OSCE in Pediatrics (March 4th 2008, Sir Ganga Ram Hospital)

1. OSCE
4 March-08
th
Center For Child Health
Sir Ganga Ram Hospital

2. Spot 1
10 yr old male
child presented
with multiple
cranial nerve
palsies of 2 wks
duration. MRI
done is shown
here
• Spot the diagnosis with type
• Views of picture A and B and what does
the MRI depicts
• Early important clinical clue for
hydrocephalus after 1st month of life

3. • Severe communicating hydrocephalus
• Contrast-enhanced axial (A) and coronal
(B) T1- weighted MR images depict
diffuse leptomeningeal enhancement in
the basal cistern. Strong enhancement
of the bilateral thickened third nerves
(arrowheads in A)
• Open squamo parietal suture beyond
first month of life

4. Spot 2
Prematurely (28 wks)
born SGA baby,
ventilated for 18 days,
hemodynamically was
unstable and had
neonatal seizures. USG
cranium done at 6 wks of
age is shown here…
• Name the investigation with view
• Spot the diagnosis with grade
• Significance of the diagnosis and
intervention
• Protective antenatal factors

5. • Sonogram cranium (coronal view)
showing cystic periventricular
leukomalacia
• Cystic Periventricular Leukomalacia,
Grade III (De Veries classification)
• C-PVL strongest indicator of cerebral
palsy, especially spastic diplegia so
palsy
early stimulation programme with
occupational therapy
• Antenatal steroids and Anemia

6. Spot 3
3 yr old male child from Utter
Pradesh admitted with high
grade fever x 4-5 days and
generalized seizures for 1 day.
There were (B/L)6th and 7th CN
palsy with dystonias. Similar
cases are being reported from
the same area. His most
important investigation is given
here….
Name of the investigation and identify the Spot
Main transmitter to man
Subclinical cases, what %
Preventive strategy

7. • T2-weighted MRI of the brain
showing Panda sign
• Female Culex mosquito (Culex
tritanirhynchus and Vishnui)
Vishnui
• 99% cases are sub clinical
• Vaccine in the inter epidemic
period and Fogging with
malathion sprayed in 3 km range
from the infected cases

8. Spot 4
EEG of a 60 hrs old
newborn who required
resuscitation at Birth
with a 5 minute APGAR
of 5. Child had seizures
in first 12 hrs of life
Identify the spot
Its significance
Name of the staging system other than Sarnat and Sarnat
and give its component

9. • EEG showing Burst Suppression
pattern
• It indicates serious outcome in HIE
patients
• Levene’s staging system (Mild,
Moderate and Severe)
– Consciousness
– Tone
– Seizures
– Sucking/Respiration

10. Spot 5
11 yrs old male child
admitted with slurring of
speech, ataxia and
dystonias. On inv.he found
to have renal tubular
acidosis and active rickets.
Give the most possible diagnosis
Pattern of inheritance
Most specific investigation
Specific treatment and advise to family
members

11. • Wilson disease with lenticular
degeneration
• Autosomal recessive
• Hepatic copper content (µg/gm dry wt. of
liver- it exceeds >250 µg/gm dry wt.)
• D-Penicillamine with Pyridoxine and Zinc
and all family members should be screen
with slit lamp examination

12. Spot 6 4 yrs old male child
brought with a history of
developmental delay. He
found to have mild
mental retardation and
Sensory neuropathy. He
is from low SE group
and his father is a
laborer. X-ray is shown
here…..
Most probable diagnosis
Treatment options
Indication for treatment
Urine investigation

13. • Lead posioning
• CaNa2EDTA (Calcium Versanate) and BAL
in symptomatic child
• If lead levels >45 µgm% (N <10 µgm%)
• Urine – Increased Zinc protoporphyrin

14. Spot 7 6 yrs old male child
presented with seizures,
delayed development, some
problem in vision and
fainting attack which are
not due to seizures. He had
myoclonic seizures during
the infancy. His only clinical
finding is given here
Possible diagnosis and spot the arrowed structure
Pattern of inheritance
Investigation you would ask for and what do you expect
One eye finding
Treatment of choice for seizures and its important ocular
S?E

15. • Tuberous Sclerosis, Ash leaf
Sclerosis
macule
• Autosomal Dominant trait
• CT head for subependymal nodes
• Retinal hamartoma
• Vigabatrin and loss of peripheral
vision

16. Spot 8
• Identify the Spot
• Main Uses
• Normal test indicates what?

17. • BERA- Brainstem Evoked
BERA
Response Audiometry
• Post meningitis/Bilirubin induced
neurotoxity
• Normal test – normal retro
cochlear nervous pathway

18. Spot 9
Six days after undergoing liver
transplantation, a 12 yr old patient's levels
of gamma-glutamyl transferase (GGT),
alkaline phosphatase, and bilirubin begin
to rise.
•Which is the most appropriate next step
in diagnosis?
•What if kidneys were transplanted and
BUN/Cr used to be increased and why?

