Wadia OSCE

September 2011

Wadia CME Sept 2011

Station 1 marks 5

1. Describe: MRI axial image of thigh 1/2

2. Diagnosis: Dermatomyositis 1

3. Diagnostic Criteria: Classic Rash + 3 of the following 1

1. Weakness

2. Muscle enzyme elevation

3. EMG changes

4. Muscle Biopsy

1. Describe: USG abdomen, ½

2. Diagnosis: Intussusception 1

3. Treatment : emergency hydrostatic reduction( if not in shock)

If unsuccessful ..surgery 1

Wadia CME Sept 2011

Station 2 ( marks 1 + 1+1 ½ +1 ½ =5 How is scoliosis screened clinically? Forward bending Test. To observe Rib cage asymmetry.

How do you calculate Cobb Angle? This is measured using the superior and inferior end plates of the most tilted vertebrae at the end of each curve.

Give Differential Diagnosis of congenital Torticollis. Hemivertebra

Klippel Feil

Muscular

Positional deformation

Unilat. Absence of SCM

Write Skeletal features of Marfan syndrome Pectus carinatum

Pectus excavatum, needing surgery

Reduced upper-segment to lower-segment ratio or arm span to height ratio >1.05

Wrist and thumb signs

Scoliosis of >20° or spondylolisthesis

Reduced extension at the elbows (<170°)

Medial displacement of the medial malleolus, causing pes planus

Protrusio acetabulae of any degree (ascertained on radiographs)

Wadia CME Sept 2011

Station – 3 marks 6 Name the act related to

hospital waste management. Biomedical Waste (management and handling) rules, 1998, India

How will you discard 500 ml of blood? Chemical disinfection with one percent hypochlorite solution followed by discharge into drains.

Which is the best type of incinerator available? Double chamber pyrolytic incinerator.

Write the formulae for the following:

Net protein utilization ( NPU) : nitrogen retained / nitrogen intake x 100

Standard deviation: Sq.root of ∑ (x- x’)2 / n Use n if N>30 & “n-1” if n<30

Child survival index: 1000-UFMR / 10

Wadia CME Sept 2011

Station 4 Marks 1x5 = 5 As per IAP 2010 Recommendations 1. Which of the following vaccines are under “Special Circumstances Vaccines” ( negative

marking for wrong name) 1. IPV

1. Influenza

2. Yellow fever

1. PCV

2. MMR

2. A child comes to you for routine immunization at 5 yr and 2 months. She has recd. All her vaccinations till date. She has not suffered from any viral exanthem till now. Name the vaccines that you would ask to be taken now.

1. DT / DTaP

2. MMR (2ND DOSE)

3. TYPHOID

4. CHICKENPOX ( 2ND DOSE)

3. Mention the dosage schedule of Qudrivalent HPV vaccine : 0,2,6 months from 10 yr onwards

4. What is ‘Basic reproductive number’ (Ro)? measures the average number of secondary cases generated by one primary case in a susceptible population.

5. In case of an infant requiring Measles Vaccine; 1. Needle should enter at an angle of ____ to the skin. 45 degree

2. The site of injection. Thigh

Station 5 Anion gap + compensation + diagnosis = 3 x2 =6 total

Sr. Na – 135 mEq/l

Sr. K - 3.5 mEq/l

Sr. Cl- 85 mEq/l

ABG: pH- 7.55

pCO2- 48 mm Hg

HCO3- 40 mEq/l

What is the diagnosis?

Comment on compensation.

pCO2= 40 + .7 x [40-28]= 48.5

Suggests appropriate compensation

Anion Gap Na- [HCO3 +Cl] = 16

Diagnosis: metabolic alkalosis

An 8 year old child was diagnosed as acute rheumatic fever and discharged on Tab. Aspirin for 6 wks. The child was readmitted with c/o nausea, vomitting 2 days duration f/b rapid respiration, fever, seizure, altered sensorium.

Data:

Sr. Na – 140 mEq/l

Sr. K - 3.8 mEq/l

Sr. Cl- 98 mEq/l

ABG: pH- 7.55

pCO2- 19 mm Hg

HCO3- 10 mEq/l

PT, PTT- elevated

SGPT- 438 units

Sr. Salicylate level- 58 mg/dl [mild elevation].

