DNB Pediatrics OSCE CME (Command Hospital, Pune)

COMMAND HOSPITAL PUNE
25TH July 2008

INTRODUCTION to
Objective structured clinical examination

Observation Stations &
Clinical Examination

5 min each

OBSERVED
STATION

OBSERVED
STATION

OBSERVED
STATION
OBSERVED REST
STATION STATION

REST STATION

STATION 1 OBSERVED REST STATION
STATION

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Bio otype Blank OSCE Sheets
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1. STATIONS:
2. OBSERVED STATION: Foreign Body Apiration: demonstrate action on a manikin
3. Statistics
4. Neonatal Chest X ray with MAS and umbilical venous cannulation. Qs on complications and heparin infusion
5. Rest Station
6. Spirometry
7. OBSERVED STATION: History Taking: examiner is observing your procedures.
8. History taking of a 4 year old child with febrile seizures—have all the points to diagnose, prognosticate and manage the child
covered.
9. Congenital Anomaly: Qs on diagnosis, prognosis and causes of death.
10. Photomicrograph of a PBS of a haemolytic anaemia. Qs on the abnormalities of the RBCs, the diagnosis, two inv, two treatment
stratigies.
11. X- Ray Chest of a CHD. Qs on radiological findings, diagnosis, antenatal history, DD, definitive manangement of the condition.
12. Cavernous sinus thrombosis
13. OBSERVED STATION: drug counselling to the mother of a child with bronchial asthma: from the drugs to devices.
14. Photomicrograph of a PBS of different types of mononuclear WBCs. Qs on identification of the cells.
15. Photograph of a dermatological condition. Qs on diagnosis, etiology, management.
16. Vaccine: Qs on a particular vaccine, its storage, route, indications.
17. Drug: Qs on the mechanism of action, group, metaboism, SEs.
18. OBSERVED STATION: Examination of a system.
19. Photograph of a Karyotype. Qs on the abnormality, diagnosis, 3 CFs, type of inheritance.
20. Micronutrients and their deficiency disorders.
21. Biostatics: calculation of relative risk, Odd’s ratio and Attributable risk.
22. Photograph of an ectoparasite. Qs on identification, disease caused, drug therapy.
23. ECG: abnormality, axis, diagnosis, complications, management.
24. OBSERVED STATION: examiner asses the skills. Newborn gestational age assessment.
25. REST STATION
26. Neonatal: HMD:Qs four risk factors, ventilation modalitiws, ABG: a/A ratio, A-aDO2, OI for the ABG & ventilator settings.
27. Lab Test: Haemolytic anaemia, antenatal diagnosis, management.
28. Short Stature scenario with Ht, Wt, SMR, Bone age given. Qs on endocrine inv.
29. Drugs: doses, routes, antidotes.
30. Clinical Situation: GBS
31. Photograph of oxygen delivery devices: Qs on Fio2 rates delivered.
32.

REST STATION


If patient presents with fever and toxaemia, give three
differential diagnosis
 Give three modalities of management

1. Lung Abcess
2. Infected Bronchogenic cyst
3. Infected Hydatid Cyst

1. Antibiotics (anaerobic +aerobic)
2. Chest physiotherapy
3. Percutaneous CT guided aspiration

0.5 each
Total 3 marks

What is the lesion ?
Give two management modalities.
What complication can occur during management &
how can it be prevented?

NCC 1
NCC:
Anticonvulsants 1
Albendazole

Increase in Cerebral Edema 1
Use steroid cover

Total 3 marks

Describe the lesion.
What are the management modalities of such lesions
especially if they are leading to complications ?

Haemangioma scalp 1

Conservative 2
Oral steroids
Local steroids
PDL: pulse dyed laser
IFN alfa interferon (in case of haemangiomas causing
pressure effects or erosion leading to significant
morbidity)

Total 3 marks

Worrisome Hemangiomas
Multiple cutaneous hemangiomas: Associated with
visceral hemangiomas (e.g., liver)
Large hemangiomas: May cause significant disfigurement of
underlying structures and may be associated with congestive
heart failure
"Beard" hemangiomas: May be a marker for underlying
laryngeal or subglottic hemangioma that may impair
respiratory function
Midline spinal hemangiomas: May be a marker for
underlying spinal cord abnormality
Head and neck hemangiomas: May be associated with
other congenital anomalies, including central nervous system,
cardiac, ocular, and sternal defects (e.g., Posterior fossa
malformation, Hemangioma, Arterial abnormalities,
Coarctation, Eye abnormalities, Sternal defects [PHACES]
syndrome).
Vulnerable anatomic locations: Impair vital functions,
cause disfigurement (e.g. periocular, neck, lip, nasal tip)
Ulcerated hemangiomas: Increased risk of superinfection,
cause pain and lead to scarring

What are two imp radiological abnormalities?
What is the diagnosis ?
What are the three imp investigations ?
What are the metabolic abnormalities expected?
What is the management ?

 Distension of stomach
 No gas in the intestines

 Pyloric Stenosis

 USS abdomen: pyloric thickness >4mm/ pyloric
length >14 mm
 S electrolytes
 Ba studies

 Hypochloremic, hypokalemic, metabolic alkalosis

 Management of the fluid & electrolytes
 Ramstedt’s pyloromyotomy

0.5 each
Total 5 marks

What is the likely organism ?

Pnematoceles 1

Likely organism Staphylococcus
1

Total 2 mark

Give five radiological findings ?

1 Ground glass appearance of bone 2
2 Thinned cortex
3 Periosteal calcification
4 White line of Fraenkel (well calcified cartilage)
5 Wimberger’s sign (white ring)

Scurvy 1

1 Vit C 100-200 mg/ day1
2 Dietary Therapy

Total 4 marks

What was the lesion ?
What was the procedure carried out ?
What are the complications ?

VSD 1
Device implant 1

Device displacement 2
Emboli formation
Haemolytic Anaemia

Total 3 marks

Name the Investigation ?
What are the further investigations ?

MCU

Posterior urethral Valves

DTPA (diethylene tetra amine pentoic acid) Function
DMSA (dimercapto succinic acid) -scarring

Total 3 marks

What is the abnormality?
How is it suspected clinically ?

1. .Bowelloops in lt hemithorax, mediastinal shift to right 1
2. Congenital diaphragmatic hernia 1

3. Respiratory distress
Mediastinal shift
Bowel sounds in the thorax
Scaphoid abdomen 2

4. Avoid B&M vent
prop up and decompress stomach
Ventilate
Treat PPHN
Surgical correction
Antenatal tracheal ligation 3

CDH
Pleuroperitoneal membrane defect
Fetal lung development
Pseudoglandular stage 5 to 16 weeks
Canalicular 16 to 24 weeks
Saccular stage
Alveolar stage continues till 8 years of life

What is the abnormality?

What is the likely diagnosis?

Delineate management.

Mention 3 complications

Multiple fluid levels.
gasless lower abdomen 1
Small bowel obstruction 1
Surgical correction 1
Dyselectrolytemia 1
Perforation
Exaggerated hyperbilirubinemia
Dysmotility syndrome

Martin: Fanaroff and Martin's Neonatal-Perinatal Medicine, 8th ed.,

Describe the X –ray
Diagnosis
Give three recent advances in management

Hyper inflated lung fields with areas of atelectasis interspersed
with areas of overinflation 1
MAS 1
Lung lavage
surfactant instillation
HFOV
NO
liquid ventilation 2

What is the abnormality
Three high risk situations when this condition is
imminent
Management

Pneumothorax 1
CDH
Ventilation
Post surfactant ventilation 2
Chest tube drainage 1

What is the abnormality
What is it a complication of

Pneumomediastinum 1
Forceful ventilation 1

Identify the abnormality
Clinical presentation
Treatment

Pneumopericardium 1
Shock with weak pulses 1
Drainage 1

What are the MRI findings ?
What is the DD
What further inv will you do on the CSF to confirm
the diagnosis ?

Acute disseminated encephalomyelitis

3 marks

Oligoclonal bands are also found in:
 Multiple sclerosis
 Devic's disease
 Systemic lupus erythematosus
 Neurosarcoidosis
 SSPE
 Subarachnoid haemorrhage
 Syphilis
 CNS Lymphoma

What are the MRI findings ?
What could be the etiology ?

Multifocal cerebral & cerebellar encephalomalacia
Sequel of ischaemic injury in the perinatal period.

2 marks

What is the likely diagnosis ?
What is the IP?
Which is the commonest site?