19. • Ultrasound of biliary tract and Doppler studies of the
anastomosed vessels
• In all other solid organ transplants, deterioration of
function 5-6 days out would suggest an acute
rejection episode, and appropriate biopsies would
be done to confirm the diagnosis.
In the case of the liver, however, antigenic reactions
liver
are less common, whereas technical problems with
the biliary and vascular anastomosis are the most
common cause of early functional deterioration.

20. Spot 10
A 3-year old boy presented with FTT. The
child was apparently fine for the first
couple of years. He began to have
diarrhea with light colored stools. Although
stool examinations were performed, it was
unclear what the report is. The child was
placed on a high protein, high calorie diet
with vitamins and supplements. However,
he showed very little improvement over a
•Identify the spot
4 month period. Barium exam showed
"large dilated loops of hypotonic bowel"), •Best diagnostic
the child was admitted with a diagnosis of possibility
celiac disease. Stool examinations has
•Treatment ?
shown in the picture

21. • This image contains a Giardia lamblia
trophozoite
• Three stool examinations on altrenate
days detects around 90%
• Metronidazole is the treatment of
Choice x 5 days and Others are
Albendazole, Furazolidine

22. Spot 11
• A 13-year-old, obese boy complains of persistent knee pain
for several weeks. The family brings him in because he has
been limping. He sits in the examining table with the sole of
limping
the foot on the affected side pointing to the other leg.
Physical examination is normal for the knee, but shows
limited hip motion. As the hip is flexed, the leg goes into
motion
external rotation and cannot be rotated internally.
internally
Which of the following is the
most likely diagnosis?

23. • Slipped capital femoral epiphysis is an
orthopedic emergency.
– The clinical picture is classic: a chubby male
in his early teens who is limping and cannot
rotate his leg internally.

24. Spot 12
• A 14-year-old boy dives into the shallow end of a
swimming pool and hits his head against the
bottom. When he is rescued, he shows a complete
lack of neurologic function below the neck. He is
neck
still breathing on his own, but he cannot move or
own
feel his arms and legs. The paramedics carefully
legs
immobilize his neck for transportation to the
hospital, and they alert the emergency department
to his impending arrival.
– Once there, which treatment would most likely have an
immediate benefit for this patient? (other than ABC)

25. • There is some evidence that high-
dose corticosteroids administered as
soon as possible after the injury will
result in a better ultimate outcome

26. Spot 13
• 8 yrs old child resident of Delhi is admitted with
fever x 5-6 days, loss of appetite x 6 days and
hepato splenomegaly. His peripheral smear is
shown above
– Spot the picture (name the form of parasite)
– Name of the culture media
– Drugs used to treat resistant cases

27. • Kala Azar (LD bodies-Amastigote form,
form
non flagelated form)
• NNN media (Novy, MacNeil & Nicolle)
• AMB, Pentamidine, Aminosidine,
Miltefosine, Recombinant INF gamma,
Allopurinol and adjunct splenectomy

28. Spot 14
2 month old male, "fussy", diarrhea and vomiting;
flatulence. Breast-fed. He had Viral gastroenteritis
10 days previously. Before the infection, mother's
milk was well tolerated. Body weight within normal
limits. Moderately dehydrated. Urine shows
presence of reducing sugars. No reaction for
glucose. You make a diagnosis of lactose
intolerance and start him on reduced lactose diet..
• Indications for changing diet in case
of non or poor response
• What are diet A, B and C

29. • Indications
– Stool frequency >10 watery stool/day even
after 48 hrs of starting diet
– Return of the signs of dehydration any time
after staring diet
– Failure to establish wt,gain by 7th day of
dietary management
• Types of diet
– Diet A (reduced lactose)
– Diet B (lactose free)
– Diet C (Monosaccharide diet)

30. Spot 15
2 yr old male child presented with diarrhea of 3 wks
duration with failure to thrive. He was started with
nutrition rich feeds (Simyl-MCT drops, HMF
sachet and pedia sure) and antibiotics at a
sure
peripheral health center 7 fays back. Since then
diarrhoea has even increased and patient is
loosing weight. He was Moderately dehydrated at
admission. His daily stool output comes around
185 ml and his stool Na+ 42 mEq/L and K+ 3.8
mEq/L. Sister didn’t sent the stool pH and
mEq/L
reducing substance.
What is the diagnosis based on these investigations
Calculate the osmotic Gap
What is the treatment next

31. • Chronic diarrhoea (Secondary
lactose intolerance- Osmotic
diarrhoea)
diarrhoea
• Osmotic Gap : 290-(2 x Stool Na+K)
If Gap >100 its osmotic diarrhoea
• Remove the osmotic load from the
diet and stop feeding for 24 hrs and
then restart the lactose free diet
without adding any nutritional stuff

32. http://groups.yahoo.com/group/PediatricsDNB/
Theory: http://dnbpediatricstheory.blogspot.in/
OSCE: http://oscepediatrics.blogspot.in/
Clinical: http://clinicalpediatrics.blogspot.in/
Practicals: http://practicalpediatrics.blogspot.in/
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