Wadia OSCE                  September 2011Wadia CME Sept 2011
Station 1                                       marks 51.   Describe: MRI axial image of thigh 1/22.   Diagnosis: Dermatom...
Station 2 ( marks 1 + 1+1 ½ +1 ½ =5   How is scoliosis screened clinically? Forward bending Test. To observe Rib cage asy...
Station – 3                                     marks 6   Name the act related to          Write the formulae for the   ...
Station 4 Marks 1x5 = 5As per IAP 2010 Recommendations1.        Which of the following vaccines are under “Special Circums...
Station 5Anion gap + compensation + diagnosis = 3 x2 =6 totalSr. Na – 135 mEq/l                       An 8 year old child ...
Answer- 6 marks 3*2=6    3 yr old boy referred to hospital with severe epistaxis and multiple bruising on his limbs. He  ...
Station 7 marks 1+ ½ + ½ + 1+1 =4    A 10 yr old girl, brought with H/O rapidly progressive, both lower limb weakness    ...
Station 8marks ½ +1 + 1+ ½ +1=41.   Identify the Inheritance pattern. Auto. dominant2.   Give 4 examples. Achondroplasia /...
Station 9    marks 1*5=5As per Indian Pediatric Nephrology Guidelines 20111.       Define : Significant Pyuria: > 5 leukoc...
Station -10 1*4=4 marks                                      From Slovis TL, editor: Caffeys pediatric diagnostic imaging,...
Station 11 who growth charts:marks ½ + ½ +1 + 1+ 2 =5   Q. Will the standards be applicable to all children?   Answer: c...
Station – 12Marks ½ + ½+ 1 + 2= 4    A 10 yr old child with H/o rheumatic heart disease is on Inj. Benzathine Penicillin ...
Station -13Marks (1+ 1 + ½ )+( ½ *3) + ½ + ½ =5   A 3 yr old girl has been brought with h/o red staining of diapers. Her ...
Station 14Marks ½ +1 ½ + 2 =4   What is Stokes Adam Syndrome?   refers to a sudden, transient episode of syncope, occasi...
Answer 15 marks ( ½ *4) + 1 + (½*6) = 6A.        Marasmus admission Criteria     1.      Less than 6 months     2.      NO...
Answer 16A 14 yr boy treated for attempted suicide , now gettingdischarged, you have been asked to counsel. (Total marks 8...
Answer 17Counsel the mother, whose child has been diagnosed with Haemophilia A (Totalmarks 8)   Introduction   Explain t...
Answer 18 (Total marks 8)Perform Lumbar Puncture in this 3 year old child1.       Introduces.2.       Explain to parents t...
Answer 19 (Total marks 8)Explain the procedure of insulin administration6 units Actrapid and 4 units Insulatard.1.      In...
Answer 20 (Total marks 8)Preterm child is being discharged after 1 month of NICU Stay under you,Counsel mother1.    No nee...
Answer 21 (Total marks 8)Kindly do the developmental assessment of this 4 year old boy.   Gross Motor:-       Walks up a...
Answer 22 (Total marks 8)Examine a patient with Mediastinal Lymph Nodes and SuspectedLymphoma   Pallor   Lymphadenopathy...
Station 23marks : ½ + (1 ½ only if all four drugs) + 1 + 1 =4    Product code 15 (PWBs)1.      Identify the product      ...
Station 24Marks : 1 ½ + ½ + ½ + 1 ½ = 4   Give (any 3)D/D of Bowing of legs       Physiological       Rickets       Bl...
 Wish   you all the best             Wadia CME Sept 2011
http://groups.yahoo.com/group/PediatricsDNB/         Theory: http://dnbpediatricstheory.blogspot.in/         OSCE: http://...