TB Spine 1
2 YRS 1
Thoraclumbar
area of max stress
valveless venous drainage 2

4 mark

What are the MRI
findings ?
Likely etiology
Likely CSF picture

TBM

Increased proteins
3 mark
Increased cells likely lymphocytes
Low sugar

What is the X ray suggestive of ?
What is the likely organism?
What are the complications?
What is the drug of choice?
What is the duration of therapy?

Lobar Pneumonia
Pnemococous/Staphylococcus
Synpneumonic effusion, empyema,
Penicillin for susceptible org and cefotaxime /
vancomycin for penicillin resistant org
10-14 d

5 marks

Questions
1. What is the anatomical structure in which coin is
lodged?
2. What is the location of carina with respect to
thoracic vertebrae?
3. What are the anatomical areas of esophageal
narrowing?
4. How can this foreign body be removed?

Answers 1

Esophagus
When foreign bodies lodge in the esophagus, the flat
surface of the object is seen in the AP view *
T 4 1

Anatomic areas of esophageal narrowing 3
Cricoid
Tracheal bifurcation
Gastro-esophageal junction
Endoscopy
1
*

Question
1. What is the diagnosis?
2. Fill in the blanks
In an exudative pleural fluid
a. Proteins >
b. Pleural Fluid LDH > ………….
c. Fluid to serum LDH ratio > ………..
d. Cell count ………
3. What does VATS stand for?

Answers 2
1. Pleural Effusion (Right)
2. Fill in the blanks
In an exudative pleural fluid
0.5
a. Proteins > 3.0 g/dL
0.5
b. Pleural Fluid LDH > 200 IU/L
c. Fluid to serum LDH ratio > 0.6 0.5
d. Cell count > 1000 0.5
3. Video Assisted Thoracoscopic Surgery 1

Questions
1. Diagnosis?
2. What are the first two steps in treatment of hypoxic spell?
3. In a cyanotic newborn, how can you distinguish pulmonary
disease from cyanotic congenital heart disease?
4. Which cardiac conditions are associated with following
a. Egg Shaped Heart
b. Snowman silhouette
c. Rib notching

Answers 1.5
1. Cyanotic Congenital Heart Disese
Probably TOF
 The heart size is normal
 Pulmonary vascular markings are decreased
 A hypoplastic main pulmonary artery segment
contributes to the formation of the “boot-shaped”
heart.

Pediatric cardiology
Myung K Park 5th ed

Answers 1
2. Knee Chest Position 1
Morphine
1
3. Hyperoxia Test
4. X-ray appearances
a. Egg Shaped Heart Transposition of great arteries 0.5
b. Snowman silhouette Total anomalous pulmonary
venous return (supracardiac) 0.5
c. Rib notching Co-arctation of aorta (long
standing) 0.5

Park: Pediatric Cardiology for Practitioners, 5th ed.

3 day neonate with
Lethargy
Feed refusal
Abdominal distension

Questions
1. What stage of NEC is depicted in the
X-ray?
2. What is the radiological feature of Bell stage III
NEC?
3. Name two more conditions associated with
pneumatosis intestinalis?

Answers 1
1. NEC Stage II 1
2. Pneumoperitoneum
2
3. Any two of following
Hirschsprung's disease, Pseudomembranous
enterocolitis, Neonatal ulcerative colitis,
Ischemic bowel disease

PART 5 Neonatal Necrotizing Enterocolitis

6 weeks infant
Case of Cholestatic jaundice
(Extra-Hepatic Biliary Atresia)
c/o swelling left thigh

Questions
1. What is the likely cause of fracture femur in this
case?
2. How can this complication be prevented?
3. How do you manage pruritus in these patients?
4. An infant with cholestasis, triangular facies, and a
pulmonic stenosis murmur is likely to have what
syndrome?

Answers 1
1. Metabolic Bone disease (secondary to Vitamin D
deficiency due to malabsorption of fat soluble
vitamins)
1
2. Replace 5,000-8,000 U /d of D2,or
3 -5 µg/kq/d of 25-hydroxycholecalciferol
3. Ursodeoxycholic acid 15-20 mg/kg/day 1
4. Alagille syndrome
1
(Arteriohepatic dysplasia)

L Previously healthy 7 years
girl c/o
c
Sudden onset weakness right
upper and lower limb
t Facial palsy right (UMN)
Normal sensorium
No fever/ trauma/ seizures

Questions
1. What is the level of lesion on MRI?
2. What are the structures marked
c
t
3. Which hemoglobinopathy can be associated with
this kind of presentation?
4. A dilated and unreactive pupil indicates the
compression of what structure?

Answers 2
1. Infarct in the left basal ganglia, the posterior limb
of internal capsule, and the head of the caudate 1

Answers
2. C Caudate 0.5
nucleus
T Thalamus
0.5
P Putamen
G Globus pallidus

White arrows indicate the ant
and post limbs of internal
capsule

1

Answers 1
1
3. Sickle cell anemia
1
4. Compression of 3rd cranial nerve 1

Questions?
1. Diagnosis?
2. What is the treatment (mention complete
schedule)?

Answers
1
1. Miliary tuberculosis
2. 2HRZE + 7HR 1
IAP Group 4

1. Diagnosis
2. What are the
embryologic events that
lead to this
development?
3. What are three causes
of respiratory distress in
a baby born with this
condition?

Answers 1
1. Congenital Diagphragmatic Hernia
2. The posterolateral portion of the diaphragm has remained 1
open between the ninth and tenth weeks of gestation as a
result the viscera will pass into the chest, and a CDH will
result.
3. a) Mechanical compression of the lungs from the herniated
1
viscera
b) Pulmonary hypoplasia from compression of the
developing lungs in utero 1
c) Pulmonary hypertension
1

Questions
Describe the lesion?
Give two D/D
What is the triad of tumor lysis syndrome?

Answers 1
Osteolytic lesion of skull
2
Histiocytosis
Ewing`s Sarcoma
Lymphoma 3
Bone cyst
Hyperuricemia, hyperkalemia, and
hyperphosphatemia

Questions
1. Describe the X-ray appearance
2. Pathogenesis of the appearance
3. Possible Diagnosis
4. Which disorder is most commonly associated with
an elevated MCHC?
5. How is the corrected reticulocyte count calculated?

Answers
1. Sunray appearance 1

2. Medullary widening 1

3. Chronic hemolytic anaemia 1
4. Hereditary spherocytosis
1
5. Corrected retic count
= reticulocyte % × (patient Hct/normal Hct) 1

Below is a midline sagittal cut of a MRI scan of the
brain. View the midline anatomic diagram of the brain
and identify the following structures

Answer
S - Suprasellar cistern
P0 - Pons
P - Midbrain (cerebral peduncles)
M - Medulla
C - Quadrigeminal plate (superior and inferior
colliculi)
Q - Quadrigeminal cistern
V - Fourth ventricle

1 mark each

Question
1. Diagnosis?
2. What is the emergency management of the
condition?
3. What is subsequent management after the
emergency management is over?

Answers 1
1. Pneumothorax, 1
with mediastinal shift
1
2. Put in a needle in second intercostal space
3. Intercostal drain
1

Questions
2. Describe three features seen on the X-ray of the
disease?
3. What biochemical test would help clinch the
diagnosis?
4. What is the treatment of the condition?

Answers 1

1. Rickets 0.5

2. a) Cupping 0.5
b) Widening of distal end of metaphysis
0.5
c) Fraying
3. Calcium, Phosphorus, Alkaline phosphatase 1.5
4. Injection Vitamin D 6 lac unit IM stat
PO Calcium
1

1

Questions
2. What is the clinical sign for the diagnosis called as?
3. Name one intervention which can lead to this?

Answers 1

1. Pneumopericardium 1
2. Hammans sign
1
3. Invasive ventilation with high pressures

X-ray neck lateral
view in a child
with respiratory
distress

Questions
2. Which is the commonest organism implicated in
this disease?
3. What antibiotics are useful in this condition?

Answers
1. Epiglottitis 1
2. Hemophilus influenzae type B 1
3. Cephalosporins/ Ampicillin/ sulbactam 1

Questions
1. Diagnosis
2. By what gestational age would this defect occur?
3. This can be prevented in subsequent pregnancies
by intake of Folic acid. Folic acid should be taken in
what dose and started when?

Answers 1

1. Occipital Encephalocele 1
2. 26 days post conception
3. Folic acid
Dose: 0.4mg/day 1

Periconceptional period 1

Questions
1. Diagnosis
2. What is the clinical
picture?
3. What is the requirement of
echo before surgery?

