 metabolites seen in the urine Name the main organs involved What are the Xray findings called

Slide 21: 

Mucopolysaccharidosis Hunter, Hurler, Scheie, Sanfillipo, Matoteaux Lamy, Morquio, Sly Urine electrophoresis Dermatan, Keratan, Heparan sulphate liver, spleen, bone, cornea, hearing, cardiac Dysostosis multiplex

Question: 

Question Name two manifestations of Vit E deficiency in preterm babies? Useful effect of Vit E is by virtue of which chemical property ? Normal daily requirements of Vit E in preterm babies? Vit E deficiency is diagnosed by a serum ratio of alpha-tocopherol : lipid of less than 1 ml of “ Evion” contains how many …….. International Units of Tocopherol

Slide 23: 

A1: Hemolytic anemia, Thrombocytosis, edema A2 : Antioxidant A3: 5-25 IU / day. A4 : 0.8 mg/grms. A5 50 IU

Slide 24: 

You have been called to attend a call from the O.T of a primi mother with a 35 wks IUGR baby. Mother has PIH and now the fetus has developed fetal bradycardia and doppler studies show absent flows in MCA. Half an hour ago there was meconium staining of the amniotic fluid ? How will you proceed on reaching the O.T?

Answer: 

Answer Switch on the warmer ( 1 mark) Wash hands ( 2 marks) Check equipment ( 5 marks) Endotracheal tubes Laryngoscope working AMBU bag functioning Oxygen and reservoir working Suction machine Check attachments of meconium aspirator. ( 2 marks)

Question: 

Question 8 month old boy brought to the clinic with failure to thrive, recurrent vomiting and polyuria. On examination, the child weighed 5.5 kg for a birth weight of 3 kg. He was normotensive, had no evidence of rickets, and systemic examination was normal. Investigations revealed Hb -12.1g%, BUN -8mg%, s. creatinine -0.4 mg%, s. Na -141mEq/l, s. potassium -2.5mEq/l, s. Cl -90mEq/l, blood gas pH -7.52, HCO3 -30mEq/l. Blood levels of renin and aldosterone are markedly increased. Urinary chlorides 35mEq/l. Questions (A) Diagnosis? (B) Differential diagnosis? (C) What is the treatment?

Answer: 

Answer Bartter’s syndrome Gitelman’s syndrome presents at a later age and is milder in presentation. Hypomagnesemia and hypocalciuria are features of this syndrome. Potassium supplementation of 3 to 4 mEq/kg/day. Indomethacin 1 to 4 mg/kg/day.

A child developed parotid swelling 10 days after MMR vaccine. [4 marks]: 

A child developed parotid swelling 10 days after MMR vaccine. [4 marks] What is the likely cause? [1] Can MMR be given to children who already have had mumps in the past? [1] Should MMR be given only to girls? [1] Should adolescent girls be given MMR vaccine if they have not received the same in their childhood? [1]

Answers: 

Answers It is most likely a side effect of mumps component of the MMR vaccine, as parotitis occurring within 1 – 2 weeks after vaccination is a known complication Parotitis itself can have different etiologies other than mumps. Moreover MMR protects against measles & rubella as well, hence MMR can be given to children who have had mumps in the past. MMR should be given to both sexes as both are vulnerable to measles, mumps as well as rubella. It is advisable to give MMR to adolescent girls if they have not received the same in their childhood in order to prevent the possible congenital rubella syndrome in the future offspring especially if the mother has no protective antibodies against rubella. However, pregnancy following the vaccine should be avoided for at least for 3 months.

Slide 30: 

A three year old girl having past history of meningitis has breast enlargement since 8 months and menstrual bleeding a) What is the diagnosis b) What results do you expect in hormonal investigations c) What is the treatment of choice d) What bone age will you expect

Slide 31: 

A-central precocious puberty B-increased LH , FSH and estradiole.LH>FSH C-GnRH analogues D-advanced bone age

Slide 32: 

A 6 years type 1 diabetic child weighing 20 kg was recently diagnosed and was decided to start on insulin therapy of 1 u/kg in mixed split regimen. a) Show calculations of insulin therapy he should receive b) What counseling would you give regarding possible complication of insulin therapy c) This child was adviced diet having low glycemic index.What is glycemic index of a food d) What base line investigations would you do at start of treatment

Answer: 

Answer A-combination of regular and lente (1:2) insulin sub-cut,2/3 before breakfast and remaining before dinner.2/3 of 20=13u BBF of which 2/3 I.e 8 u lente 5u regular,rest 1/3=7 before lunch out of which 2/3 I.e.4 u lente and 3 u regular. B-counsel for hypoglycemia and its treatment C-Glycemic index is a measure of rise of blood sugar after a particular type of food is eaten,in comparison with glucose which is 100. D-Base line investigations-fundus exam,serum lipids,TFT

Slide 34: 

Q1. At what age ECG resembles an adult ECG ____________ Q2. Tall P waves in lead II is defined as height more than _____________ mm Q3. Maximum P wave duration in children is __________________ seconds Q4. Maximum P wave duration in infants < 12 months__________________ second Q5. PR interval- lower limit in less than 3 years __________________ second

answer : 

answer Ans 1. 3 Ans 2. 3mm Ans3. 0.1 second Ans 4 0.08 second Ans 5 0.08 second

Slide 36: 

You are performing an exchange transfusion. There has been a blood spill of around 75cc accidentally. Give appropriate disinfection instructions to the new helper in your NICU.

