BANGALORE BAPTIST HOSPITAL DEPARTMENT OF PEDIATRICSPEDIATRICS OSCE WORKSHOP 3/9/11 ANSWERS TO OSCEs
OSCE STATION - VACCINEIn a primary health centre monthly requirement of DPT is 280 doses. Lead time (timebetween ordering of new stock and its receipt) is 1 week. a. Calculate what should be the buffer stock 1 b. What should be the minimum stock level (reorder level)? 2 c. What is the maximum stock level? 2Buffer stock serves as cushion or buffer against emergencies, major fluctuations in vaccinedemands or unexpected transport delays. (25% of monthly requirment for vaccines and 10%of monthly requirement for syringes). DPT buffer stock should be 25% of 280 = 70Minimum stock level (reorder level) is the the least amount you should have in stock, usuallyexpressed as weeks/ months of supply. It is the amount of stock you will have between placingand receiving an order plus the buffer stock. Since lead time is 1 week, the minimum stockshould be 1 week requirement i,e 280 devided by 4 = 70. Buffer stock is 70. So, minimum stocklevel is 70+ 70 = 140.Maximum stock level is largest amount of stock you should have, usually expressed as weeks/months supply. It is minimum stock plus amount of stock used between orders. 140 + 3 weeksstock of 210 doses. (1 week stock is 280 divided by 4 = 70. So 3 weeks stock is 70 multiplied by3 = 210.).Maximum stock = 210 + 140 = 350 doses.
OSCE STATION – X RAYS1.a. What is the diagnosis? 1b. What is this sign called? 1c. What are the structures that cause this appearance in this condition? 0.5a. Total anomalous pulmonary venous drainage- supracardiac typeb. Snow man appearance, figure of 8 appearance c. Cardiomegaly with increased vascular markings Dilatation of both the left and right innominate veins and right SVC producing theclassical snow man or figure of 8 appearance Superior mediastinum is enlarged secondary to right venacava, innominate artery andascending vertical vein.
2.a. Describe the findings on the spine 1b. Name the disease where this is seen 1c Name 2 other skeletal complications of this condition. 0.5a. Infarction affecting the central part of the vertebrae (fed by a spinal artery branch) resultsin the characteristic h vertebrae of sickle cell disease. The outer portions of the plates arespared because of the numerous apophyseal arteries. The lateral cxr shows multiple vertebralend-plate irregularities and depressions. The peripheral portions of the end-plates are spared.The appearance is due to bone infarction and subsequent collapse. This is an early example ofthe classical h-shaped vertebrae seen in sickle-cell anaemia.b. Sickle cell anemia (also seen in Gauchers disease)c. Dactylitis, avascular necrosis of femoral head and humerus, osteomyelitis
OSCE STATION - KARYOTYPE1. a. Identify the karyotype. 1 b. What is the basic genetic defect? 0.5 c. List four clinical features of the same. 1 a. Fragile X syndrome b. 200-2000 repeats of CGG/CCG on fragile site of distal long arm of chromosome X c. Mental retardation, macro-orchidism, long face, prominent jaw, stereotyped speech and behaviour.
2.a. Identify the karyotype 1b. What is the basic genetic defect? 0.5c. List four clinical features. 1 a. Cri-du-chat syndrome b. 5p deletion c. Characteristic cry, hypotonia, microcephaly with prominent metopic suture, hypertelorism, bilateral epicanthic folds, high arched palate, flat nasal bridge, short stature and mental retardation.