Answers
1. Tracheo-esophageal fistula
2. Excessive drooling
Respiratory distress
3. To rule out associated
Congenital heart diseases
Right sided aorta

PART 3 Selected Thoracic Gastrointestinal Anomalies

Name three complications.
What is the period of infectivity.

• Chicken pox 1
1. Pneumonia 1
2. Encephalitis
3. Ataxia
4. ADEM
5. Progressive varicella: organ invol, h’ge

• Airborne or direct contact : contagious 2 days before
& till all lesions are dry 1
Total 3 marks

1. Give the diagnosis.

2. Give four important components.

3. State the most important prognostic factors.

1. Prune- Belly Syndrome 0.5
2. Important components
a. Abnormal abdominal musculature 0.5
b. Abdominal cryptorchidism0.5
c. Renal and ureteric anomalies with VUR 0.5
d. Pulmonary hypoplasia 0.5
3. Long term complication
a. ESRD 0.5
4. Prognostic factors
a. Degree of renal dysplasia 0.5
b. Pulmonary hypoplasia` 0.5
(Total marks 4.0)


2. State mode of inheritance.

3. Name five important components.

4. Name most frequent immunological defect.

1. Ataxia – Telengiectasia 0.5
2. Autosomal recessive 0.5
3. Important components
a. Cerebellar ataxia 0.5
b. Oculo-cutaneous telengiectasia 0.5
c. Immuno-deficiency 0.5
d. Sino-pulmonary infections 0.5
e. Lympho - reticular malignancies 0.5
4. Selective absence of Ig A 0.5
(Total marks 4.0)
(NO MARKS IF FIRST ANSWER IS WRONG)

1. Seckel Syndrome 2.0
2. Important features 2.0
a. Microcephaly
b. Beak like nose “Bird face”
c. Hypertelorism
d. GU anomalies
e. Growth retardation
(Total marks 4.0)


2. Give three important complications.

3. List three treatment modalities

1.Giant haemangioma 0.5
2.DIC 1.5

1. State the diagnosis
2. Name the abnormal karyotypes
3. List three prenatal diagnostic techniques
4. Indication for parental screening

1. Down Syndrome 0.5
2. Trisomy 21 1.5
Translocation
Mosaicism
3. Triple screen (b-HCG, a fetopr, estradiol)1.5
Ultrasonography
Fetal DNA analysis
(maternal age >35 yrs)
4. Translocation0.5
(Total marks 4)

(No marks if first answer is wrong)

What is the condition? 1
Describe the lesions. 1
What is the mode of inheritance? 1
What is CNS association? 1

Tuberous sclerosis
Ash leaf macule , shagreen patch, angiofibroma
Autosomal dominant
Characteristic brain lesions are tubers located in
convolutions of cerebral hemisphere typically in the
subependymal region.

What is the condition?

How will you treat it?

Bitot’s spots

Vit A 6 mo to 1 year 1 lac U oral rpt 48 hrs
1 yr to 6 years 2

2 marks

What is this condition?
Name a metabolic complication arising
from this condition
2 marks

Collodion baby (Ichthyosis)

Hypernatremic dehydration

2 marks

What is the
abnormality seen?

What is the diagnosis?
What other
investigation would you
advise in this case?

Absence of depression of the right angle of mouth while
crying
DAOM (deficiency of depressor anguli oris muscle)

2D echocardiography as the condition is associated
with cardiac anomalies

3 marks

QUESTIONS

What is the condition?
What is the root value of nerves involved?
What is the life threatening complication associated
2 marks

Erb- Duchenne palsy

 C5,C6
Diaphragmatic paralysis

3 marks
Chapter 27 – Birth Injuries

Martin: Fanaroff and Martin's Neonatal-Perinatal Medicine, 8th ed

Name the condition.

What is the natural
course of these lesions?

Strawberry angiomas

Lesions increase over the first few months of life and
then regress

2 marks

Describe the
abnormality 1

What is the likely
diagnosis1

Webbed neck

In a female
 Turner syndrome
In a male
 Noonan’s Syndrome

2 marks

Questions
Diagnosis
Commonest differential
Management

Answers
Epulis: granular cell tumor of gum
Hemangioma
Surgical excision
 Carbondioxide laser excision

4 marks

Chapter 26 – Physical Examination of the Newborn

Questions
Abnormalities
Syndrome
Inheritance

Answers
Proptosis ,high forehead,mid facial hypoplasia.
Crouzon’s syndrome.
Autosomal Dominant

3 marks

What is the Diagnosis ?
What is the Differential Diagnosis?
What are the assoc anomalies?
What is the Management ?

1. GASTROCHISIS 1

2. OMPHALOCOELE 1

3. Beckwith Wiedman
Trisomies
Congenital cardiac anomalies 1

4. Cover defect with sterile draping
fluid replacement
Early surgical correction 1

PART 4 Selected Abdominal Gastrointestinal Anomalies

1. Give the diagnosis

2. Give five important components

3. Name an important metabolic abnormality and its
management

1. Hemihypertrophy Syndrome 0.5
2. Important features
a. Macrosomia / (Hemi hypertrophy) 0.5

b. Macroglossia 0.5
c. Hepato-splenomegaly 0.5
d. Omphalocele 0.5
e. Embryonal tumours 0.5
3. Metabolic abnormality & management
a. Hyperinsulism Hypoglycaemia 0.5
b. Diazoxide / pancreactectomy 0.5
(Total marks 4.0)

Chapter 28 – Congenital Anomalies


2. Name the most important endocrinal feature
3. Name the most important cardiovascular problem
4. Name the mainstay of management

1. Congenital Lipodystrophy 1.0
2. Insulin resistant DM 1.0
3. Hypertrophic cardiomyopathy 1.0
4. Dietary fat regulation 1.0
(Totalmarks 4)
(No marks if first answer is wrong)

1. Give the diagnosis
2. List clinical staging.
3. What is the most important sequel and it’s
prediction?
4. Outline the treatment.

1. Kawasaki Disease 0.5
2. Clinical Staging
a. Acute febrile phase 0.5
b. Sub-acute phase 0.5
c. Convalescent phase 0.5
3. Complication and prediction
a. Coronary artery aneurism 0.5
b. Onset of coronary artery changes 0.5
within 2 months of onset of illness
1. Treatment
a. IVIG 0.5
b. High dose aspirin 0.5
(Total marks 4.0)


2. What is the embryologic basis
of these defects?

3. In an otherwise healthy child,
when are these defects
repaired?

Answers
1. Bilateral Cleft Lip and Palate 1
2. Cleft lip
- Hypoplasia of mesenchymal layer 1 resulting in
failure of medial nasal and maxillary process to join
Cleft palate
- Failure of palatal shelves to fuse 1
3. Cleft lip By 3 Months 1 Cleft
palate By one year 1

Questions
1. What is the likely diagnosis?
2. What is the mode of inheritance?
3. State True or False
a. Limb shortening is greatest in
proximal segments.
b. Fingers often have a trident
configuration.
c. Lumbar canal stenosis generally
does not develop till early
adulthood.

Answers
1. Achondroplasia 1
2. Autosomal dominant 1
3. True/ false
a. True 1
b. True 1
c. True 1

A 3 year girl presents with
Severe pruritus esp
During night and after
Taking bath with warm
Water. Pruritus is most
Significant in web spaces
Of hands and toes

Questions
1. Diagnosis
2. What is causative
organism?
3. What is Topical Rx?
4. What is oral Rx?

Answers 1

1. Scabies 1

2. Sarcoptes scabie 1

3. Permethrin 5%
1
4. Ivermectin

 An infant presents with periorificial and acral
dermatitis, diarrhea, alopecia and nail dystrophy.

Questions
1. Diagnosis?
2. What laboratory test helps to clinch the diagnosis?
3. What is the treatment?
4. Name any three IEM which can have similar
finding.

Answers 1

1. Acrodermatitis enteropathica 1
2. Low plasma zinc concentration
3. PO Zinc (zinc sulfate, acetate,or gluconate) 50-150mg/day 1
4. Any three of following
Maple syrup urine disease, 3
Organic aciduria,
Methylmalonic acidemia,
Biotinidase deficiency
Essential fatty acid deficiency

Questions
1. Name the neurocutaneous
marker seen
2. In NF-1 what is the diagnostic
criteria with respect to this
marker?
3. Name a X-linked dominant
neurocutaneous syndrome
4. What are the three stages of
syndrome in question 3?