Analysis: ( Compensation / anion gap / Diagnosis)

Alkalemia / Respiratory

If compensation is proper, HCO3 decreases by 1mEq/l for fall of every 10 mm Hg pCO2

So expected drop of HCO3 is 4mEq/l

Expected HCO3- 20 mEq/l

Actual HCO3- 10 mEq/l

This suggests inappropriate compensation i.e.

associated Metabolic Acidosis

Anion Gap= 140-[98 + 10]= 32

i.e wide AG

Diagnosis : Respiratory Alkalosis with wide Anion Gap Metabolic Acidosis

Source: Dr N C Joshi : Wadia CME Sept 2011

Answer- 6 marks 3*2=6 3 yr old boy referred to hospital with severe epistaxis and multiple bruising on his limbs. He

had been well previously and there were no other abnormalities on physical examination. He had not had any medications. Family history was negative for any illness.

Hb 10.3

WBC 13300 N- 43 L 30

Platelets 3 x 109 /l

INR 1.2 ….. PTTK Normal

LFT / Platelet Antibodies Negative / ESR 20

1. Acute Idiopathic Thrombocytopenic Purpura / Acute Leukemia.

2. Bone marrow aspiration to exclude Leukemia.

3. Expectant / Steroids / IVIG.

A healthy boy was delivered and both mother and baby were discharged on day 3. Twelve hours after discharge, child was brought to hospital with severe vesiculo-pustular rash……. History now revealed a “Mild” vesiculo-pustular rash in mother 24 hours prior to delivery and two children suffering from chickenpox next door.

1. Neonatal Chickenpox.

2. Admit and IV Acyclovir.

3. Zoster Immune Globulin….. And in case rash develops IV Acyclovir.

Wadia CME Sept 2011

Station 7 marks 1+ ½ + ½ + 1+1 =4 A 10 yr old girl, brought with H/O rapidly progressive, both lower limb weakness

since 3 days. She was apparently normal except for a history of “sore throat and bilateral neck swelling with fever about 20 days back.

She started with difficulty while walking and not being able to pass urine despite of the sensation being there.

On examination: normal sensorium and cranial nerves. Had normal neurology findings in both upper limb and shoulder. Lower limb, symmetrical flaccid paralysis; distal more than proximal. DTJ were exaggerated and Planters were extensors. There was a sensory discrepancy below T8 and Temp / light touch were affected. Vibration and position were normal. Her Urinary bladder was palpable.

1. What is your differential diagnosis / diagnosis? Acute Transverse myelitis / SOL in spine ( Koch’s / vascular infarct / bleed / Bony spikule)

2. What is the investigation of choice? MRI spine

3. Treatment: IV steroid pulse

4. Name (any 2) causative factors for this condition: Post / Para infectious / SLE with thrombosis / Lyme disease.

5. Describe the components of Type 1 and 2 … Arnold Chiari malformation

Type 1: Cerebellar Tonsillar herniation type 2 : with Meningomeylocele

Wadia CME Sept 2011

Station 8 marks ½ +1 + 1+ ½ +1=4

1. Identify the Inheritance pattern. Auto. dominant

2. Give 4 examples. Achondroplasia / Tuberous sclerosis / Neurofibromatosis/ marfan / Huntington / Wardenburg….

3. What is “pseudo-dominant” Inheritance pattern on a pedigree.

Name any one situation of the same… Homozygous AR has a partner who is Heterozygous AR results in a pedigree that appears to be Dominant like

4. Mention the Fragile site and give main clinical manifestation of Fragile X syndrome. Xq27.3

5. The main clinical manifestations of fragile X syndrome in affected males are mental retardation, autistic behavior, macro-orchidism, and characteristic facial features

Wadia CME Sept 2011

Station 9 marks 1*5=5 As per Indian Pediatric Nephrology Guidelines 2011

1. Define : Significant Pyuria: > 5 leukocytes /hpf in Centrifuged sample OR >10 leukocytes / mm3 in Fresh Uncentrifuged sample.

2. Define: Simple UTI : UTI with low grade fever<39, Dysuria, frequency, urgency; and absence of symptoms of complicated UTI

3. A child has 1st attack of UTI at 18 months: which investigations will you ask & when ( USG / VCUG/ DMSA) : USG: soon after Diagnosis. And DMSA 2-3 months later …… NO VCUG ..unless one of them is abnormal

4. Mx of VUR grade IV : ( w.r.t. prophylaxis and/or Surgery) Antibiotic prophylaxis until 5 yr… Consider surgery if Breakthrough Febrile UTI. After 5 yr Prophylaxis only if Bowel Bladder Dysfunction.

