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OSCE Sir Ganga Ram Hospital

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  1. 1. OSCECentre for Child HealthSir Ganga Ram Hospital
  2. 2. STATION 1 This 9-month-old infant was cyanosed at birth and had a cardiac operation at 3 months of age. What condition is shown here? Name all features of this condition?
  3. 3. Answer 1• left sided Horner’s syndrome• It results in ptosis (drooping upper eyelid), miosis (constricted pupil), and occasionally apparent enophthalmos (the impression that the eye is sunk in) and anhidrosis (decreased sweating ) on one side of the face
  4. 4. STATION 2A 14-year-old boy from Uttarakhand was seen in the Accident &Emergency Department of Sir Ganga Ram Hospital with a generalisedconvulsion. His parents said that he had complained for two weekspreviously of mild headaches, which had occurred at different times ofthe day. At the age of 12 he was found to be sniffing glue butsubsequently told his parents he had discontinued the practice. Hisprogress at school was good and his behaviour had been normal.On the afternoon of admission he had complained of a suddengeneralised headache; despite this he had gone to see some friends butreturned home with the headache. His mother had given himparacetamol. As he was sitting down to watch television, he becamestiff and had a generalised convulsion.The family called an ambulanceand rectal diazepam was administered. He continued to fit and on arrivalat the hospital, intravenous lorazepam was required to terminate theconvulsion. He remained very drowsy and non-responsive.
  5. 5. STATION 2On examination, there was some resistance to flexion of hisneck but he was afebrile. His respirations were laboured,he was not cyanosed and was well perfused peripherally.His blood pressure was 160/90 mmHg. Examination of hisheart, respiratory system and abdomen were normal.His pupils were of equal size and both reacted sluggishlyto light. Examination of the fundi showed noabnormalities; there was a generalised increase in tone inhis limbs but no focal abnormal neurological signs.
  6. 6. STATION 2• What is the most appropriate investigation to establish the diagnosis?• What are the two most appropriate forms of immediate management?• What is the most likely diagnosis?
  7. 7. ANSWER 2• CT scan• administer intravenous mannitol and arrange for intubation and ventilation• subarachnoid haemorrhage
  8. 8. STATION 3A 14-year-old boy presented with an 8 weeks history of occasional vomiting, weight loss,listlessness and increasing pallor.During this period he complained intermittently of headache, pain in the lower chestanteriorly, and episodes of feeling hot and breathless. He had been short of breath onexertion. He had been drinking more water and passing more urine than previously. Hecomplained of pains in his hands and feet and his family doctor arranged for an x-ray (Q9).His parents reported that since the onset of the illness his heart rate had become rapid andhis heart beat unduly forceful.He had a long history of episodes of fever, abdominal pain and vomiting which had beendiagnosed as “abdominal migraine”. Both parents and his 4-year-old brother were healthy.His father was a factory worker and the family lived in a modern two-bedroomed flat.
  9. 9. STATION 3On examination his weight was 30kg and his height was 138cm (growth charts Q11). Hewas alert and afebrile. His respiratory rate was 40/minute and his pulse rate was130/minute. There was some pitting oedema over the dorsum of each foot. Jugular venouspressure was 5cm above the sternal angle. The apex beat was in the fifth interspace in theanterior axillary line and was thrusting in character. The first and second heart sounds werenormal; the third heart sound was heard in the apical and left parasternal regions. Thefemoral pulses were readily palpable.The blood pressure was 160/110 mmHg. Fine crepitations were heard at both lung bases.The appearance of the fundus is shown (Q10). The liver edge was palpable 3cm below thecostal margin. Neither bladder nor kidneys could be palpated and there was no abdominaltenderness. Urinalysis was positive for protein (+) and negative for both glucose and blood.
  10. 10. • Hb 9.2 g/dl •urea 78 mg/dl• MCV 73 fl • creatinine 3.4mg/dl• MCH 23 pg • total protein 70 g/l• MCHC 31 g/l • albumin 38 g/l• WBC 8.0 x 109/l •S.calcium 2.1 mmol/l• •S. phosphate 2.7 mmol/l neutrophils 5.20 x 109/l (normal range 0.99-1.57)• lymphocytes 2.64 x 109/l •alkaline phosphate 496 IU/l• monocytes 0.08 x 109/l (normal range for age 71-234)• eosinophils 0.08 x 109/l •Chest x-ray normal• Na-133 /K-4 •Abdominal ultrasound: Kidneys• S. chloride 97 mmol/l small with increased echogenicity• S. bicarbonate 20 mmol/l •No bladder abnormality
  11. 11. STATION 4 What is the most important abnormality on the radiograph of the hand shown of the boy in St 3? A delayed bone age B osteomalacia C osteoporosis D splayed epiphyses E subperiosteal erosions
  12. 12. ANSWER 4E subperiostial erosions
  13. 13. STATION 5 What is the most likely pathogenesis of the abnormality shown in X-ray shown in STATION 4?A chronic ill healthB hypophosphataemiaC poor dietary calcium intakeD primary hyperparathyroidismE secondary hyperparathyroidismF vitamin D deficiency
  14. 14. ANSWER 5E secondary hyperparathyroidism
  15. 15. STATION 6
  16. 16. STATION 6 What are the two most important features demonstrated on the growth chart?A bone age: advancedB bone age: delayedC bone age: normalD height: highE height: lowF height: normalG pubertal staging: advancedH pubertal staging: delayedI pubertal staging: normalJ weight for height: highK weight for height: lowL weight for height: normal
  17. 17. Answers 6E Height: lowH pubertal staging: delayed
  18. 18. STATION 7What is the bestinterpretationof the appearanceof the opticfundus ?