Answers
1. Café-au lait macule 1
2. Six or more CAL macules larger than 5 mm in greatest diameter in
prepubertal

And larger than 15 mm in greatest diameter in postpubertal
individuals
1
3. Incontinentia pigmenti
4. Stage 1-Vesicular stage
Stage 2-Verrucous stage
Stage 3-Pigmented stage

1

1

1

Questions
1. What is exhibited in the
photographs a and b?
2. Diagnosis?
a
3. What is the mode of
inheritance?
4. What is the major ocular
criteria for diagnosis?

b

Answers 1
1. a: Hypermobility of finger joints. 1
b: Positive thumb (Steinberg) sign
1
2. Marfan syndrome
3. Autosomal dominant 1

4. Ectopia lentis 1
(superior and temporal )

1. Diagnosis
2. What is the pattern of inheritance?
3. What is the characteristic radiographic image called?
4. What is the opthalmologic complication?

Answers 1

1. Sturge weber syndrome 1
2. Sporadic
1
3. Tram track appearance
1
4. Bupthalmos

Questions
2. What are the three
species associated with it?
3. What are useful methods
for diagnosing tinea
infections?

Answers 1
1. Tinea infection 1

2. Trichophyton 1
Microsporum 1
Epidermophyton
3. Potassium hydroxide (KOH) preparations 1
Fungal culture of skin scrapings inoculated on
DTM (dermatophyte test media) 1

Questions
1. What is the clinical condition called?
2. Which is the commonest malignancy associated
with this?
3. Which chromosome is implicated in malignancy
mentioned in question 2?
4. What other malignant disorders are associated with
the malignancy being discussed?

Answers 1
1. Leucocoria 1
2. Retinoblastoma
1
3. RB1 gene Chr 13q 14
1
4. Osteosarcoma
Soft tissue sarcomas 1

Malignant melanoma 1

Examination

Lax skin folds

Lab – 1(Blood)
• Age – 4 yrs
• Hb – 7 g%
• RBCs – Polychromatophilic reticulocytosis,
many spherocytes, central pallor less
conspicuous
• WBC and platelet series- normal
• Bone Marrow – Erythroid Hyperplasia
• Questions
– Differential diagnosis
– Confirmatory test

Answers: Lab – 1(Blood)
• Anemia
• Increased retic count – Hemolysis
• PBS – spherocytes, other series normal
• Bone marrow – hyperplastic – hemolysis
• D/D of hemolytic anemia with spherocytes
– Hereditary spherocytosis – osmotic fragility
– Autoimmune hemolytic anemia – coombs test
– Wilsons disease – serum ceruloplasmin
– Burns - History

Total 2 marks

Lab – 2 (Blood)
• Age – 3yrs
• Hb – 6 gm%
• TLC – 1500/cmm
• Platelets – 20,000/cmm
• Bone marrow – Cellularity reduced
• Questions
– Diagnosis?
– Name 2 infectious causes

Answers: Lab – 2 (Blood)
All three cell lines are depressed
Bone marrow depression
Diagnosis- Aplastic anemia
Causes
CMV
Hepatitis B
HIV

Total 2 marks

Lab – 3 (Urine)
•Age – 9yrs
•Appearance - Turbid
•Sp Gr – 1019
•Proteins – 4 +
•RBCs – 6 to 10 per HPF, occasional RBC casts seen
Questions
– Diagnosis?
– Causes?

Answers: Lab – 3 (Urine)
Sp Gr – normal
Nephrotic range proteinuria
Microscopic hematuria with RBC casts – glomerular
pathology
Nephrotic syndrome with hematuria – Nephritic
onset Nephrotic syndrome
Common causes – Idiopathic, SLE, Malaria, HSP,
Hepatitis B

Total 3 marks

Lab – 4 (CSF)
Age – 3 days term neonate
CSF –
 Appearance – clear
 Proteins – 10 mg/dl
 Glucose – 45 mg/dl ( Blood sugar – 80 mg/dl)
 Cells – WBC – 6/cmm pred neutros
Questions
What is your interpretation

Answers: Lab – 4 (CSF)
Normal CSF in a neonate

WBC 11+/-10 (90th centile-22)
 polys 2.2+/-3.8 % (90th centile- 6)
Protein 84+/-45 mg/dl
Glucose 46+/-10 mg/dl

Interpretation – normal CSF report

Total 3 marks

Lab - 5 Peritoneal fluid
• AGE 10 yrs
• Peritoneal fluid
– Protein 4.5g/dl
– LDH 750 IU (90u/L)
– WBC 7500/cmm
– GLUCOSE 56mg/dl (Blood sugar 80mg/dl)
Question
– Diagnosis?
– Treatment?

Answer : Lab - 5 Peritoneal fluid
 Normal value
Transudate Exudate
Sp Gr <1.016 >1.106
Protein <3gm/dl >3gm/dl
WBCs <1000/cmm >1000/cmm
RBCs <10,000/cmm Variable
Glucose = serum <serum
pH 7.4 to 7.5 <7.4

 Diagnosis
Tuberculosis
 Treatment-
ATT as per IAP consensus Group 4
2 HRZE / 7 HR

Total 2 marks

2. What is the mutation that results in this disease?
3. What are the three main categories of crises in patients with
sickle cell disease?

Answers 1

1. Sickle cell disease
2. On the beta chain, valine is substituted for 1
glutamic acid at position 6
3. Aplastic crisis 1

Vaso-occlusive crisis 1
Acute splenic sequestration
1

Nathan and Oski's Hematology of Infancy and Childhood,
6th ed. 2003, pp 802-811

Questions
1. Describe the cells seen.
2. Name one condition each
from following category in
which these cells are seen
a. Neurological
b. Metabolic
c. Hepatic
d. Endocrinal

Answers 1

1. Acanthocytosis
2. Conditions
1
a. Neurological Neuroacantocytosis
1
b. Metabolic Abetalipoproteinemia
c. Hepatic Severe liver dysfunction 1

d. Endocrinal Hypothyroidism 1

What is this modality of investigation?
Name three common indications .

Answer: Spots: 1
Radionuclide bone scan
Indication
Metastasis
Osteomyelitis
Stress fracture

Total 2 marks

What is this modality of investigation?
Name one common indication .

Answer : Spots: 2
Hepatobiliary scintigraphy
Indication
Biliary atresia

Total 2 marks

What are the cardiac conditions associated ?
What are the endocrinal conditions associated ?

Turner’s Syndrome

1. Bicuspid aortic valve
2. Co of aorta
3. AS
4. MVP
5. TAPVR

Hypogonadism
Hypothyroidism
Type-II DM

Total 4 marks

Questions
2. Give two sexual
characters in this
condition
3. Give one cardiac
condition that may be
associated with this
condition
4. What would be the
plasma levels of
a. FSH
b. LH
c. Testosterone

Answers 1
1. Klinefelter Syndrome (47 XXY)
2. Any two 2
Lack secondary sexual characteristics
Infertility, azoospermia
Gynecomastia
Testicular dysgenesis
3. Any one
Mitral valve prolapse (55%) 0.5
Varicose veins (20-40%)
4. Plasma levels of
a. FSH Increased 0.5
b. LH Increased
0.5
c. Testosterone Decreased
0.5

Questions
a. Diagnosis
b. Commonest differential how do you distinguish
between two?
c. Give 3 Steps of management

Answers
PSVT
Sinus tachycardia - there is beat to beat variability.
Vagal manoeuvres:
Carotid Massage
Ice packs over face
Valsalva manouver

Adenosine drug of choice.

4 marks
4 marks

Questions
Abnormalities
Management
Which drug eliminates the causative agent

Answers
ECG changes of hyperkalemia
Calcium gluconate, sodabicarb, asthalin nebulisation,
insulin
Kayexelate resin.

4 marks

What disease does this PBS picture suggest ?

Case
pH 7.51 (7.35-7.45) This is the ABG of a 6 week
PO2 12 KPa (95 mmHg) neonate admitted with
PCO2 4.7 KPa (35 mmHg) projectile vomiting
Blood Urea 11 mmol/l
Sodium 131 mmol/l
Potassium 3 mmol/l
Chloride 83 mmol/l

Questions
1. What type of alkalosis the patient has: metabolic/
respiratory?
2. What is the most likely diagnosis?
3. What are the ultrasonographic criteria to diagnose
the condition?
4. What is the treatment of choice?