OSCE in Pediatrics (Wadia, Sept 2011)
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OSCE in Pediatrics (Wadia, Sept 2011)

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OSCE in Pediatrics (Wadia, Sept 2011)

  1. 1. Wadia OSCE September 2011Wadia CME Sept 2011
  2. 2. Station 1 marks 51. Describe: MRI axial image of thigh 1/22. Diagnosis: Dermatomyositis 1 1. Describe: USG abdomen, ½3. Diagnostic Criteria: Classic Rash + 3 of the 2. Diagnosis: Intussusception 1 following 1 1. Weakness 3. Treatment : emergency 2. Muscle enzyme elevation hydrostatic reduction( if not in 3. EMG changes shock) 4. Muscle Biopsy If unsuccessful ..surgery 1 Wadia CME Sept 2011
  3. 3. Station 2 ( marks 1 + 1+1 ½ +1 ½ =5 How is scoliosis screened clinically? Forward bending Test. To observe Rib cage asymmetry. How do you calculate Cobb Angle? This is measured using the superior and inferior end plates of the most tilted vertebrae at the end of each curve. Give Differential Diagnosis of congenital Torticollis.  Hemivertebra  Klippel Feil  Muscular  Positional deformation  Unilat. Absence of SCM Write Skeletal features of Marfan syndrome  Pectus carinatum  Pectus excavatum, needing surgery  Reduced upper-segment to lower-segment ratio or arm span to height ratio >1.05  Wrist and thumb signs  Scoliosis of >20° or spondylolisthesis  Reduced extension at the elbows (<170°)  Medial displacement of the medial malleolus, causing pes planus  Protrusio acetabulae of any degree (ascertained on radiographs) Wadia CME Sept 2011
  4. 4. Station – 3 marks 6 Name the act related to  Write the formulae for the hospital waste management. Biomedical Waste following: (management and handling)  Net protein utilization ( rules, 1998, India NPU) : nitrogen retained / How will you discard 500 ml of blood? Chemical nitrogen intake x 100 disinfection with one  Standard deviation: percent hypochlorite solution followed by Sq.root of ∑ (x- x’)2 / n discharge into drains. Use n if N>30 & “n-1” if Which is the best type of n<30 incinerator available? Double chamber pyrolytic  Child survival index: 1000- incinerator. UFMR / 10 Wadia CME Sept 2011
  5. 5. Station 4 Marks 1x5 = 5As per IAP 2010 Recommendations1. Which of the following vaccines are under “Special Circumstances Vaccines” ( negative marking for wrong name) 1. IPV 1. Influenza 2. Yellow fever 1. PCV 2. MMR2. A child comes to you for routine immunization at 5 yr and 2 months. She has recd. All her vaccinations till date. She has not suffered from any viral exanthem till now. Name the vaccines that you would ask to be taken now. 1. DT / DTaP 2. MMR (2ND DOSE) 3. TYPHOID 4. CHICKENPOX ( 2ND DOSE)3. Mention the dosage schedule of Qudrivalent HPV vaccine : 0,2,6 months from 10 yr onwards4. What is ‘Basic reproductive number’ (Ro)? measures the average number of secondary cases generated by one primary case in a susceptible population.5. In case of an infant requiring Measles Vaccine; 1. Needle should enter at an angle of ____ to the skin. 45 degree 2. The site of injection. Thigh
  6. 6. Station 5Anion gap + compensation + diagnosis = 3 x2 =6 totalSr. Na – 135 mEq/l An 8 year old child was diagnosed as acute rheumatic fever and discharged on Tab. Aspirin for 6 wks. The child was readmitted with c/o nausea, vomitting 2 days duration f/b rapid respiration, fever, seizure, alteredSr. K - 3.5 mEq/l Data: sensorium.Sr. Cl- 85 mEq/l Sr. Na – 140 mEq/l Sr. K - 3.8 mEq/lABG: pH- 7.55 Sr. Cl- 98 mEq/l ABG: pH- 7.55 pCO2- 48 mm Hg pCO2- 19 mm Hg HCO3- 40 mEq/l HCO3- 10 mEq/l PT, PTT- elevated SGPT- 438 units Sr. Salicylate level- 58 mg/dl [mild elevation]. What is the diagnosis?  Analysis: ( Compensation / anion gap / Diagnosis) Comment on compensation. Alkalemia / Respiratory If compensation is proper, HCO3 decreases by 1mEq/l for fall of every 10 mm Hg pCO2pCO2= 40 + .7 x [40-28]= 48.5 So expected drop of HCO3 is 4mEq/lSuggests appropriate Expected HCO3- 20 mEq/l Actual HCO3- 10 mEq/l compensation This suggests inappropriate compensation i.e.Anion Gap Na- [HCO3 +Cl] = 16 associated Metabolic Acidosis Anion Gap= 140-[98 + 10]= 32Diagnosis: metabolic alkalosis i.e wide AG  Diagnosis : Respiratory Alkalosis with wide Anion Gap Metabolic Acidosis Source: Dr N C Joshi : Wadia CME Sept 2011