OSCE STATION- AUDIOGRAM1. a What is the study? b. Interpret the same. c. Give two conditions for the same. a. Audiogram 1 b. Bilateral conductive deafness 1 c. Ear wax, otitis media 0.5
2.a. Interpret the study. b. Give two conditions for the same a. Bilateral sensorineural deafness 1.5 b. CMV, congenital rubella syndrome, ototoxic drugs 1
OSCE STATION- INTRAOSSEOUS NEEDLE INSERTIONDemonstrate the procedure and verbalize the samePretends to wash hands and follows universal precautions- 0.5Paints and drapes the leg and places it in slight external rotation 0.5Identifies the tibial tuberosity and locates the site one finger breadth below and medial to it0.5Stabilizes the leg at the knee joint and does not place the hand below the leg 0.5Holds the needle like a knife and inserts the needle perpendicular to the tibia in a twistingmanner 0.5Continues to insert the needle till there is a give way feeling once in the marrow space 0.5Needle is steady once in the marrow space 0.5Aspirates the marrow and flushes with a small volume of saline and makes sure there is noswelling of soft tissues 0.5Fixes the needle and connects IV fluid 0.5Verbalizes the whole procedure 0.5
OSCE STATION- CLINICAL EXAMINATIONExamine the motor system of the child excluding reflexesFindings will be documented in the next stationMeasures bulk in all the areas 1Examines tone 2Examines power in all four limbs 2Examines gait 1
OSCE STATION- DOCUMENTATION OF CLINICAL FINDINGSDocument the findings of motor system excluding reflexesPosture 1Bulk 1Tone 1Power 2Gait 1
OSCE STATION- SLIDES a. Identify the slide 1.5 b. Mention the clinical condition concerned with the same 0.5 c. Mention the drugs used to treat the same. 0.5 a. Bone marrow smear showing Leishmania donovani b. Kala Azar/ Leishmaniasis c. Sodium stilbogluconate, pentamidine
2. a. Identify the slide 1.5 b. Mention the clinical condition concerned 0.5 c. Mention two complications of the same 0.5 a. Corynebacterium diphtheriae b. Diphtheria c. Toxic myocarditis, toxic neuritis, air way obstruction
OSCE STATION- CASE SCENARIOA father brings his 5 year old son Raju to OPD concerned that he is hyperactive. Past historyshows that he was treated for iron deficiency anaemia with 5mg/kg/day elemental iron for 3months an year back. He has also been treated at home for stomach pains and constipationwith a laxative. His sister has been diagnosed with ADHD and is repeating Std 1. Father hasan automobile repair shop and mother is a housewife and is 3 months pregnant. Onexamination, Raju is in the 10th percentile for height and weight. His attention span is veryshort and he has difficulty following simple instructions. Except for the slightly delayedlanguage and social skills, Raju has reached most important developmental milestones.a) What is the diagnosis? 1 Lead poisoningb) What test would you order to confirm or rule out your diagnosis? 0.5 Venous blood lead levelsc) Which family member is at greatest risk? 0.5 The unborn babyd) Name two drugs used for treatment 0.5 Calcium disodium EDTA BAL(dimercaprol) D-penicillamine Succimer(DMSA)
OSCE STATION- CASE SCENARIOSoumya is 4 months pregnant with her first child. Her 15 year old brother Jai began to havedifficulty in climbing stairs at 4 years of age. He is now confined to a wheelchair. All otherfamily members including Sowmya are normal. She is worried that her child may be affected.a. What is the most likely clinical diagnosis? Duchennes muscular dystrophy 1b. What is the inheritance pattern? 0.5 X linked recessivec. What are the chances that Sowmya could be affected with the same diasease? 0 %. She will be a carrier. 0.5d. What would you recommend for antenatal diagnosis? 0.5 Chorionic villi sampling by 12 weeks of gestation for DNA analysis
OSCE STATION- CLINICAL PHOTOGRAPH1. 1. a. Identify the rash 1 b. Name the clinical condition in which it is seen. 1 a. Erythema marginatum b. Rheumatic fever
OSCE STATION- CLINICAL PHOTOGRAPH2.a. Identify the clinical condition. 1.5 Beckwith Wiedemann syndrome.b. What are the physical findings? 1 Hemihypertrophy, macroglossia, omphalocoele, macrosomia, visceromegalyc. What is the metabolic abnormality? 0.5 Hyperinsulinemic hypoglycemia.