Answers
1. Metabolic alkalosis
2. Congenital hypertrophic pyloric stenosis
3. Ultrasonographic diagnostic criteria
a) Pyloric thickness>4mm or
b) Pyloric length > 14mm
4. Pyloromyotomy (Ramstedt)

This is blood glucose profile of a 10 year boy
with Diabetes. His Hb A1C is 12%. At that time
his treatment included:
Insulin Morning Evening
Regular 6U 3U
NPH 8U 5U
400 Blood glucose profile
Blood Glucose (Mg/dl)

350
300
250
200
150
100
50
0
t
AM

AM

AM
00

00

00

gh

00

00

00
12

17

22

12

17

22
ni
00

00

00
id
M
6:

6:

6:
TIME
2

Questions
1. What changes would you institute in insulin
dosage?
2. Considering his Hb A1c over what period his
glycaemic control is likely to be unsatisfactory?
3. When do you start screening for diabetic
retinopathy ?
4. What is the preferred method for screening for
diabetic retinopathy?

Answers 1
1. Increase
morning regular
insulin dose by 2
Units 1
2. 3 months
3. After 5 years in 1
prepubertal
children
after 2 years in 1
pubertal
children 1
4. Fundal
photography

D/D of polyuria and polydipsia

2. What is the preferred treatment and dose?
3. Give three alternative drugs for treatment.

Answers 1

1. Ventricular tachycardia
1
2. Cardioversion 0.5 to 1 joule/kg
3. Amiodarone 1

Procainamide 1
Lidocaine 1

Park: Pediatric Cardiology for Practitioners, 5th ed

How does SVT in children differ from physiologic
sinus tachycardia?
SVT typically has the following features:
Sudden onset and termination rather than a gradual
change in rate
Persistent ventricular rate of >180 bpm
Fixed or almost fixed RR interval on ECG
Abnormal P-wave shape or axis or absent P waves
Little change in heart rate with activity, crying, or
breath holding

Case
A 5 year girl is brought after accidental ingestion of
unquantified insecticide with salivation, lacrimation
and miosis

Questions
1. Name three muscarinic actions of OP poisoning
2. What is the specific antidote?

Answers
3
1. Increased oral and tracheal secretions, miosis,
salivation, lacrimation, urination, vomiting,
cramping, defecation, and bradycardia
2. Atropine
1

OP poisoning effects
Muscarinic effects:
Increased oral and tracheal secretions, miosis,
salivation, lacrimation, urination, vomiting, cramping,
defecation, and bradycardia; may progress to frank
pulmonary edema
Central nervous system effects:
Agitation, delirium, seizures, and/or coma
Nicotinic effects:
Sweating, muscle fasciculation, and, ultimately,
paralysis

Case
A 8 year old boy is admitted after consumtion of > 60
tablets of ferrous sulfate kept at home

Questions
1. Which stage of iron toxicity is free of any
symptoms?
2. What is the preferred method of gastrointestinal
decontamination in patients with iron overdose?
3. What is the antidote with dose?
4. What metal intoxication can mimic Kawasaki
disease?

Answers 1
1. Stage 2 (6-24 hours): Iron silently accumulates in
the mitochondria during this period, which is
relatively free of symptoms.
2. Whole-bowel irrigation
-Syrup of ipecac is no longer recommended, and activated charcoal will 1
not adsorb iron. Many adult-strength iron-containing pills are very large
and are often too large for orogastric lavage
3. Deferoxamine 1
Up to 15 mg/kg per hour via continuous IV infusion 1
4. Mercury
1
Acrodynia

Iron Toxicity Stages
Stage 1 (0.5-6 hours): During this stage, iron exhibits a direct
corrosive effect on the small bowel.
Symptoms include nausea, vomiting, abdominal pain, and/or
gastrointestinal hemorrhage.
Stage 2 (6-24 hours): Iron silently accumulates in the
mitochondria during this period, which is relatively free of
symptoms.
Stage 3 (4-40 hours): This phase is characterized by systemic
toxicity with shock, metabolic acidosis, depressed cardiac
function, and hepatic necrosis.
Stage 4 (2-8 weeks): During this phase, pyloric stenosis and
obstruction can develop as a result of earlier local bowel
irritation.

Disease
Present Absent

a b
Positive
Test
c d
Negative

•Sensitivity •Positive predictive value
• T(+)/ D(+) = a/a+c •D+/T+ = a/a+b

•Specificity •Negative predictive value
• T(-)/ D (-) = d/b+d • D-/ T- = d/ c+d

Case
Analyse the table below

Test Has disease No disease

Positive 90 10

Negative 10 90

1. Calculate sensitivity
2. Calculate specificity

Answer 1

1. Sensitivity 90% 1

2. Specificity 90%

Case Urine Pure
growth
Multiple
growth
microscopy

On auditing urine
growth, following >50 WBC 95 15
were the result
<50 WBC 10 200

1. Calcute positive predictive value of urine
microscopy
2. Calculate negative predictive value urine
microscopy

Answer 1

1. PPV 95/110

1
2. NPV 200/210

Case 8
A 13-year old boy develops right upper-quadrant pain
and fever with chills and rigors.
An abdominal ultrasound reveals
Hyperechoic liver parenchyma
Dilatation of several intrahepatic bile ducts
Few bilateral renal cysts.

Questions
1. What is the Diagnosis?
2. What is the cause of fever with chills in this case?
3. What are the components of this
disease/syndrome?
4. Which gene has been implicated for the above?

Answers 1

1. Caroli’s syndrome 1
2. Cholangitis 1
3. Intra-hepatic ductal ectasia
AR Polycystic kidney Disease 1

4. PKHD1 gene 1

Case9
A 3 year old boy a case of steroid sensitive nephrotic
syndrome in remission has been brought with
Periorbital puffiness
Proteinuria on dipstick evaluation at home

Questions
1. What are the components of nephrotic syndrome?
2. How do you define proteinuria of nephrotic range
on dipstick?
3. How do you define relapse?
4. What is the treatment of relapse?

Answers
1. Nephrotic Syndrome 0.5
 Heavy proteinuria 0.5
 Hypoalbuminemia
0.5
 Edema
 Hypercholesterolemia 0.5

Answers 1
2. Urine protein 3+/4+ (on dipstick)
3. Urine albumin 0.5
 3+ or 4+ (or proteinuria >40 mg/m2/h)
0.5
 for 3 consecutive early morning specimens
 having been in remission previously 0.5
0.5
2. Prednisolone
 2 mg/kg/day (single or divided doses) until urine protein is 0.5
trace or nil for 3 consecutive days
 Then 1.5 mg/kg on alternate days for 4 weeks
 Then discontinued 0.5
0.5

Case10
A 12 year old girl a case of chronic kidney disease due
to FSGS is evaluated in OPD for hypertension, poor
growth and dyslipidemia.

Questions
1. How do you determine GFR using serum creatinine with
Schwartz formula?
2. What is Stage II Chronic Kidney disease (CKD) in terms of
GFR?
3. State True/ False
a. Growth hormone is a mode of treatment for short stature due
to CKD.
b. Anemia in CKD is caused primarily due to loss of ferritin in
urine.
c. The most common form of renal osteodystrophy seen with
CKD is high turnover bone disease.

Answers
1. GFR(ml/min/1.73m2)
1
= k x Height (cm)
serum creatinine (mg/dL)
where k is
 0.33 for low-birthweight infants younger than 1 yr,
 0.45 for term AGA infants younger than 1 yr,
 0.55 for children and adolescent females
 and 0.70 for adolescent males

Answers 1
2. Stage 2 CKD: GFR 60-89 ml/kg/1.73m2
3. True/ False 1
a. True
Children with CKD who remain <2 SD for height despite optimal medical
support may benefir from rHuGH (0.05mg/kg/d)
b. False 1
Anemia is primarily the result of inadequate erythropoietin production
c. True
The most common finding in renal osteodystrophy is osteitis fibrosa cystica 1
(high turnover bone disease secondary to hyperparathyroidism)

Answers
2. Stage 2 CKD: GFR 60-89 ml/kg/1.73m2 1
3. True/ False
a. True 1
Children with CKD who remain <2 SD for height despite optimal medical
support may benefir from rHuGH (0.05mg/kg/d)
b. False
Anemia is primarily the result of inadequate erythropoietin production 1
c. True
The most common finding in renal osteodystrophy is osteitis fibrosa cystica
(high turnover bone disease secondary to hyperparathyroidism) 1

What are the main causes of chronic renal
disease in children that result in renal
transplantation?