  7. 7. Answer- 6 marks 3*2=6 3 yr old boy referred to hospital with severe epistaxis and multiple bruising on his limbs. He had been well previously and there were no other abnormalities on physical examination. He had not had any medications. Family history was negative for any illness. Hb 10.3 WBC 13300 N- 43 L 30 Platelets 3 x 109 /l INR 1.2 ….. PTTK Normal LFT / Platelet Antibodies Negative / ESR 201. Acute Idiopathic Thrombocytopenic Purpura / Acute Leukemia.2. Bone marrow aspiration to exclude Leukemia.3. Expectant / Steroids / IVIG. A healthy boy was delivered and both mother and baby were discharged on day 3. Twelve hours after discharge, child was brought to hospital with severe vesiculo-pustular rash……. History now revealed a “Mild” vesiculo- pustular rash in mother 24 hours prior to delivery and two children suffering from chickenpox next door.1. Neonatal Chickenpox.2. Admit and IV Acyclovir.3. Zoster Immune Globulin….. And in case rash develops IV Acyclovir. Wadia CME Sept 2011
  8. 8. Station 7 marks 1+ ½ + ½ + 1+1 =4 A 10 yr old girl, brought with H/O rapidly progressive, both lower limb weakness since 3 days. She was apparently normal except for a history of “sore throat and bilateral neck swelling with fever about 20 days back. She started with difficulty while walking and not being able to pass urine despite of the sensation being there. On examination: normal sensorium and cranial nerves. Had normal neurology findings in both upper limb and shoulder. Lower limb, symmetrical flaccid paralysis; distal more than proximal. DTJ were exaggerated and Planters were extensors. There was a sensory discrepancy below T8 and Temp / light touch were affected. Vibration and position were normal. Her Urinary bladder was palpable.1. What is your differential diagnosis / diagnosis? Acute Transverse myelitis / SOL in spine ( Koch’s / vascular infarct / bleed / Bony spikule)2. What is the investigation of choice? MRI spine3. Treatment: IV steroid pulse4. Name (any 2) causative factors for this condition: Post / Para infectious / SLE with thrombosis / Lyme disease.5. Describe the components of Type 1 and 2 … Arnold Chiari malformation Type 1: Cerebellar Tonsillar herniation type 2 : with Meningomeylocele Wadia CME Sept 2011
  9. 9. Station 8marks ½ +1 + 1+ ½ +1=41. Identify the Inheritance pattern. Auto. dominant2. Give 4 examples. Achondroplasia / Tuberous sclerosis / Neurofibromatosis/ marfan / Huntington / Wardenburg….3. What is “pseudo-dominant” Inheritance pattern on a pedigree. Name any one situation of the same… Homozygous AR has a partner who is Heterozygous AR results in a pedigree that appears to be Dominant like4. Mention the Fragile site and give main clinical manifestation of Fragile X syndrome. Xq27.35. The main clinical manifestations of fragile X syndrome in affected males are mental retardation, autistic behavior, macro-orchidism, and characteristic facial features Wadia CME Sept 2011
  10. 10. Station 9 marks 1*5=5As per Indian Pediatric Nephrology Guidelines 20111. Define : Significant Pyuria: > 5 leukocytes /hpf in Centrifuged sample OR >10 leukocytes / mm3 in Fresh Uncentrifuged sample.2. Define: Simple UTI : UTI with low grade fever<39, Dysuria, frequency, urgency; and absence of symptoms of complicated UTI3. A child has 1st attack of UTI at 18 months: which investigations will you ask & when ( USG / VCUG/ DMSA) : USG: soon after Diagnosis. And DMSA 2-3 months later …… NO VCUG ..unless one of them is abnormal4. Mx of VUR grade IV : ( w.r.t. prophylaxis and/or Surgery) Antibiotic prophylaxis until 5 yr… Consider surgery if Breakthrough Febrile UTI. After 5 yr Prophylaxis only if Bowel Bladder Dysfunction.5. Mention ( any 4) clinical features suggesting underlying Structural abnormality:  Distended Bladder  palpable kidneys  tight phimosis  Vulval Synechiae  Patulous anus  Incontinence  Surgical scars Wadia CME Sept 2011
