OSCE4 March-08 thCenter For Child HealthSir Ganga Ram Hospital
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
• 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
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
• 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
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
• 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
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
• 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
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
• 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
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
• Lead posioning• CaNa2EDTA (Calcium Versanate) and BAL in symptomatic child• If lead levels >45 µgm% (N <10 µgm%)• Urine – Increased Zinc protoporphyrin
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
• Tuberous Sclerosis, Ash leaf Sclerosis macule• Autosomal Dominant trait• CT head for subependymal nodes• Retinal hamartoma• Vigabatrin and loss of peripheral vision
Spot 8 • Identify the Spot • Main Uses • Normal test indicates what?
• BERA- Brainstem Evoked BERA Response Audiometry• Post meningitis/Bilirubin induced neurotoxity• Normal test – normal retro cochlear nervous pathway
Spot 9Six days after undergoing livertransplantation, a 12 yr old patients levelsof gamma-glutamyl transferase (GGT),alkaline phosphatase, and bilirubin beginto rise. •Which is the most appropriate next step in diagnosis? •What if kidneys were transplanted and BUN/Cr used to be increased and why?
• 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.
Spot 10A 3-year old boy presented with FTT. Thechild was apparently fine for the firstcouple of years. He began to havediarrhea with light colored stools. Althoughstool examinations were performed, it wasunclear what the report is. The child wasplaced on a high protein, high calorie dietwith vitamins and supplements. However,he showed very little improvement over a •Identify the spot4 month period. Barium exam showed"large dilated loops of hypotonic bowel"), •Best diagnosticthe child was admitted with a diagnosis of possibilityceliac disease. Stool examinations has •Treatment ?shown in the picture
• 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
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?
• 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.
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)
• There is some evidence that high- dose corticosteroids administered as soon as possible after the injury will result in a better ultimate outcome
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
• 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
Spot 14 2 month old male, "fussy", diarrhea and vomiting; flatulence. Breast-fed. He had Viral gastroenteritis 10 days previously. Before the infection, mothers 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
• 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)
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
• 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