Obstructive uropathy
Aplastic/hypoplastic/dysplastic kidneys
Focal segmental glomerulosclerosis

Questions
1. Define Time constant
2. Two conditions with increased time constant
3. Two conditions with decreased time constant

Answers
1

1.Time constant is the product of compliance and
resistance(amount of time required for proximal
airway pressure to equilibrate with alveolar pressure)
2.Asthma and bronchiolitis
3.Pneumonia and pulmonary edema 1

1

Nelson18th edition pg 1722

Questions
1. Mechanism of grunting
2. Significance of grunting
3. Helpful in which conditions (name two)

Answers 1

1. Produced by expiration against a partially closed
glottis expiration
1
2. Attempt to maintain positive airway pressure
during expiration for as long as possible.
3. Alveolar diseases(pneumonia/pulmonary
edema/HMD) and small airway 1
obstruction(bronchiolitis)

Nelson18th edition pg 1724

Questions
1. Significance of clubbing
2. Two thoracic causes of clubbing
3. Two extrathoracic causes of clubbing
4. Sign associated with clubbing

Answers 1

1. Chronic hypoxia 1
2. Small lung cancer and lung abscess
1
3. Cyanotic heart diseases and IBD
4. Schamroth’s sign 1

Case
The EEG record is from a 5 month infant who
episodically raises his arms and then flexes his neck,
trunk and hips. The episodes last a few seconds and
end with a brief cry and return to normal posture.
The episodes occur in quick succession with several
hours passing between each cluster of attacks.

Questions
1. What does the EEG show?
2. What syndrome is suggested by the history and
EEG?
3. Give one genodermatoses condition associated with
this syndrome.
4. What is the long term prognosis?

Answers 1
1. Hypsarrhythmia
 Large amplitude slow wave activity mixed with
multifocal spikes and sharp waves

Answers 1
2. Infantile spasms- West Syndrome 1
3. Tuberous Sclerosis
4. Treatment
1
 Unsatisfactory on most occasions
 AED`s Vigabatrin
Benzodiazepines
(Clonazepam/ Nitrazepam)
 Steroids/ ACTH

What is the classic triad of
infantile spasms?
Spasms, hypsarhythmia, and developmental
regression

Infantile spasms are known as West's syndrome, and
the condition is named for the physician who first
described the condition in his own son in 1841.

After what period can AEDs be
safely discontinued?
When the child is free of seizures for 2 years

Smith R, Ball R: Discontinuing anticonvulsant medication in children.
Arch Dis Child 87:259-260, 2002

Case 15
The examination of a newborn reveals a lump of soft
tissue of size of 50 paise coin overlying the lower
spine. There is no neurological deficit.

Questions?
2. What is likely risk of recurrence of disorder in
future pregnancies?
3. What intervention started at what time and for
how long, can reduce the risk of intervention?
4. What are the options for managing bladder
incontinence in this condition?

Answers dysraphism
1. Occult spinal
1

2. Risk of recurrence 1

One affected child 3-4%
Two affected Children 10%
3. Intervention Folic acid 400 mcg/d 1
Started Periconceptionally 0.5
(started before pregnancy)
Continued Till 12 wks of preg 0.5

Answers 2
4. Bladder incontinence management
 Clean intermittent catheterization
 Artificial urinary sphincter
 Surgical urinary diversion
 Augmentation cystoplasty

What is the likelihood that a patient with
myelomeningocele will have
hydrocephalus?

Hydrocephalus is seen in 95% of children with
thoracic or high lumbar myelomeningocele.

The incidence decreases progressively with more
caudal spinal defects to a minimum of 60% if the
myelomeningocele is located in the sacrum.

Case 16
A 6-month-old child was noted to be normal at birth,
but over the ensuing months you have been
somewhat concerned about his slowish weight gain
and his mild delay in achieving developmental
milestones.
The family calls you urgently at 7:00 A.M. noting that
their child seems unable to move the right side of his
body.

Questions?
1. Which of the following conditions might explain this child’s
condition?
a. Phenylketonuria
b. Homocystinuria
c. Cystathioninuria
d. Maple syrup urine disease
e. Histidinemia
1. Which one other systemic examination would you like to do?
2. What investigation would confirm the etiology?
3. What treatment would you institute as a long term measure?

Answers 1
1. Homocystinuria (b)
1
2. Eye (Ectopia lentis)
3. Elevated plasma levels for homocystine 1

4. Vitamin B6 (200-1,000 mg/24 hr) 1

Folic acid 1-5mg/24 hr
Vit B 12 (1-2 g/24hrs)

Match the following

Match the following sign/symptom with the expected
location of the lesion in the brain:

a. Deafferented pupil  Nystagmus.

b. Cerebellum  Tonic deviation of the eye(s).

c. Ipsilateral cortex  Marcus Gunn pupil.

d. Midbrain tectum  Horner’s syndrome.

e Pons  Midposition pupils

f. Cribriform plate of ethmoid  Pinpoint pupils
 Leakage of CSF from nose.

Answer
a. Deafferented pupil Marcus Gunn pupil
b. Cerebellum Nystagmus
c. Ipsilateral cortex Tonic deviation of the eye(s)
d. Midbrain tectum Midposition pupils
e. Pons Pinpoint pupils
f. Cribriform plate Leakage of CSF from nose

3 marks

Match the following
Thrombotic stroke.
a. Rete mirabile of Moyamoya.
b. Right-to-left cardiac shunt. Embolic stroke.
c. Arteriovenous
malformations. Intracerebral hemorrhage.

Answer
a. Rete mirabile of Thrombotic stroke
Moyamoya.
b. Right-to-left cardiac Embolic stroke
shunt.
c. Arteriovenous Intracerebral h`age
malformations.

Case19
A 4-year-old child is observed to hold his eyelids open
with his fingers and has drooping of eyes, especially in
the evening. He has some trouble swallowing his
food. He can throw a ball, and he runs well.
He undergoes EMG and is diagnosed as

MYASTHENIA GRAVIS

Questions?
1. What is the characteristic EMG in Myasthenia?
2. What is the chest X-ray finding in this condition?
3. What is the clinical test for diagnosing myasthenia?
4. Which antibiotics can worsen the condition?
5. What drugs are used for treatment?

Answers 1
1. Decremental response to repetitive stimulation
2. Enlarged thymus 1
3. Edrophonium test
1
4. Aminoglycosides
5. Neostigmine 0.4mg/kg PO 4-6 hrly 1
0.04mg/kg IM 4-6 hrly
0.5

0.5

Fleisher GR, Ludwig S (eds): Textbook of Pediatric Emergency Medicine, 3rd ed.

Case 20
Examination of the cerebrospinal fluid of an 8-year-
old, mildly febrile child with nuchal rigidity and
intermittent stupor for 3 weeks shows the following:
White blood cells 100/μL (all lymphocytes)
Negative Gram stain
Protein 750 mg/dL
Glucose 25 mg/dL

Questions?
1. What are the likely differential diagnosis?
2. What drugs can be used to reduce intracranial
tension?
3. Which cranial nerve is involved in false localizing
sign?

Answers 1
1. Tubercular/ Fungal meningitis 1
2. Mannitol, glycerol
1
3. Sixth cranial Nerve (Abducens)

Case 21
At birth, an infant is noted to have an abnormal
neurologic examination.
Over the next 1-2 weeks he develops severe
progressive central nervous system degeneration, an
enlarged liver and spleen, macroglossia, coarse facial
features, and a cherry-red spot in the eye.

Question
1. The laboratory finding likely to explain this child’s
problem is
a. Reduced serum hexosaminidase A activity
b. Deficient activity of acid beta-galactosidase
c. A defective gene on the X chromosome
d. Complete lack of acid alpha-galactosidase activity
e. Deficient activity of galactosyl-3-sulfate-ceramide sulfatase

Answers 1
1. Deficient activity of acid beta-galactosidase (b)
1
2. Type 1 GM1 gangliosidosis

22
For each description select the most likely diagnosis:

Clinical scenario
1. Eye blinking or throat-clearing noises
in an otherwise healthy 8-year old Diagnosis
boy
2. A 6-year-old boy with eye twitching a. Transient tic disorder of
and ecolalia childhood
3. A 2-year-old infant who was born
prematurely and is unable to walk or b. Tourette syndrome
talk c. Cerebral palsy
4. A 14-year-old girl with a history of
precocious puberty who now d. Tuberous sclerosis
develops a large goiter
e. McCune-Albright syndrome
5. An infant with infantile spasms, a
hypsarrhythmic EEG pattern, and
ash-leaf depigmentation on her back

Answer
1. Transient tic disorder of childhood
2. Tourette syndrome
3. Cerebral palsy
4. McCune-Albright syndrome
5. Tuberous sclerosis

Total 5 marks

Case scenario 23
16 year boy followed up in your clinic for several
years. His latest lung function tests are
FVC 85%
FEV1 57%
PEF 53%
FEV1/FVC 67%

Questions
1. Diagnosis
2. Which of the above measurement is best for
monitoring

List the possible acute side effects
of salbutamol
General: Hypoxemia, tachyphylaxis
Renal: Hypokalemia
Cardiovascular: Tachycardia, palpitations,
premature ventricular contractions, atrial fibrillation
Neurologic: Headache, irritability, insomnia, tremor,
weakness
Gastrointestinal: Nausea, heartburn, vomiting

What proportion of childhood asthmatics
"outgrow" their symptoms?
30-50%

Sears MR, Greene JM, Willan AR, et al: A longitudinal, population-based,
cohort study of childhood asthma followed to adulthood.
N Engl J Med 349:1414-1422, 2003.