Slide 37: 

3 (0.5 marks for each mentioned points) A ) Aseptic precautions Cover with absorbent material eg: tissue paper/ newspaper Pour 1% hypochlorite around and then over the contaminated area. Leave for 10 min Remove with gloves Throw it in a bin of infectious waste lined with a yellow bag Clean the area with a mop, which is disinfected by putting in a bucket of bleaching solution. Wash the mop in running tap water and then dry it. Wear gloves during the above mentioned cleaning and decontamination procedures.

Question: 

Question Enumerate the government of India community nutrition programme

Answer: 

Answer Vitamin A prophylaxis programme Prophylaxis against nutritional anemia Iodine deficiency disorders control programme Special nutrition programme Balwadi nutrition porgramme ICDS programme Mid-day meal programme

Slide 40: 

Assess the gestational age of this newborn infant using the Ballard score. Assessment correct upto+- 2 wks Examine this newborn. Classify as term/ preterm and justify the same

Answer: 

Answer Take weight length of this baby Ask for gestational age form observer Specify the weight for gestational age of this child with the help of your data and provided chart. Checklist Anthropometry and gestation Assessment of gestational age Look for ear, nipple, genitalia and sole creases Look for tone and posture Classifies correctly as term/preterm Justifies diagnosis convincingly Uses infantometer for length, records correct length Checks zero error of scale Take naked weight Records correctly Clarifies as AGA/SGA correctly demonstrates correct process for classification Gentle careful handling

Slide 42: 

Examine the abdomen of this child

Answer: 

Answer Introduces and asks for permission Exposes the entire abdomen including genitals for inspection. Palpation of liver and spleen Assess the liver span by percussion and palpation Does bimanual palpation Examines genitalia Auscultates for bowel sounds Performs shifting dullness +/- elicits fluid thrill Examines back and anus Covers the abdomen Thanks the mother /child

Slide 44: 

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?

Slide 45: 

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

Slide 46: 

10 yr old boy presents with 2 episodes of gross hematuria. He also has hearing impairment. What is the likely diagnosis? Which are the other extra renal manifestations present in this condition? What are the patterns of inheritance?

Answer (A) Alport Syndrome (B) Bilateral sensorineural hearing loss Ocular abnormalities-anterior lenticonus, Macular flecks, corneal erosions Leiomyomatosis of the oesophagus, tracheobronchial tree, female genitals. ( C ) X linked disease-85% AR-10% AD-5% : 

Answer (A) Alport Syndrome (B) Bilateral sensorineural hearing loss Ocular abnormalities-anterior lenticonus, Macular flecks, corneal erosions Leiomyomatosis of the oesophagus, tracheobronchial tree, female genitals. ( C ) X linked disease-85% AR-10% AD-5%

Slide 48: 

This child has thrombocytopenia .Spot the diagnosis. Enumerate the common sites of involvement. What are the associated features? What are the modalities of treatment?

Answer a) Kasabach –Merritt syndrome b) Cutaneous involvement C) Enlarging vascular anomaly, Thrombocytopenia, Microangiopathic hemolytic anemia, Consumption coagulopathy d) Surgical excision laser photocoagulation,corticosteroids in high doses, local Xray therapy,antiangiogenic agents such as interferon alpha2.: 

Answer a) Kasabach –Merritt syndrome b) Cutaneous involvement C) Enlarging vascular anomaly, Thrombocytopenia, Microangiopathic hemolytic anemia, Consumption coagulopathy d) Surgical excision laser photocoagulation,corticosteroids in high doses, local Xray therapy,antiangiogenic agents such as interferon alpha2.

Slide 50: 

2 week old boy born of 3 rd degree CM presents with persistent vomiting and increasing lethargy.On examination he was 10% dehydrated and unwell. His systemic examination was otherwise normal.Septic screen was negative, RFT-normal, Hb-16gm/dl, S.Na -115mEq,S.K-6.5 mEq , blood sugar-90mg/dl. What is the diagnosis? What investigation would you like to do confirm the diagnosis. What is the mode of inheritance of this disorder?

ANSWER The diagnosis is congenital adrenal hyperplasia Diagnosis- Estimation of 17 hydroxyprogesterone levels. Mode of inheritance - AR: 

ANSWER The diagnosis is congenital adrenal hyperplasia Diagnosis- Estimation of 17 hydroxyprogesterone levels. Mode of inheritance - AR What are the two main presenting features at birth?

Spot the Diagnosis: 

Spot the Diagnosis What are the two main presenting features at birth? B) What complication can occur if the condition is not diagnosed promptly?

ANSWER: 

ANSWER Tracheo-esophageal Fistula. Frothing at mouth ,chocking at feeds, vomitting.. Aspiration Pneumonia.