OSCE STATION- PEDIGREE1. a. Identify the inheritance pattern 1.5 Autosomal dominant inheritance b. Mention four clinical conditions with the same inheritance 1 Neurofibromatosis type-1, Von Willebrands disease, Autosomal dominant polycystic kidney, Hereditay spherocytosis
2. a. Identify the inheritance 1.5 Mitochondrial inheritance b. Mention two clinical conditions with the same inheritance 1 Lebers hereditary optic atrophy Kerans Sayers disease
OSCE STATION - ECG1. a. Identify the ECG rhythm 1 Sinus tachycardia b. Write the points in favour of your diagnosis. 0.5 HR 170 beats/min Presence of P waves preceding ORS narrow QRS<0.8 sec
OSCE STATION2.a. Identify the ECG rhythm1b. Write the points in favour of your diagnosis.0.5 a. Supra ventricular tachycardia b. HR 300 beats/min Absence of P waves Narrow QRS<0.8
3.a. What is the diagnosis? 1 Hyperkalemia b. Mention the drugs used to treat this condition. 1 Inj.Calcium glucaonate 10/% Inj Sodium bicarbonate Salbutamol nebulization Glucose insulin drip
OSCE STATION-ULTRASOUND1. a. What is the clinical diagnosis? 1.5 Intaventricular hemorrhage b. Mention four causes for the same Prematurity- germinal matrix bleed Haemorrhagiic disease of the newborn Neonatal ITP Trauma/ Child abuse 1
2.a. What is the diagnosis? 1.5 Congenital hypertrophic pyloric stenosisb. What is the electrolyte imbalance seen? 1 Hypochloremic metabolic alkalosis
OSCE STATION- ASTHMA COUNSELING9 year old Arun has been diagnosed with bronchial asthma. His mother has been explainedabout the chronic nature of the illness and treatment options. She is anxious about themeasures she can take at home to prevent recurrent attacks. In the next 5 minutes talk toArun’s mother about “PREVENTION and ELIMINATION OF TRIGGERS AT HOME”You are being observed by the examiner for health education and communication skills.MotherWhat precautions should I take at home to prevent my child from getting recurrent attacks?EXAMINER CHECKLIST (maximum 3 marks for 6 and above)SKILL1. Bed room to be kept clean and dust free2. Wet mopping preferable to dry mopping3. Light plain curtains, bed sheets easily washable ones in child’s bedroom (to be washed inhot water)4. Regular dusting of calendars and paintings and books when child not at home5. Keeping animal pets like dogs and cats away from the child’s bed room6. Smoking to be avoided at home7. Strong and pungent odours like wet paint, disinfectants minimized8. Windows to be kept open when strong smells of cooking or smoke at home9. Windows to be closed when outside air is very much polluted or full of pollen from flowers and trees10. Avoid very cold foodsATTITUDE (0.5 mark each)1. INTRODUCTION TO THE MOTHER2. MANNER OF THE STUDENT IS GENTLE WITH THE MOTHER3. EXPLANATION TO THE M0THER IS CLEAR AND ORGANISED4. TAKES FEEDBACK FROM THE MOTEHR TO BE SURE IF SHE HAS UNDERSTOOD
OSCE STATION- ORDER SHEETMehul, one year old child weighing 10 kg is admitted with loose stools and vomiting with noobvious signs of dehydration. His serum sodium is 160 meq/l and serum potassium is3.5 meq/l.Urine output is adequate. a. Calculate the free water deficit 2 FWD = 0.6 x wt x (1 - 145/current sodium) = 560 ml b. Write the fluid orders for this child. 3 Hypernatremia should be corrected over 48 hours Serum sodium should be monitored serially Fluid order for each day= maintenance fluid +half of FWD + ongoing losses Adequate urine out implies 2ml/kg/hr= 480ml/day Maintenance fluid= 1000ml + Half of FWD = 280 ml + Ongoing losses = 480ml Total fluid requirement per day = 1760 ml D50.45NS 440 ml IV Q 6 hourly with 5meq Inj KCl in each 500 ml of IV fluid to be given each day for two days
OSCE STATION1. a. Identify the clinical condition 2 Pyothorax b. What is the sign seen in the imaging study? 1 Split pleura sign c. How will you treat the condition? IV antibiotics Intercostal drainage VATS
OSCE STATION2.What is the diagnosis? 1Extradural hematoma
3.What is the diagnosis? 1Subdural hematoma
OSCE STATION 1 a. Identify the slide 1.5 Macrocytic anemia b. Mention two causes for the same 1 B12 deficiency Folate deficiency
2.a. Identify the slide 1.5 AMLb. Mention two points of identification 1 Large immature cells Two or more nucleoli Auer rods- distinctive rod like red staining structures
OSCE STATION: BLS c. 14 year old male child has collapsed suddenly. Provide one rescuer CPR for the child Please clean the mouth of the mannequin with spirit cotton before stating CPR Checks for response- 0.5 Activates emergency response 0.5 Opens airway using head tilt and chin lift 0.5 Checks for breathing 0.5 Gives two rescue breaths 0.5 Checks for carotid pulse 0.5 Locate CPR hand position 0.5 Delivers first 30 cycles of chest compressions at the correct rate 1 Gives two rescue breaths 0.5
OSCE STATION- PFT1. Identify the study2. Identify the clinical patterns in a, b and ca.b.