Question 24
Below is diagram of lung volumes,what do the letters
A and B represent

Answer
A inspiratory reserve volume

B residual lung volume

Case No 28

7 years male c/o increasing weakness of all limbs x
3 days & URTI one week back
Examination
CNS
Bilateral facial nerve palsies
Power Grade 0 to 1 both legs; grade 3 arms
Loss of DTJ,No sensory deficit/ papilloedema
Abdomen
Palpable midline mass arising from pelvis
Other systems: Normal

Questions
2. Mention 3 investigations to clinch diagnosis.
3. What is the most sensitive measure of respiratory
muscle involvement?
4. Mention 3 modalities of treatment.
5. What is the midline mass, explain its significance
and how should it be managed?

Answers
1. Guillain-Barre Syndrome (1)
 The history points to a symmetrical motor
neuropathy without sensory nerve involvement.
 Muscle disorders should have normal DTJ
 Polio will cause asymmetrical weakness
 Spinal cord abnormalities will not cause facial
muscle weakness

Answers
2. CSF-protein cellular dissociation
NCV
EMG
(1.5)
3. The most sensitive measure of respiratory muscle involvement is (1)
VITAL CAPACITY
In children, the normal VC may be calculated as VC = 200 mL × age
in years. If the VC falls below 25% of normal, endotracheal intubation
is performed.
4. IVIG,Plasmapheresis,steroids (1.5)
5. Bladder distension due to ANS involvement (1)

Case No 30
A 2 years boy was unconscious for 1 min following head injury.

Although he is fully alert now there is bruising on the left side
of the head over the parietal bone.

Skull x-rays are performed and he is admitted for neurological
observations.

Questions
1. What clinical features would suggest requirement
of CT skull and/ or neurosurgical opinion?
2. What non-surgical temporary measures can be
used to reduce raised intracranial pressure?
3. What advice needs to be given to parents if after 24
h the child has remained well and is ready for
discharge?

Answers
1. Neurosurgical Opinion/ CT skull
a. Deteriorating level of consciousness
b. Focal neurological signs
c. Depressed Skull fracture
d. Basal Skull fracture
e. Seizures
f. CSF leak
g. Signs of Raised ICT (2)

Answers
2. Temporary manoeuvres to reduce raised ICT
 Nursing in a 30 degrees head up position
 Diuretics (Mannitol)
 Hypertonic saline
 Artificial hyperventilation
(2)

Answers
3. At discharge it should be stressed that child should
be brought back if he develops any of following:
 Vomiting
 Drowsy/ altered sensorium
 Blurred/ double vision
 Seizures (2)

CASE SCENARIO
7 year old girl presents with high irregular fever
for 3 weeks, each episode associated with
erythematous rashes over the trunk and
proximal extremities, pain and swelling of Rt
knee and easy fatigability. Has leucocytosis,
raised ESR, normal chest skiagram and
negative Mx.
1. Give most probable diagnosis.
2. List other expected systemic clinical findings
3. Give value of serology in diagnosis
4. Outline steps in management
5. List prognostic factors

1. JRA – Systemic 0.5
2. Systemic exam findings
a. Hepato – splenomegaly 0.5
b. Lymphadenopathy 0.5
c. Serous cavity effusions 0.5
3. Serology
a. ANA - Negative 0.5
b. RF - Negative 0.5
4. Management
a. “Pyramid” approach – NSAIDS, chloroquine, 1.0
methotrexate,azothiaprine/cyclophosphamide.
b. Steroids 0.5
c. TNF-alpha receptor antagonists 0.5
5. Number and severity of joint involvement 1.0
(Total Marks 6.0)

This patient becomes ill with thrombocytopenia,
profound anemia, and markedly elevated transaminases
probably has what complication?
Macrophage activation syndrome

CASE Scenario
12 yr old boy, case of Haemophilia A, is
admitted with spontaneous haemarthrosis.

1. What is the level of factor VIII ?
2. Factor VIII in treatment.
a. Level of factor VIII to be achieved
b. Dose of factor VIII
3. The patient has to undergo major surgery
a. Level of factor VIII to be achieved
b. Dose of factor VIII
4. What are the other precautions?
5. What is the role of DDAVP in haemophilia A ?

1. <1% 0.5
2. Factor VIII in treatment
a. 35-40% 1.0
b. 20 units/kg, repeat daily if required 1.0
till joint normalises
3. Dose in major surgery
a. 100% 1.0
b. 50 units/kg, infuse 2-3 units/kg/hr to 1.0
maintain level at 100%for 24 hrs
and then >50% for 7 days
4. Precautions
a. Avoid Anti-inflammatory drugs with anti-platelet 0.5
action
b. Screen for Transfusion transmitted diseases if 0.5
plasma products are used
4. Desmopressin Acetate: Release of factor VIII in mild
cases 0.5
(Total marks 6.0)

CASE Scenario
A 7 yr old girl with strong family history of
chronic fatal liver disease presents with features of
haemolysis.
1. List one clinical examination which may give the
diagnosis
2.State most probable group of aetiology based on answer
to question ‘1’
3.List three most important tests for diagnosis with
values
4.Outline the management of this child

1. Kayser-Fleischer rings 0.5
2. Wilson disease 0.5
3. Diagnostic tests
a.Serum ceruloplasmin 0.5
< 200 mg/lit 0.5
b. Urinary copper 0.5
>100 microgram/day 0.5
c. Hepatic copper 0.5
>250 microgram/gm of dry weight 0.5
1. Management
a. Restrict copper intake 0.5
b. Chelation with penicillamine 0.5
c. B6 supplementation 0.5
d. Liver transplant
0.5
(Total marks 6.0)

Identify the instrument.
Which illness is it used in ?
What are the three settings ?

Peak Flow Meter
Bronchial Asthma

1. Green zone >80% Peak Exp Flow
2. Yellow Zone 50-80 % PEF
3. Red zone < 50% PEF

Total 3 marks

Which class does this
antibiotic belong to ?
What is the spectrum?
What is the dosage?
What is the imp clinical
use?
4 marks

Oxazolidinones
Gram-positive organisms including MRSA
Penicillin-resistant pneumococci
Gram-negative anaerobes
Mycobacteria
10mg/kg/dose 8 hrly
Multiresistant gram-positive organisms, including
MRSA who have failed to respond to
vancomycin.

Indications for use of this
compound?
what is the dose?
What are the indications
When should it be started?
What are the side effects of
parenteral nutrition?
4 marks

Parental nutrition
Dose 0.5 -3.5 g/kg/day
When enteral nutrition is insufficient or contra-
indicated.
Day 1
Dyselectronemia, cholestasis, bacterial or fungal
colonisation and sepsis, thrombosis, azotemia,
thrombocytopenia

Identify the
product?
What are the
advantages of its
use?
Enumerate five
complications?

PICC 1
Preserves veins, allows concentrated infusates, permits long term IV
alimentation
1
6 complications- 3
Catheter fracture and embolisation,
Leakage
 Thrombosis of catheter
Accidental displacement / Tip Migration
Deep Venous Thrombosis
Infection

What is the equipment ?

Identify the parts.
Enumerate indications for its
use.
What are the contra-
indications?
How do you sterilise it?

5 marks

Self inflating 250 ml ambu bag 1
Oxygen , air inlet , pt outlet, valve assembly, oxygen reservoir
and pressure release valve. 1

Gasping/apneic infant, cyanosis inspite of free flow oxygen and
HR<100/m 30secs after initial steps.
1
MSAF and suspected cong diaph hernia 1
 Wash with detergent and hot water. Dry thoroughly. If visibly
soiled with blood/body fluids, clean and send to Central
Sterilization Dept 1

Identify the product?
What are the indications for use?