5. Mention ( any 4) clinical features suggesting underlying Structural abnormality: Distended Bladder

palpable kidneys

tight phimosis

Vulval Synechiae

Patulous anus

Incontinence

Surgical scars

Wadia CME Sept 2011

Station -10 1*4=4 marks

17 month old boy brought with H/o ingesting Kerosene. First X ray was taken at 3 hours and second after few hours.

• What is the role of gastric aspiration here on admission? Not to be done. • Ingestion of what amount is considered at risk for Pneumonitis ? > 30 ml • How long would you observe this child , if no abnormal symptoms develop. (

8-12 hours)

From Slovis TL, editor: Caffey's pediatric diagnostic imaging, ed 11, Philadelphia, 2008, Mosby/Elsevier, p 1287.)

A 10 month old infant was admitted with h/o irritability, vomiting, crying while passing urine. Urine microscopy revealed 2-3, RBCs; no leucocytes and urine culture was normal. No family H/o urinary stones.

Child had history of fever with cough and cold for two days (which improved without any medication except paracetamol) prior to their week long trip to China.

Child had normal mental and physical growth till now; he was was on formula feeds which were correctly prepared under sterile conditions.

What is your diagnosis? Melamine poisoning

Wadia CME Sept 2011

Station 11 who growth charts: marks ½ + ½ +1 + 1+ 2 =5 Q. Will the standards be applicable to all children?

Answer: can be applied to all children everywhere, regardless of ethnicity, socioeconomic status and type of feeding

Q. What reference data should be used for children older than 5 years?

Answer: WHO Reference 2007 for boys and girls, 5-19 years

Q. How will these new standards change current estimates of overweight (for 8 yr old )and under-nutrition ( infancy) in children?

Answer: wasting rates will be substantially higher using the new WHO standards. With respect to overweight, use of the new WHO standards will result in a greater prevalence

Q. which countries were involved in WHO MGRS study.

Answer: 6 countries representing different regions of the world: Brazil, Ghana, India, Norway, Oman, and the United States.

Q. What is Mid-parental height and Target centiles?

Answer: Boys: [(maternal height + 13) + paternal height]/2 • Girls: *maternal height + (paternal height − 13)+/2 Chart these range at “18 year”= Target Range

Trace the corresponding centile lines to current age.

This is the target centile. It corresponds to 3rd and 97th centile for this child(growth potential).

Wadia CME Sept 2011

Station – 12 Marks ½ + ½+ 1 + 2= 4 A 10 yr old child with H/o rheumatic heart disease is on Inj. Benzathine Penicillin prophylaxis.

He has taken this inj. Previously many times. He was given test dose. Immediately the child is found to have fast breathing and feeble pulse and cold / pale extremities with stridor.

1. What is the diagnosis? 1. Anaphylactic shock

2. What non-pharmacological measures to be taken? 1. Check airway and breathing

3. Name the drug / drugs with route and dose that should be used. 1. Oxygen thro Nonrebreathing mask 10 -15 lit/min.

2. IM adrenaline 0.01ml /kg ( 1:1000)

3. Diphenhydramine 1 mg/kg oral ( as IV is not available)

4. Name types of hypersensitivity reactions( in order) and write their respective mediators. 1. I : Allergy : IgE

2. II : cytotoxic : IgM /IgG –antibody mediated

III: Immune complex : IgG

IV : Delayed hypersensitivity : T cell mediated

Wadia CME Sept 2011

Station -13 Marks (1+ 1 + ½ )+( ½ *3) + ½ + ½ =5 A 3 yr old girl has been brought with h/o red staining of diapers. Her height is 101

cm ( 1 yr back it was 90 cm), weight is 17 kg ( 1 yr back it was 13 kg). She has been observed to be more quiet than usual with intermittent episodes of laughing.

On examination : No skin / mucosal bleeding. Abdominal exam no organomegaly. Neurology NAD

USG abdomen normal.

Routine Hemat / urine / stool /Biochem NAD.

What is the likely diagnosis( give complete diagnosis) ? Isosexual central precociuos puberty

Hypothalamic Hamartoma

Gelastic seizures

What investigations would you ask for ? MRI : localisation / diagnosis

EEG : Gelastic seizures

Estradiol levels :

What is the medical treatment in this case? GnRH Analogues

In case medical treatment fails, what is the other option ? Surgery : Gammaknife/ Transpeniodal etc.