  11. 11. Station -10 1*4=4 marks From Slovis TL, editor: Caffeys pediatric diagnostic imaging, ed 11, Philadelphia, 2008, Mosby/Elsevier, p 1287.)17 month old boy brought with H/o ingesting Kerosene. First X ray wastaken at 3 hours and second after few hours. • What is the role of gastric aspiration here on admission? Not to be done. • Ingestion of what amount is considered at risk for Pneumonitis ? > 30 ml • How long would you observe this child , if no abnormal symptoms develop. ( 8-12 hours)  A 10 month old infant was admitted with h/o irritability, vomiting, crying while passing urine. Urine microscopy revealed 2-3, RBCs; no leucocytes and urine culture was normal. No family H/o urinary stones.  Child had history of fever with cough and cold for two days (which improved without any medication except paracetamol) prior to their week long trip to China.  Child had normal mental and physical growth till now; he was was on formula feeds which were correctly prepared under sterile conditions.  What is your diagnosis? Melamine poisoning Wadia CME Sept 2011
  12. 12. Station 11 who growth charts:marks ½ + ½ +1 + 1+ 2 =5 Q. Will the standards be applicable to all children? Answer: can be applied to all children everywhere, regardless of ethnicity, socioeconomic status and type of feeding Q. What reference data should be used for children older than 5 years? Answer: WHO Reference 2007 for boys and girls, 5-19 years Q. How will these new standards change current estimates of overweight (for 8 yr old )and under- nutrition ( infancy) in children? Answer: wasting rates will be substantially higher using the new WHO standards. With respect to overweight, use of the new WHO standards will result in a greater prevalence Q. which countries were involved in WHO MGRS study. Answer: 6 countries representing different regions of the world: Brazil, Ghana, India, Norway, Oman, and the United States. Q. What is Mid-parental height and Target centiles? Answer: Boys: [(maternal height + 13) + paternal height]/2 • Girls: *maternal height + (paternal height − 13)+/2 Chart these range at “18 year”= Target Range Trace the corresponding centile lines to current age. This is the target centile. It corresponds to 3rd and 97th centile for this child(growth potential). Wadia CME Sept 2011
  13. 13. Station – 12Marks ½ + ½+ 1 + 2= 4 A 10 yr old child with H/o rheumatic heart disease is on Inj. Benzathine Penicillin prophylaxis. He has taken this inj. Previously many times. He was given test dose. Immediately the child is found to have fast breathing and feeble pulse and cold / pale extremities with stridor.1. What is the diagnosis? 1. Anaphylactic shock2. What non-pharmacological measures to be taken? 1. Check airway and breathing3. Name the drug / drugs with route and dose that should be used. 1. Oxygen thro Nonrebreathing mask 10 -15 lit/min. 2. IM adrenaline 0.01ml /kg ( 1:1000) 3. Diphenhydramine 1 mg/kg oral ( as IV is not available)4. Name types of hypersensitivity reactions( in order) and write their respective mediators. 1. I : Allergy : IgE 2. II : cytotoxic : IgM /IgG –antibody mediated  III: Immune complex : IgG  IV : Delayed hypersensitivity : T cell mediated Wadia CME Sept 2011
  14. 14. Station -13Marks (1+ 1 + ½ )+( ½ *3) + ½ + ½ =5 A 3 yr old girl has been brought with h/o red staining of diapers. Her height is 101 cm ( 1 yr back it was 90 cm), weight is 17 kg ( 1 yr back it was 13 kg). She has been observed to be more quiet than usual with intermittent episodes of laughing. On examination : No skin / mucosal bleeding. Abdominal exam no organomegaly. Neurology NAD USG abdomen normal. Routine Hemat / urine / stool /Biochem NAD. What is the likely diagnosis( give complete diagnosis) ?  Isosexual central precociuos puberty  Hypothalamic Hamartoma  Gelastic seizures What investigations would you ask for ?  MRI : localisation / diagnosis  EEG : Gelastic seizures  Estradiol levels : What is the medical treatment in this case? GnRH Analogues In case medical treatment fails, what is the other option ? Surgery : Gammaknife/ Transpeniodal etc. Wadia CME Sept 2011