Enumerate three precautions ?

 Surfactant 0.5
 4ml/kg 0.5
 Surfactant replacement therapy for prevention and treatment of RDS
in preterms, 0.5

 Survanta should not be removed from the refrigerator for more than
24 hours and it should not be warmed and returned to the refrigerator
more than once.
 Do not suction the infant for 1 hour after dosing unless signs of
significant airway obstruction occur.
 Marked improvements in oxygenation and decrease in lung
compliance may occur within minutes of administration of
SURVANTA. Therefore, frequent and careful clinical observation and
monitoring.
 Donot shake the vial 1.5

What is the equipment?
What are the indications of its
use?
What are the advantages?

Double lumen endotracheal tube 1

For surfactant instillation 1
To aid lung lavage

Permits efficient drug instillation without
interrupting ventilation 1

Identify the equipment
Indications for usage
Complications (mention any three)

 Bubble CPAP apparatus 1
 Indications - 2
• If FiO2 requirement is > 0.3
• SA Score > 4
• ABG Score > 3 on oxygen therapy
• Frequent apnea with documented hypoxemia
• Clinically significant chest retractions after extubation from
mechanical ventilation
• Complications 1
• Air leak
• Reduced venous return
• IVH

Which class does this
antibiotic belong to ?
What is the spectrum?
What is the two imp side
effects?

Carbapenems
Widest spectrum of antimicrobial activity among the
β-lactam antibiotics against both gm-ve and gm +
organisms except MRSA.
20 - 40mg/kg/dose 12hrly
Transient agranulocytosis, thrombocytopenia.
Seizures

2 marks

ABG1
pH 7.28

PaCO254mmHg

PaO2 45mmHg

HCO3 29mEq/L

Base excess +7

What are the-

Abnormalities? 1

Diagnosis? 1

Likely causes? 1

Low pH, high PaCO2, low PaO2, high HCO3

Uncompensated respiratory acidosis with hypoxemia

RESPIRATORY FAILURE (pneumonia, RDS)

ABG 2
pH 7.57
PaCO2 22mmHg
PaO2 156mmHg
HCO3 18mEq/L
Base excess -8

What are the-
Abnormalities? 1
Diagnosis? 1
Likely cause? 1

High pH, low PaCO2, high PaO2, low HCO3

UNCOMPENSATED RESPIRATORY ALKALOSIS
WITH HYPEROXIA

Hyperventilation with high FiO2

ABG 3
 pH 7.32
 PaCO2 30mmHg

 PaO2 70mmHg

 HCO3 12mEq/L
 Base excess -8

QUESTIONS
 ABNORMALITIES 1
 DIAGNOSIS 1

 LIKELY CAUSES 1

• Low pH, low PaCO2, normal PaO2, low HCO3
• UNCOMPENSATED METABOLIC ACIDOSIS
• SHOCK, RENAL FAILURE

ABG 4
 pH 7.60
 PaCO2 21mmHg

 PaO2 65mmHg

 HCO3 24mEq/L
 Base excess +2

QUESTIONS
 ABNORMALITIES 1

 DIAGNOSIS 1

 LIKELY CAUSES 1

High pH, low PaCO2, normal PaO2, normal HCO3
UNCOMPENSATED RESPIRATORY ALKALOSIS

HYPERVENTILATION (BRONCHIAL ASTHMA)

ABG 5
 pH 7.36
 PaCO2 70mmHg

 PaO2 75mmHg

 HCO3 35mEq/L
 Base excess +14

Low pH, high PaCO2, normal PaO2, high HCO3

COMPENSATED RESPIRATORY ACIDOSIS

VENTILATED INFANT WITH TUBE BLOCK

ABG 6
 pH 7.52
 PaCO2 47mmHg

 PaO2 80mmHg

 HCO3 30mEq/L
 Base excess +3

High pH, high PaCO2, normal PaO2, high HCO3

UNCOMPENSATED METABOLIC ALKALOSIS

VOMITING, PYLORIC STENOSIS

ABG 7
 pH 7.14
 PaCO2 54mmHg

 PaO2 55mmHg

 HCO3 14 mEq/L
 Base excess -7

QUESTIONS
 ABNORMALITIES 1
 DIAGNOSIS 1
 LIKELY CAUSES 1

 Low pH, high PaCO2, normal PaO2, low HCO3

 UNCOMPENSATED RESPIRATORY AND METABOLIC
ACIDOSIS

 INFANT ON VENTILATOR WITH TUBE BLOCK &
SHOCK

Describe the
lesion.
What is the DD ?

Brain Stem cell glioma,

1 mark

Observed Station 1
DRUG COUNSELLING

4 yr old boy weighing 15 Kg , diagnosed as Nephrotic
Syndrome to be started on steroids.

1. Introduces self/ puts the child
and attendant at ease. 0.5
2. Explains the disease in simple words 0.5
3. Explains the medication
 Dose 0.5
 Frequency 0.5
 Relationship with meals 0.5
4. Explains side effects
 GIT 0.5
 Steroid effect 0.5
5. Explains monitoring of response
 Urinary output 0.5
 Body weight 0.5
6. Asks for queries if any. 0.5
7. Advises to report back if any problems. 0.5
8. Advises about pain abdomen 0.5
(Total marks 6.0)

Observed Station 2
DRUG COUNSELING

A 8yr old boy, weighing 30 kg, diagnosed as DM Type
I requires 30 units insulin/day,
in two divided doses ,combining short and
intermediate acting insulins.
Counsel regarding administration.

1.Introduces self & puts child and 0.5
attendant at ease.
2. Explains the problem in brief. 0.5
3. Familiarizes the attendant with the injectables 0.5
and the syringes.
4. Explains dose, time of injection and relationship 2.0
with meals, sites, route and rotation of sites
5. Explains the calculation of dose in ml. 1.0
6. Explains the sequence of loading (regular first). 0.5
7. Briefs about hypoglycemia incl mgt. 0.5
8. Inquires about any doubts and advises to report 0.5 back in
case of any problems.
(Dose – 2/3rd before breakfast,1/3rd before dinner)
(Ratio intermediate /regular 2:1/3:1)
(Total marks 6.0)

Observed Station 3
COUNSELING

24 yr old lady diagnosed as HIV + at 36 weeks of gestation.
Counsel regarding perinatal transmission and follow up.

1. Ensures the presence of husband 0.5
2. Introduces self/ puts the couple at ease. 0.5
3. Explains the disease in simple words 0.5
4. Explains the incidence and modes of perinatal
transmission
20-30% 0.5
Prenatal 0.5
Intranatal 0.5
Breast feeding 0.5
5. Explains modalities of reducing rate of transmission
ART to mother and child 1.0
LSCS Vs Vaginal delivery 1.0
Breast feeding Vs top feeding 1.0
6. Explains effect of measures – reduction by 50% 1.0
7. Explains screening of the infant 0.5
8. Explains safety of cuddling, petting and kissing 1.0
9. Asks for queries if any. 0.5
10. Advises to report back if any problems. 0.5

(Total marks 10.0)

Observed Station 4
Drug Counseling
4 yr old child (15Kg) ,a case of gen tonic-clonic
seizures has been advised syr carbamezapine (100
mg/5ml).Counsel the mother regarding
administration.

1. Introduces self & puts child and 0.5
attendant at ease.
3. Familiarizes the attendant with the drug 0.5
and dispenser
4. Explains dose(75 mg-3.5 ml), in 3 divided 0.5 doses
5. Advises not to miss the dose 0.5
6. Increase to (150 mg – 7.5 ml) 0.5
7. Explains side effects 1.0
8. Calls for blood counts weekly 0.5
9. Calls for serum levels of the drug 1.0
10. Advises to report in case of doubt 0.5
(Total marks 6.0)

Observed Station 5
DRUG COUNSELING

2 yr old child weighing 10 Kg is being discharged after
admission for febrile seizure. Counsel the mother regarding
domiciliary management of seizure with rectal diazepam.

1. Introduces self & puts child and 0.5
attendant at ease.
3. Familiarizes the attendant with the drug, 0.5
the syringe and the catheter.
4. Explains dose(3mg), and loading of the syringe 0.5
5. Explains the position of the child (lateral) 0.5
6. Explains introduction of the catheter (lubrication, 1.0
and length of introduction)
7. Explains pushing the drug 0.5
8. Advises pinching of the buttocks together after 1.0
9. Withdrawing the catheter)
10. Advises one repetition after 15 mts 0.5
11. Explains side effects 0.5

(Total marks 6.0)

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