c. 1. Spirometry- flow volume curves 2. a. normal curve b. restrictive lung diseasse c. obstructive lung disease
OSCE STATION – NALSResuscitate a newborn with the provided equipments.Please ask questions regarding status of infant –wherever necessary.1) Check the following equipments before proceeding furtherØ Bag mask valveØ Laryngoscope2) Get information about the infant from the observer before proceeding to resuscitateand at each step whenever necessaryAnswer KeyCheck list for observer.Bag mask valve…does the candidate 1- attach reservoir?- check pop off valve?Laryngoscope – Checks bulb & handleDoes candidate ask the following 3 questions? 1Ø Crying well – breathing well or not?Ø Pink or blue colour?Ø Good muscle tone?The Observer Should Say Baby Is Not BreathingDoes he clear airway/provide warmth/ position dry infant/stimulate? 1and then ask status of babyObserver Says: Baby Still Not Breathing wellDoes he give PPV for 30 seconds? 1Correct positionEC clamp technique
Chest expansionand then ask status of babyObserver Says Hr- 50/Min, BlueDoes he start chest compressions? 1Correct technique?Recent changes in Neonatal resusciatation (2010 guidelines)
OSCE STATION- ANTHROPOMETRYPHYSICAL EXAMINATION STATION (TIME 5 MINUTES)Measure the following in this child and document.1. Standing height2. Head circumference3. Chest circumference4. Upper segment to lower segment ratioYou are being observed for skills in anthropometry.
EXAMINER CHECK LISTHEAD CIRCUMFERENCE 11. Occipital protruberance to supraorbital ridges2. Crossed tape method (firm pressure on hair to compress)STANDING HEIGHT 11. Heels buttocks and back brought in contact with vertical surface- wall2. Frankfurt plane—horizontal3. Head piece firmly over vertex to compress hairCHEST CIRCUMFERENCE 1Measures the chest circumference at the level of nipplesLOWER SEGMENTMeasures from pubic symphysis to soleUPPER SEGMENTStanding height – lower segmentUPPER SEGMENT TO LOWER SEGMENT RATIO 1ATTITUDE 11. EXPLAINED TO THE CHILD WHAT HE IS GOING TO DO2. WAS GENTLE WITH THE CHILD3. WAS COURTEOUS
OSCE STATION- DRUGPROSTAGLANDIN E1 1. What are the indications for administration? 2 2. Mention four adverse effects of this drug? 2 3. How do you monitor the newborn when the drug is given? 11. INDICATIONS 1. Transposition of the great vessels. 2. Lesions with ductal dependent pulmonary blood flow- TOF, PS, pulmonary atresia, tricuspid atresia, Ebsteins anomaly 3. Lesions with ductal dependent systemic blood flow- AS, COA, hypoplastic left heart syndrome, interrupted aortic arch2. ADVERSE EFFECTS 1. Apnoea. 2. Hypotension. 3. Hyperthermia (transient). 4. Hypoglycaemia 5. Tachycardia. 6. Bradycardia. 7. Seizures. 8. Diarrhoea. 9. Skin flush secondary to vasodilation- occurs more frequently with intraarterial administration. 10. Sepsis, cardiac arrest, disseminated intravascular coagulation, hypokalaemia, oedema, cortical proliferation of the long bones.3. MONITORING o Observe respiratory effort closely o Monitor arterial pressure closely. o Watch for apnea o Watch for bleeding diathesis-
OSCE STATION- SENSITIVITY/ SPECIFICITY1000 babies were born in a maternity home in 2010. 185 babies had cord TSH more than25µIU/ml. 95 of these turned out to be congenital hypothyroidism. 5 babies had cord TSH lessthan 25 µIU/ml who later on had proven congenital hypothyroidism.Calculate the following for newborn thyroid screening test- a. True positive and true negative 1 b. Sensitivity 1 c. Specificity 1 d. Positive predictive value 1 e. Negative predictive value 1 Total population = 1000 Positive test = 185 Negative test = 815 True positive = 95 False positive = 90 Flase negative = 5 True negative = 810 Sensitivity = TP/ TP + FN x 100 = 95% Specificity = TN/ TN + FP x 100 = 90% Positive predictive value= TP/ TP + FP x 100 = 51.4% Negative predictive value= TN/ TN + FN x100= 99.4%