  19. 19. ANSWER 7Hypertensive retinopathy Group I: minimal narrowing of the retinal arteries Group II: narrowing of the retinal arteries in conjunction with regions of focal narrowing and arteriovenous nicking Group III: abnormalities seen in groups I and II, as well as retinal hemorrhages, hard exudation, and cotton-wool spots Group IV (i.e., malignant hypertension): abnormalities encountered in groups I through III, as well as swelling of the optic nerve head.
  20. 20. STATION 8What is the most likely cause of his breathlessness?A anaemiaB left ventricular failureC metabolic acidosisD myocardial ischaemiaE raised intracranial pressureF right ventricular failure
  21. 21. Answer 8B - Left ventricular failure
  22. 22. STATION 9What is the most likely cause of his renal impairment?A acute tubular necrosisB chronic glomerulonephritisC hypertensive nephropathyD hypovolaemiaE reflux nephropathy
  23. 23. ANSWER 9E - reflux nephropathy
  24. 24. STATION 10Which of the following renal investigations should now be performed?A abdominal CTB DMSA isotope scanC MAG 3 isotope scanD micturating cysto-urethrogram (MCUG)E renal arteriogramF renal biopsy
  25. 25. ANSWER 10DMSA istope scanmicturating cysto-urethrogram (MCUG)
  26. 26. STATION 11What is the best description of this lesion?
  27. 27. Answer 11cavernous haemangioma
  28. 28. STATION 12What are the two mostimportantabnormalities present?
  29. 29. Answer 12left pleural effusionmediastinal shift
  30. 30. STATION 13 This is the face of a boy aged five years. What is the most likely diagnosis?
  31. 31. Answer 13• Stevens-Johnson syndrome• Both Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis can start with non-specific symptoms such as cough, aching, headaches, and feverishness. This may be followed by a red rash across the face and the trunk of the body, which can continue to spread to other parts of the body. The rash can form into blisters, and these blisters can form in areas such as the eyes, mouth and vaginal area. The mucous membranes can become inflamed, and with Toxic Epidermal Necrolysis layers of the skin can also come away with ease and often the skin peels away in sheets. The hair and nails can also come away in some cases, and sufferers can become cold and feverish.
  32. 32. STATION 14An 8-month-old male infant is referred because ofnon-bilious vomiting. His general practitioner(GP) had seen him frequently for constipationover the last few months. Examination reveals athin, non-dysmorphic infant weighing 6.8kg (1stcentile). He has a scaphoid abdomen and hiscapillary refill time is three seconds. Generalexamination was otherwise unremarkable.
  33. 33. STATION 14Hb 12.2 g/dl Urine microscopyWBC 13 x 109/l - no red cellsneutrophils 9.4 x 109/l - no white cellslymphocytes 3.6 x 109/lPlatelets 373 x 109/l - no castsplasma sodium 154 mmol/l Urine osmolalityplasma potassium 3.8 mmol/l -180 mOsm/kgplasma urea 6.0 mmol/l
  34. 34. STATION 141.What is the most likely diagnosis?2 .What would be the most appropriate test to confirm the diagnosis?
  35. 35. Answer 141. diabetes insipidus2. response to DDAVP
  36. 36. STATION 15 This is an x-ray of the abdomen in a 12-year- old girl who attended a school for children with learning difficulties and complained of recurrent abdominal pain. What abnormality can be seen on the plain abdominal film?
  37. 37. ANSWER 15• Nephrocalcinosis
  38. 38. STATION 16A 2-week-old male infant, Blood gases:previously well, pH 7.33 (plasma hydrogenpresented with vomiting. ion concentration 47Hb 12.9 g/dl nmol/l)WBC 18.5 x 109/l PaO2 6.7 kPa (50 mmHg)neutrophils 10.0 x 109/l PaCO2 4.5 kPa (34 mmHg)lymphocytes 7.8 x 109/lmonocytes 0.7 x 109/l plasma bicarbonate 17.3 mmol/lplatelets 604 x 109/lblood glucose 4.2 mmol/l Base deficit -7.8 mmol/lNa- 123/K-6.2BUN-12 mg/dl
  39. 39. STATION 16What is the most likely diagnosis?
  40. 40. ANSWER 16Congenital adrenal hyperplasia(21-hydroxylase deficiency)
  41. 41. STATION 17 • The dentist reported this incidental finding in a 16- year-old female. • What is the diagnosis? A aberrant parathyroid B cavernous haemangioma C cystic hygroma D lingual thyroid E lymphoma F mucus retention cyst G peri-tonsillar abscess H rhabdomyosarcoma
  42. 42. Answer 17D – Lingual Thyroid
  43. 43. STATION 18 • What two abnormalities are seen on the CT scan with IV contrast of a 4 yr old boy? • What is the likely diagnosis?
  44. 44. Answer 181. -displaced right kidney - solid tumour of the right kidney2. Wilms tumour
  45. 45. STATION 19 • What are your findings on this smear?
  46. 46. Answer 19• Malarial parasite
  47. 47. STATION 20 • What are your findings on this smear?
  48. 48. Answer 20• Sickle cell anemia
  49. 49. STATION 21 • What are your findings on this smear?
  50. 50. Answer 21• Blasts seen- most likely lymphoblasts
  51. 51. STATION 22 • What are your findings on this smear?
  52. 52. Answer 22• Band cell –Immature neutrophil
  53. 53. STATION 23 • What are your findings on this smear?
  54. 54. Answer 23• Micro Hypo Anemia
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