  15. 15. Station 14Marks ½ +1 ½ + 2 =4 What is Stokes Adam Syndrome? refers to a sudden, transient episode of syncope, occasionally featuring seizures with Heart block. Write True / False. 1. The QRS complex is commonly of normal duration in congenital heart block whereas the QRS Duration is usually prolonged in surgically induced heart blocks.: True 2. Prolongation of PR interval is a more reliable early sign of Digitalis toxicity than arrhythmia.: True 3. In Sinus Rhtythm P wave is upright in lead II and inverted in aVR. : True Wadia CME Sept 2011
  16. 16. Answer 15 marks ( ½ *4) + 1 + (½*6) = 6A. Marasmus admission Criteria 1. Less than 6 months 2. NOT alert 3. Appetite NOT preserved 4. Clinically NOT well 5. Home environment NOT conduciveB. Stabilization phase and Rehabilitation phaseC. 10 goals of management 1. Hypoglycemia 2. Hypothermia 3. Dehydration 4. Electrolytes 5. Infection 6. Micronutrients 7. Cautious feeding 8. Catch up growth 9. Sensory stimulation 10. Prepare for follow up Wadia CME Sept 2011
  17. 17. Answer 16A 14 yr boy treated for attempted suicide , now gettingdischarged, you have been asked to counsel. (Total marks 8)1. Introduce/ Language2. Try to get comfortable with some small talk.3. Promise Confidentiality4. Ask any Future Plans of another attempt5. Any Signs of depression (Sleep well ?, Want to listen to music?)6. What will you do after going home?7. What were the stressors (Girlfriend , Marks)8. Ask substance abuse9. Where did he get this idea from?10. Tell Him : make him feel he is not worthless, family and friends still love you , will welcome you home without change in attitude, try to have confidence when there are stress events , Other career options, examples of Sachin Tendulkar, singers,11. Take a Promise to not do it again12. Any such thoughts , call me up.13. We will meet regularly14. Continue your medications15. If you want , we can speak to your parents or teachers16. Never hide anything from parents17. Thanks for your time and sharing your intimate/ personal. Wadia CME Sept 2011
  18. 18. Answer 17Counsel the mother, whose child has been diagnosed with Haemophilia A (Totalmarks 8) Introduction Explain the disease Removal of guilt Problem addressed – current problems (Jt. Bleed )) Associated problems.. deep bleeds Treatment drug / dosage / side effect to watch Factor VIII / Cryo / FFP On discharge : precautions at home Precautions at school / play . Helmet / knee / elbow To inform about condition in case of any future medical intervention Counsel for future preg/ posibility of prenatal diagnosis for her and others in Family Investigate other RELEVENT members School / play Future cure / vaccination MAY come up … When to follow up When to come in emergency? Ask if they have any more questions? Thank the Mother Wadia CME Sept 2011
  19. 19. Answer 18 (Total marks 8)Perform Lumbar Puncture in this 3 year old child1. Introduces.2. Explain to parents the Need for Procedure & consent3. Checks or asks for blood glucose level4. Keeps resuscitation equip ready5. Checks Vitals and AF6. Universal precaution for self7. Clean / Drape8. Identifies the site9. Sedation (Midazolam) ,[ No need for Atropine]10. Position (Left Recumbent )11. LA (Deep into Dura and Outside)12. Correct direction(Towards Umbilicus) and “give way” mentioned13. [Newborn 23/22 G , 1 inch], [Pediatric 22 G 1.5 inch], [Adolscent LP needle].14. Post procedure , mild pressure and seal15. Will send for cells / biochemistry / culture16. Post procedure position [Head Low],17. Explain to mother that procedure was uneventful18. Instructions to monitor this child19. BIOWASTE DISPOSAL20. Thanks the Mother Wadia CME Sept 2011
