MOCK OSCE IN PEDIATRICSOct 2013Dr. Ashwin Borade

27TH Oct 2013

This is a PBS and photograph of a 10 year old boy who has presented with fatigue, fever, and malaise of > 1week in duration.On examination, he has generalized lymphadenopathy, splenomegaly and hepatomegaly. (1X5=5)1) describe the main features in each picture2) what is the diagnosis3) Write 3 complications that may occur4) What medication is contraindicated5) what is the treatment

1.

• Answer (1X5=5)• Picture 1 shows tonsillitis with membrane formation,

picture 2 shows atypical mononuclear cells which are enlarged with irregular nuclei and basophilic pleomorphic cytoplasm

• Infectious mononucleosis• Splenic hemorrhage/ splenic rupture/ airway

obstruction causing drooling/ stridor and respiratory distress/ thrombocytopenia/ Coombs positive hemolytic anemia/ GBS/ Reyes syndrome

• Ampicillin and amoxycillin• Rest and symptomatic treatment / avoidance of contact

sports or strenuous athletic activities during the first 2-3 weeks of illness or while splenomegaly is present.

1.

• A • Name the Method used in slide 1/2• Enumerate the steps 1• Name two organisms which can• be stained by this method 1

• B

• Identify the PS 1/2• Name 4 conditions in which it can be seen 2

2.

• A • Zheil Neelson technique(1/2)• Steps: 1Heat and dry, fix the smear Add carbol fuschin Heat for approx 5 minutes, do not boil Decolorize with 20% sulfuric acid Decolorize with ethanolWash with water Counter stain with Methylene blue • Myco tuberculosis , M. Leprae, Nocardia

2.

B

• Eosinophilia • Allergic disorders/ Tissue invasive helminth

infections/ Malignant disorders/ Rheumatological diseases/ Hyper – IgE syndrome

2.

This is a picture of a 5 year old boy with a characteristic rash which was preceded by a prodromal phase consisting of low grade fever, headache and mild URTI.

Describe the 2 pictures? 2What is the diagnosis? 1And the cause?1Mention two immune mediated post infectious phenomena of the above organism 2

3.

Answer

• Erythema infectiosum/ Parvovirus B19 (1+1)• Picture-1- slapped cheek appearance (1)• Picture-2- lacy reticulated rash on the arm(1)

• Rash and arthropathy are immune mediated, post infectious phenomenon(1+1)

3.

VIDEO

4.

Station

• Identify the sign 1/2• What is it used to detect? 1/2• Name three conditions it can be associated

with 2

4.

answer

• Trousseau’s sign 1• Latent tetany 1• Hypocalcemia/ hypomagnesemia/ metabolic

alkalosis 3

4.

Disorder Platelets PT APTT TT FDP

DIC

Hemophilia A

Von Willebrand

ITP

Chronic liver disease

5.

Disorder Platelets PT APTT TT FDP

DICDec Inc

Inc Inc Inc

Hemophilia A N N inc N N

Von Willebrand N

N inc N N

ITP Dec N N N N

Chronic liver disease

Dec/N Inc Inc N N

5.

Identify inheritance A & BGive example of each and peculiarity of each

• A

• A

6.

A

• DIGENIC INHERITANCE.• Digenic inheritance explains the occurrence of retinitis

pigmentosa (RP) in children of parents who each carry a different RP-associated gene. Both parents have normal vision, as would be expected, but the offspring who were double heterozygotes developed RP.

• Digenic pedigrees exhibit characteristics of both autosomal dominant (vertical transmission) and autosomal recessive inheritance (1 in 4 recurrence risk). A couple in which the two partners are carriers for two different genes may have affected children. Any child, however, might transmit both mutations to an offspring, as in dominant inheritance.

6.

B

• Pseudodominant inheritance refers to the observation of apparent dominant (parent to child) transmission of a known autosomal recessive disorder

• This occurs when a homozygous affected individual has a partner who is a heterozygous carrier, and it is most likely to occur for relatively common traits, such as sickle cell anemia or congenital deafness due to connexin26 gene mutation.

6.

Milestone Age of attaining ( in months)

Follows moving object 180

Sustain social contact, listen to music

Polysyllable vowel sound

Creep or crawl

Plays simple ball game

Hope of feet

Name 4 colors

Make tower of 4 cubes

Dress and undress

Put 3 words together

7.

Milestone Age of attaining ( in months)

Follows moving object 180 2

Sustain social contact, listen to music 3

Polysyllable vowel sound 7

Creep or crowl 10

Plays simple ball game 12

Hope of feet 48

Name 4 colours 60

Make tower of 4 cubes 18

Dress and undress 60

Put 3 words together 24

7.

Write formula for

• PAO2

• VA

• Ventilation index• OI• A-aO2 gradient

8.

• PAO2=PI02- (PaCo2 /R)

• VA= (VT-VD) X RR

• Ventilation index= PIP X VR/1000XPaCO2• OI={(MAP X FIO2)/PaO2 } X100• A-aO2 gradient= PAO2-PaO2

8.