Wadia CME Sept 2011

Station 14 Marks ½ +1 ½ + 2 =4 What is Stokes Adam Syndrome? refers to a sudden, transient episode of syncope, occasionally

featuring seizures with Heart block. Write True / False.

1. The QRS complex is commonly of normal duration in congenital heart block whereas the QRS Duration is usually prolonged in surgically induced heart blocks.: True

2. Prolongation of PR interval is a more reliable early sign of Digitalis toxicity than arrhythmia.: True

3. In Sinus Rhtythm P wave is upright in lead II and inverted in aVR. : True

Wadia CME Sept 2011

Answer 15 marks ( ½ *4) + 1 + (½*6) = 6 A. Marasmus admission Criteria

1. Less than 6 months

2. NOT alert

3. Appetite NOT preserved

4. Clinically NOT well

5. Home environment NOT conducive

B. Stabilization phase and Rehabilitation phase

C. 10 goals of management 1. Hypoglycemia

2. Hypothermia

3. Dehydration

4. Electrolytes

5. Infection

6. Micronutrients

7. Cautious feeding

8. Catch up growth

9. Sensory stimulation

10. Prepare for follow up

Wadia CME Sept 2011

Answer 16 A 14 yr boy treated for attempted suicide , now getting discharged, you have been asked to counsel. (Total marks 8) 1. Introduce/ Language

2. Try to get comfortable with some small talk.

3. Promise Confidentiality

4. Ask any Future Plans of another attempt

5. Any Signs of depression (Sleep well ?, Want to listen to music?)

6. What will you do after going home?

7. What were the stressors (Girlfriend , Marks)

8. Ask substance abuse

9. Where did he get this idea from?

10. Tell Him : make him feel he is not worthless, family and friends still love you , will welcome you home without change in attitude, try to have confidence when there are stress events , Other career options, examples of Sachin Tendulkar, singers,

11. Take a Promise to not do it again

12. Any such thoughts , call me up.

13. We will meet regularly

14. Continue your medications

15. If you want , we can speak to your parents or teachers

16. Never hide anything from parents

17. Thanks for your time and sharing your intimate/ personal.

Wadia CME Sept 2011

Answer 17

Counsel the mother, whose child has been diagnosed with Haemophilia A (Total marks 8)

Introduction

Explain the disease

Removal of guilt

Problem addressed – current problems (Jt. Bleed ))

Associated problems.. deep bleeds

Treatment drug / dosage / side effect to watch Factor VIII / Cryo / FFP

On discharge : precautions at home

Precautions at school / play . Helmet / knee / elbow

To inform about condition in case of any future medical intervention

Counsel for future preg/ posibility of prenatal diagnosis for her and others in Family

Investigate other RELEVENT members

School / play

Future cure / vaccination MAY come up …

When to follow up

When to come in emergency?

Ask if they have any more questions?

Thank the Mother

Wadia CME Sept 2011

Answer 18 (Total marks 8) Perform Lumbar Puncture in this 3 year old child

1. Introduces.

2. Explain to parents the Need for Procedure & consent

3. Checks or asks for blood glucose level

4. Keeps resuscitation equip ready

5. Checks Vitals and AF

6. Universal precaution for self

7. Clean / Drape

8. Identifies the site

9. Sedation (Midazolam) ,[ No need for Atropine]

10. Position (Left Recumbent )

11. LA (Deep into Dura and Outside)

12. Correct direction(Towards Umbilicus) and “give way” mentioned

13. [Newborn 23/22 G , 1 inch], [Pediatric 22 G 1.5 inch], [Adolscent LP needle].

14. Post procedure , mild pressure and seal

15. Will send for cells / biochemistry / culture

16. Post procedure position [Head Low],

17. Explain to mother that procedure was uneventful

18. Instructions to monitor this child

19. BIOWASTE DISPOSAL

20. Thanks the Mother

Wadia CME Sept 2011

Answer 19 (Total marks 8) Explain the procedure of insulin administration 6 units Actrapid and 4 units Insulatard.