OSCE STATION – NATIONAL HEALTH PROGRAMME1. 28 year old Meera who has delivered 1 hour ago in your hospital. Baby weighs 2.8 kg and has no apparent problem. She was tested HIV positive during early preganency. Her CD4 count was 500. She has been on Anti retroviral drugs (tripple drug regimen) since 14 weeks of gestation.a. What is advice regarding breast feeding and weaning? 1.5 Exclusive breast feeding upto six months Start complementary feeds at six months Continue breast feeds with complementary feeds upto one year of ageb. What is the advice regarding ART for the baby? 1 Syrup nevirapine 15 mg OD for 6 weeks only2. 25 years old, Mrs Nazeema has delivered a female baby weighing 3 kgs one hour back. She was unbooked and was detected to be HIV positive during delivery. She was given nevirapine during delivery. a. What is the advice regarding breast feeding? 1.5 Exclusive breast feeding upto six months Start complementary feeds at six months Continue breast feeds with complementary feeds upto one year of age b. What is the advice regarding ART for the baby? 1 Syrup nevirapine 15 mg OD for 6 weeks Syrup nevirapine 20 mg OD for 6 weeks -6 months Syrup nevirapine 15 mg OD for 6 -9 months Syrup nevirapine 15 mg OD for 9 months to 1 year Syrup nevirapine to be continued for one week after all the breast feeding is stopped.
OSCE STATION 1. 3 year old child with loose stools- Na- 134 meq/l, K – 2.9 meq/l, Cl – 113 meq/l, HCO3- 16 2 ABG- ph- 7.31, PCO2- 34, HCO3- 16 a. Calculate anion gap ( Na +K) – (Cl+HCO3)= 7.9 b. What is the acid base imbalance? Compensated Metabolic acidosis Expected PCO2 = (1.5x HCO3) + 8 +/- 2 = 32+/- 2 2. 10 year old child with salycilate poisoning. 1.5 Anion gap= 30 ABG- ph- 7.3, pCO2 = 32, HCO3= 10 What is the acid base imbalance? Expected PCO2= 23 +/-2 Actual PCO2= 32, so there is respiratory acidosis also In all cases of high anion gap metabolic acidosis, corrected HCO3 = Actual HCO3 + [anion gap-12] , should be calculated. Corrected HCO3 = 28 Corrected HCO3 > 24 is associated with coexisting metabolic alkalosis This child has - metabolic acidosis with respiratory acidosis with co-existing metabolic alkalosis 3. 5 year old child with severe respiratory distress 1.5 PaO2=56, PaCO2= 50 Calculate d(A-a) PAO2= 150-1.25(PaCO2)=87.5 d(A-a)= PAO2-PaO2 = 31.5
OSCE STATION- DEVELOPMENTAL ASSESSMENTI. Child ‘A’ walks up and down stairs with alternating legs.a) What would be your assessment of the age of this child?b) Name 2 adaptive milestones specific for this age.II. Child B - copies cross and square - Imitates construction of “gate” of 5 cubes a) What would be the child’s probable age? b) Mention 2 specific motor milestones for this age.III. Match the followinga) Palmar grasp gone - 8 monthsb) Transfers object from hand-to-hand - 4 monthsc) Turn pages of book - 5.5 monthsd) Thumb finger grasp - 12 months
I. a) 30 months b) • Makes tower of 9 cubes • makes vertical and horizontal strokes, but generally will not join them to make cross; • imitates circular stroke, forming closed figureII. a) 48 months b) – Hops on one foot - throws ball overhand - Uses scissors to cut out pictures - Climbs wellIII. a) 4 months b) 5.5 months c) 12 months d) 8 months
OSCE STATION- MORTALITY RATESTotal births in 2006 – 1,00000Died between 28 weeks to term - 500Died during first week – 300Died after one week but before one month – 100Total deaths under 1 year – 100 Calculatea. Perinatal mortality rateb. Neonatal mortality ratec. Infant mortality ratePMR =Total perinatal deaths/Total no. of live births X 1000800/1.00000 X 1000 = 8 per 1000 birthsNMR =Total neonatal deaths/Total live births X 1000400/1.00000 X 1000 = 4.0/ 1000 live birthsIMR =No. of deaths < one year/Total live births X 10001000/100000 X 1000 = 10/ 1000 live births