• .A 12 yrs old female brought in general OPD with c/o fever, malaise, weight loss and recurrent headache since 3 months . On examination she had asymmetrical blood pressure and claudication

• What is the diagnosis?• What are diagnostic criteria?• What are types of same?• What is drug of choice for new case, relapse

case and refractory case

9.

answer

• takayasu arteritis• New case- steroid• Relapse- methotrexate• Refractory- cyclophosphamide

9.

9.

• What is the clinical condition called?• Which is the commonest malignancy associated with this?• Which chromosome is implicated in malignancy

mentioned in question 2?• What other malignant disorders are associated

with the malignancy being discussed?

10.

answer

• Leucocoria

• Retinoblastoma

• Rb1 gene Ch 13q 14• Osteosarcoma

Soft tissue sarcomas Malignant melanoma

10.

• . A. What is PICOT study used for?• What it an acronym for ….

• B Weight of 12 children of 2 yrs is as below

• 10, 8, 9, 10, 12, 15, 10, 6, 9, 7, 11,8• Calculate mean, mode, median

11.

A.

• PICOT is a technique medical researchers use to develop a clinical research question.

• It may form part of a formal funding or research proposal, or medical staff may use it to carry out a small-scale experiment.

• PICOT is an acronym for the five different areas the technique considers -- patient population, intervention or issue, comparison with another intervention or issue, outcome and time frame.

11.

B.

• Mean= 9.5• Median= 8.5• Mode= 10

11.

• A patient is admitted to the ICU with the following lab values:• BLOOD GASES under room air• pH: 7.199

PCO2: 32.2HCO3: 12PO2: 86.6

• ELECTROLYTES, BUN & CREATININE • Na: 136

K: 4Cl: 103

1 – Describe the metabolic condition (1) 2 – What is the expected compensation? (1) 3 – Calculate anion gap. What is the normal value? (2) 4 – Name two conditions with similar anion gap as above (1)

12.

answer

• 1- Metabolic acidosis with partial compensation

• 2 - 1 bicarb fall decreases Co2 1-1.5• 3 – Anion gap - [Na] – [Cl] – [HCO3] = 25• 4 – Septic shock, Inborn error ( lactic

acidosis), DKA etc

12.

• 2yrs old child with seizure, behavioral problems, skin abnormalities, MRI done

• What is diagnosis?• What are criteria?• What is inheritance?• What are chart eristic CNS presentation• How u follow up these cases?

13.

answer

• Tuberous sclerosis complex• Major / minor criteria• AD• Epilepsy/ cognitive impairment• F/u examination mRi 1-3 yrs• USG/CT/MRI renal 1-3 yrs• Neurodevelopment assessment

13.

13.

An eight year old child presented with malaise, anorexia, vomiting, muscle weakness and orthostatic hypotension. He had H/o a febrile illness with purpuric rash a few days before.

What is the significant finding in the picture? What is the cause of this finding? What is the possible infection preceding it and what is it called What are the possible electrolyte

abnormalities ? What is the definitive test for

diagnosis of this condition.

14.

Answer

• Hyperpigmentation of the gingival and buccal mucosa.

• Cortisol deficiency leading to increased ACTH production and Melanocyte stimulating hormone arising from the ACTH precursor POMC.

• Meningococcemia – Waterhouse-Friderichsen syndrome

• Hypoglycemia, ketosis, hyponatremia • ACTH Stimulation test

14.

• A. What is diagnosis?1/2• What are predisposing factors • for it? 1• What is t/t? 1/2• What are other manifestations? 1/2

• B .Clarithromycin• What group it belongs 1/2• What mechanism of action? 1• What organisms it act against 1

15.

• A. Guttate psoriasis• Streptococcal infection, post viral, post steriod• Topical steriod/PT• Arthritis

• B. Macrolide antibotic• By interfering with their protein synthesis. • Atypical pneumonias associated with

Chlamydophila pneumoniae, skin and skin structure infections. In addition, it is sometimes used to treat legionellosis, Helicobacter pylori, and lyme disease.

15.

• 1) Identify the condition in the CXR of an ELBW newborn

• 2) Give the definition of this condition

• 3) Mention the stages of this condition in a 34 wk old

• 4) What are the pharmacological strategies in the management of this condition

• 5) Expand INSURE

16.

answer

1)Bronchopulmonary dysplasia (BPD) 2) Current definitions include 1. total duration of oxygen supplementation requirement for >28

days,

2. degree of prematurity (<32 weeks gestational age at birth),

AND

3. Oxygen dependency at 36 weeks Postmenstrual Age.

16.

answer

3) Stages:• Mild: Breathing room air at 56 days postnatal age or

discharge*• Moderate: Need for <30% oxygen at 56 days postnatal age or

discharge*• Severe: Need for > 30% oxygen and/or positive pressure

(IMV/CPAP) at 56 days postnatal age or discharge*

(* whichever comes first)

16.

answer

4) Pharmacological strategies• -Vitamin A• -Postnatal steroids • -Superoxide dismutase• -Furosemide

5) INtubateSURfactantExtubate

16.