  20. 20. Answer 19 (Total marks 8)Explain the procedure of insulin administration6 units Actrapid and 4 units Insulatard.1. Introduction2. Explain procedure (painless , need to take daily)3. Tells about the two insulin (Milky and Plain) and insulin syringe4. Remove half an hour before from fridge and shake lightly5. To give 15-30 minutes before food6. Select areas –mark them for every day => thigh and site rotation7. Swab the top of the vial with spirit swab provided8. Takes 4U air in a syringe puts it in insulatard vial (keeping the vial upright) and then takes 6U air in a syringe puts it in actrapid vial.(vial upright)9. Inverts the bottle withdraws 6u actrapid then withdraws syringe inserts in insulatard and withdraws up to 10u i.e. 4u10. Cleans area with spirit11. Allows it to dry12. Pinches the subcutaneous area –inserts the needle at 45 degree angle and injects then withdraws needle with syringe and slowly releases pinch, no rubbing massaging13. Syringe reusable/disposal in sharp14. Can use same needle for 2-3 times15. Keep insulin in fridge16. Explain the symptoms of Hypoglycemia17. Thank you Wadia CME Sept 2011
  21. 21. Answer 20 (Total marks 8)Preterm child is being discharged after 1 month of NICU Stay under you,Counsel mother1. No need for introduction, only say hello2. Preferably insist on father being present3. Congratulations (You have gone through a lot)4. Talk of Normal Routine care in all babies5. Hypothermia (warm clothes, KMC)6. Infections (Minimal handling, less visitors, wash hands)7. Feeding (EBM only with paladi, Non Nutritive suck, No bottle Feeds, Burping)8. Normal Pattern (Stool, sleep, urine )9. Continue medications at home10. Regular vaccination (except HBV)11. No kajal ,Oil instillation12. No Bath ;Only sponge till we tell you13. Massage only if done by family member14. Follow up every week initially , Growth Monitoring15. Please arrange for somebody (Mother, Mother in Law ) to help you16. Bring to doctor (Baby Cold, Lethargic, Oliguria, Persistent vomiting, not feeding well)17. If you have any doubt , take my number18. AVOID TALKING ABOUT KEEPING A WATCH FOR DELAYED DEVELOPMENT AT THIS MEETING Wadia CME Sept 2011
  22. 22. Answer 21 (Total marks 8)Kindly do the developmental assessment of this 4 year old boy. Gross Motor:-  Walks up and down stairs by alternate feet  Hops on one feet  Throws ball overhead Fine Motor:-  Draws a man with 2-4 parts besides head  Copies a square Language:-  Tells a story  Knows three colours Social:-  Gives a account of recent experience and events  Washes face, feet and brushes teeth. Wadia CME Sept 2011
  23. 23. Answer 22 (Total marks 8)Examine a patient with Mediastinal Lymph Nodes and SuspectedLymphoma Pallor Lymphadenopathy [Axilla , Cervical, Groin, Epitrochlear] (In detail, in all positions) Abdomen examination for Hepatomegaly and Splenomegaly Trachea in centre Apex Beat (Shift of Mediastinum) Para aortic LN (Deep Abdominal Palpation) Entire Lung Examination (If time Permits) Neck examination for JVP !! Wadia CME Sept 2011
  24. 24. Station 23marks : ½ + (1 ½ only if all four drugs) + 1 + 1 =4 Product code 15 (PWBs)1. Identify the product  Name the categories for2. What does each pouch contain? pediatrics TB diagnosis3. Indication of using this pouch. under RNTCP Product Code 15 –(pediatric Wise Boxes )  New ( prev. CAT I) Prolongation of intensive phase of  Previously treated ( cat II) category I Pediatric cases (6-10 kg and 18-25 kg). Each box containing 5 pouches Each pouch containing 12 blister Combi pack of Schedule-5. The pouch consists of Isoniazid, Rifampicin, Pyrazinamide and Ethambutol to be given under direct observation thrice a week on alternate days for 1 month (12 doses). Wadia CME Sept 2011
  25. 25. Station 24Marks : 1 ½ + ½ + ½ + 1 ½ = 4 Give (any 3)D/D of Bowing of legs  Physiological  Rickets  Blounts What is the commonest inheritance pattern in Hypophosph. Rickets? X linked Dominant In the above condition, who will be having a more severe disease; Boy or Girl ? Girl Vit D resistant rickets Type 2:  Vit D3 ( normal)and 1,25(OH)2 vit D levels( high ) :  Drug of choice: Calcitriol or Alphacalcidol ( also calcium but drug of choice is calcitriol) Wadia CME Sept 2011
  26. 26.  Wish you all the best Wadia CME Sept 2011
  27. 27. 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/Download at: http://www.4shared.com/folder/t8E_yjDv/_online.html

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