1. Introduction

2. Explain procedure (painless , need to take daily)

3. Tells about the two insulin (Milky and Plain) and insulin syringe

4. Remove half an hour before from fridge and shake lightly

5. To give 15-30 minutes before food

6. Select areas –mark them for every day => thigh and site rotation

7. Swab the top of the vial with spirit swab provided

8. Takes 4U air in a syringe puts it in insulatard vial (keeping the vial upright) and then takes 6U air in a syringe puts it in actrapid vial.(vial upright)

9. Inverts the bottle withdraws 6u actrapid then withdraws syringe inserts in insulatard and withdraws up to 10u i.e. 4u

10. Cleans area with spirit

11. Allows it to dry

12. Pinches the subcutaneous area –inserts the needle at 45 degree angle and injects then withdraws needle with syringe and slowly releases pinch, no rubbing massaging

13. Syringe reusable/disposal in sharp

14. Can use same needle for 2-3 times

15. Keep insulin in fridge

16. Explain the symptoms of Hypoglycemia

17. Thank you

Wadia CME Sept 2011

Answer 20 (Total marks 8) Preterm child is being discharged after 1 month of NICU Stay under you, Counsel mother

1. No need for introduction, only say hello

2. Preferably insist on father being present

3. Congratulations (You have gone through a lot)

4. Talk of Normal Routine care in all babies

5. Hypothermia (warm clothes, KMC)

6. Infections (Minimal handling, less visitors, wash hands)

7. Feeding (EBM only with paladi, Non Nutritive suck, No bottle Feeds, Burping)

8. Normal Pattern (Stool, sleep, urine )

9. Continue medications at home

10. Regular vaccination (except HBV)

11. No kajal ,Oil instillation

12. No Bath ;Only sponge till we tell you

13. Massage only if done by family member

14. Follow up every week initially , Growth Monitoring

15. Please arrange for somebody (Mother, Mother in Law ) to help you

16. Bring to doctor (Baby Cold, Lethargic, Oliguria, Persistent vomiting, not feeding well)

17. If you have any doubt , take my number

18. AVOID TALKING ABOUT KEEPING A WATCH FOR DELAYED DEVELOPMENT AT THIS MEETING

Wadia CME Sept 2011

Answer 21 (Total marks 8) Kindly do the developmental assessment of this 4 year old boy.

Gross Motor:- Walks up and down stairs by alternate feet

Hops on one feet

Throws ball overhead

Fine Motor:- Draws a man with 2-4 parts besides head

Copies a square

Language:- Tells a story

Knows three colours

Social:- Gives a account of recent experience and events

Washes face, feet and brushes teeth.

Wadia CME Sept 2011

Answer 22 (Total marks 8) Examine a patient with Mediastinal Lymph Nodes and Suspected Lymphoma

Pallor

Lymphadenopathy [Axilla , Cervical, Groin, Epitrochlear] (In detail, in all positions)

Abdomen examination for Hepatomegaly and Splenomegaly

Trachea in centre

Apex Beat (Shift of Mediastinum)

Para aortic LN (Deep Abdominal Palpation)

Entire Lung Examination (If time Permits)

Neck examination for JVP !!

Wadia CME Sept 2011

Station 23 marks : ½ + (1 ½ only if all four drugs) + 1 + 1 =4 Product code 15 (PWBs)

1. Identify the product

2. What does each pouch contain?

3. Indication of using this pouch.

Product Code 15 –(pediatric Wise Boxes )

Prolongation of intensive phase of category I

Pediatric cases (6-10 kg and 18-25 kg).

Each box containing 5 pouches

Each pouch containing 12 blister Combi pack of Schedule-5.

The pouch consists of Isoniazid, Rifampicin, Pyrazinamide and Ethambutol to be given under direct observation thrice a week on alternate days for 1 month (12 doses).

Name the categories for pediatrics TB diagnosis under RNTCP

New ( prev. CAT I)

Previously treated ( cat II)

Wadia CME Sept 2011

Station 24 Marks : 1 ½ + ½ + ½ + 1 ½ = 4

Give (any 3)D/D of Bowing of legs Physiological

Rickets

Blounts

What is the commonest inheritance pattern in Hypophosph. Rickets? X linked Dominant

In the above condition, who will be having a more severe disease; Boy or Girl ? Girl

Vit D resistant rickets Type 2: Vit D3 ( normal)and 1,25(OH)2 vit D levels( high ) :

Drug of choice: Calcitriol or Alphacalcidol ( also calcium but drug of choice is calcitriol)

Wadia CME Sept 2011

Wadia CME Sept 2011

Wish you all the best

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