1) What is the radiological investigation

2) What sign is demonstrated?

3) What is the diagnosis?

4) What is the commonest age group in which the following condition occurs?

5) What are the other conditions associated with this abnormality?

17.

answer

• Upper GI barium meal study• Corkscrew duodenum• Malrotation with a midgut volvulus• Usually newborns and young infants• Duodenal atresia, duodenal stenosis, annular

pancreas

17.

• What are 4 categories of vaccines and explain them?• Fill the category below?

VACCINE

BCG

CHICKEN POX

MMR

DTwP

TYPHOID

DTaP

PPV23

RABIES

18.

• Categories: Category 1: Vaccine covered under Expanded Program on Immunization (EPI)

• Category 2: Vaccine recommended by IAP in addition to EPI

• Category 3: Vaccine which are to be given after one to one discussion with parents.

• Category 4: Vaccine to be given under special circumstances.

18.

VACCINE CATEGORY

BCG Category 1

CHICKEN POX Category 3

MMR Category 2

DTwP Category 1

TYPHOID Category 2

DTaP Category 3

PPV23 Category 4

RABIES Category 4

18.

TESTS RESULTS INTERPRETATION

HBsAganti-HBcanti-HBs

NegativeNegativeNegative

HBsAganti-HBcanti-HBs

NegativeNegativePositive with >10mIU/mL

HBsAganti-HBcanti-HBs

NegativePositivePositive

HBsAganti-HBcIgM anti- HBcanti-HBs

PositivePositivePositiveNegative

HBsAganti-HBcIgM anti- HBcanti-HBs

PositivePositiveNegativeNegative

19.

TESTS RESULTS INTERPRETATION

HBsAganti-HBcanti-HBs

NegativeNegativeNegative

Susceptible

HBsAganti-HBcanti-HBs

NegativeNegativePositive with >10mIU/mL

Immune due to vaccination

HBsAganti-HBcanti-HBs

NegativePositivePositive

Immune due to natural infection

HBsAganti-HBcIgM anti- HBcanti-HBs

PositivePositivePositiveNegative

Acutely infected

HBsAganti-HBcIgM anti- HBcanti-HBs

PositivePositiveNegativeNegative

Chronically infected

19.

• A .This is lead II ECG of neonate who presented with excessive crying. Systolic NIBP is 80 mm HG• 1) What is the ECG diagnosis?• 2) DC shock is available. Is DC shock treatment

of choice Y/N?• 3) If any treatment necessary, if yes mention?

20.

• B. Identify the ECG. What is the name of this condition?• Mention 4 causes for this.

20.

A

• SVT• No • Vagal maneuvers , Ice filled packs on face, Carotid

massage Adenosine with dose and method of

administration Digoxin Propanolol

20.

B

• 2nd degree AV block. Mobitz Type 1• Myocarditis• Cardiomyopathy• Myocardial infarction• Congenital heart disease• Digitalis toxicity• Cardiac surgery

20.

Match the following

1. Verapamil2. Methemoglobinemia3. TCA4. Sulfonylureas5. Propranalol 6. Anticholinergics7. INH8. Ethylene glycol9. Diazepam10. Morphine

A. FomepizoleB. OctreotideC. PyridoxineD. Methylene blueE. InsulinF. Sodium bicarbonateG. GlucagonH. PhysostigmineI. NaloxoneJ. Flumazenil

21.

• 1-E• 2-D• 3-F• 4-B• 5-G• 6-H• 7-C• 8-A• 9-J• 10-I

21.

• A premature baby was ventilated and on 2nd day had convulsions. His investigation done which is shown here

04/09/2023 CME,Indore 55

22.

• Identify and describe the investigation • Spot the diagnosis with grade• What are preventive measures?• What is the commonest neurological sequel?• What is the commonest Opthalmological

sequel?

04/09/2023 CME,Indore 56

22.

Answers

• Cranial USG showing cystic PVL• Grade 2 PVL• Early interventions , maintain normal

cerebral perfusion• Spastic diparesis• Strabismus, nystagmus, ROP

04/09/2023 CME,Indore 57

22.

Write cardiac disorder for following syndrome (1/4 X 10=2 1/2)

syndrome Cardiac disoder

Apert

Crouzon

De lange

Noonan

william

Down

Digeorge

Cong.Rubella

Maternal PKA

Carpenter

23.

Answer

syndrome Cardiac disoder

Apert VSD

Crouzon PDA/COA

De lange VSD

Noonan PS/ASD

william AS

Down ECD

Digeorge Aortic arch anomalies

Cong.Rubella PDA

Maternal PKA VSD/ASD

Carpenter PDA

23.

THANK YOU!!!

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