OSCE STATION- HISTORY TAKINGTwo year old female child is brought with global developmental delayElicit – Birth history from the mother.EXAMINER CHECK LISTIntroduces to the mother 0.5Attitude- polite, courteous, good posture, maintains eye to eye contactAsks leading questionsANTENATAL (at least six points)1. What was the age at conception? 1.52. What was the pre-pregnancy weight?3. Any pre-existing illness?4. Was it a spontaneous/assissted conception?5. Was the pregnancy booked, supervised with regular follow ups?6. What was the weight gain during pregnancy?7. Did you take iron and calcium tablets from third month to end of pregnancy?8. Did you have any fever with rash and lymphadenopathy during first three months?u9. Did you have any exposure to drugs/radiation?10.Any H/O PIH,GDM,UTI, bleeding PV?NATAL (at least six points) 1.51. Was it a hospital/home delivery?2. Who conducted the delivery?3. Were sterile precautions taken if it was a home delivery?4. What was the duration of labour?5. What was the duration of leaking PV?6. Did y fevou have any fever before or during delivery?7. Did you have any foul discharge PV?8. Was the delivery- NVD/ Cs/instrumental?9. Was it a twin delivery?POST NATAL (at least six points) 1.51. Did baby cry at birth?2. If not any treatment done?3. What was the birth weight?4. Did baby suck well on the breast?5. Did baby have any fast breathing?6. Any abnormal movements was noticed in the baby?7. Any yellowish discolouration of skin?8. Any fever, rash or poor feeding was noticed in the baby?9. Any floppiness, paucity of movements, abnormal fisting, prolonged sleeping was noticed inthe baby?
OSCE STATION – HISTORY TAKINGOne year old child Raghav is brought to your OPD with concerns of shortness of hearing.Elicit relevant history.EXAMINER CHECK LISTIntroduces to mother, polite, courteous, and asks leading questions. 0.5Response to noises of varied loudness and progression of the disease 1.5H/O trauma to the ear, ear infection, ear dischargeH/O fever with seizures and prolonged illnessDid baby receive any ototoxic drugs?ANTENATAL- H/O fever with rash and lymphadenopathy 0.5NATAL Was the baby term or preterm? 0.5POST NATAL- Did baby cry at birth? 1 What was the birth weight? Did the baby have jaundice? Do you know how high the bilirubin value was? Was the baby ventilated for any reason? Did the baby have any fever, rash and convulsions?DEVELOPMENT- When did baby start recognising your voice, 0.5 turning towards loud noises?FAMILY HISTORY OF DEAFNESS 0.5
OSCE STATION – INSTRUMENTS1. a. Identify the device 1 Peripherally inserted central catheter /epicath b. What is it used for? 0.5 To provide medium and long term IV access/ TPN in neonates
2.a. Identify the device 1 Amplatzer septal occluderb. What is it used for? 1 For device closure of ASD
3.a. Identify the device 1.5 PDA coil
OSCE STATION : IMMUNIZATIONAryan is a 1 year old healthy child. He has been fully immunized.His mother is concerned that he does not have a BCG scar. She is worried that hemay catch TB. She is also concerned about the BCG vaccine which she feels mayneed to be repeated.How do you address these two concerns?You are being observed by the examiner for health education and communicationskills.Marking:Health Education • 1 ½ marks each for : 1. Repeat BCG vaccination is required. 2. Mentioning the natural history after a BCG vaccine such as development of a nodule after 4-6 weeks with possibility of formation of abscess and ulcer. • -1 mark for mentioning a Mantoux test.Communication skills:½ mark each for the following: • Introduction to the mother • Non-verbal communication skills such as eye contact/hand gestures/body lan- guage • Verbal communication skills such as ability to explain in clear English with non- medical terminology in a clear and organized manner • Concluding with a brief summary + asking the mother if she has any questions.