Copy of osce cme24.04.2012 calicut

1

Cases

Community Control

Hospitalcontrol

P valueHospital control Vs cases

P valueCommunity control Vs cases

Age 32.533.432.10.560.04

Male (no)

6642630.060.03

• Table. Characteristics of stroke cases & controls

Table 2 : Risk factors associated with ischaemic stroke: Results of multivariable logistic regression

Risk factorsCases Vs Community controls

Cases Vs hospital controls

Odds ratioConfidenceInterval

Odds ratioConfidenceInterval

FBS4.551.63 – 12.671.170.68 – 2.02

Total Cholesterol

0.860.44 – 1.681.970.97 – 3.82

HDL0.170.09 – 0.300.270.17 – 0.44

Triglycerides0.700.37 -1.320.670.40 – 1.11

Smoking7.771.93- 31.273.951.61-9.71

Systolic BP1.881.01- 3.491.130.74 – 1.73

1

• Comment whether community controls are age & sex matched with the cases?

• Comment whether hospital controls are age & sex matched with the cases?

• Which is the statistical tests used to compare the age of cases and controls?

• Which is the statistical tests used to compare the sex of cases and controls?

• (1/2 x 4 =2)•

1

• 5. What are the significant risk factors of stroke when compared with the hospital controls?

• 6.What are the significant risk factors of stroke when compared with the community controls?

• 7.What are the significant protective factors of stroke when compared with the controls?(1 x3 = 3)

Ans1• Smoking. Odds ratio is > 1. Confidence interval does not

include 1. If the confidence interval extend from negative value to positive value it include one in the range. So there can be a situation where odds ratio become 1, in which there is no association between the groups.

• FBS, smoking, Systolic B.P• HDL Odds ratio is < 1.Confidence interval does not

include 1

ANS1Cases and community controls are not age & sex matched. P value of both

age & sex are <0.05. So the observed difference between the cases & controls is significant & They are not comparable.

• Cases and Hospital controls are age & sex matched. P value of both age & sex are >0.05. So the observed difference between the cases & controls is not significant & They are comparable

• Age is a continuous variable. Only 2 groups are there. So z test or t test can do to compare the two groups.

• Sex is a qualitative variable. So Chi square test can do to compare the groups.

2

• What is the diagnosis of this child who presented with pallor and fever and hepato splenomegaly

• What is being focussed in the electron microscope?

• How will you classify this disease?• What is the specific immune histochemical

marker for the above condition?• Name two common drugs used in the treatment

• Birbeck granules• Langerhan cell histiocytosis• Langerhan cell Histiocytosis,Hemophagocytic

lympho Histiocytosis,Malignant Histiocytosis• S100,CD1A,• Etoposide/vinblastine,steroid

ANS2

4

• This is the spirometric pattern before and after bronchodialator

• Comment on the spirometric dignosis that can be derived from the spirometric curve

• Mention the lung condition causing this pattern

ANS4A

• Obstructive pattern good response to bronchodialator with air trapping

• Asthma,bronchiolitis,FB aspirn,cystic fibrosis

4B

• Identify the spirometry abnormality• Mention the causes

ANS4B

• Restrictive desease• Chest wall abnormality,neuro muscular

disease

4C

• Identify the spirometry abnormality• Mention the causes

ANS4C

• Box pattern.Fixed upper airway obstruction

• Benign stricture follg. prolonged ET intubation

• Post tracheostomy tracheal stenosis

• Large goitre causing tracheal narrowing

5a • This new born had similar lesions over

hands,elbows and scalp at birth.Otherwise active and thriving

1.Give the most likely diagnosis2.Mention 3 major classes of this disorder

5A

• Epidermolysis bullosa• EB simplex,DystrophicEB,Junctional EB

• onychomadesis• Exaggeration of Beau line leading to proximal

separation of nail bed

5b

5c

• This is the photograph of left upper arm of a 10 mo old infant who presented with high grade fever of 7 days duration. What is the most likely diagnosis?

5d

• Kawasaki disease• Induration of BCG inoculation site

6

• Indicate the most appropriate ventilator setting parameter to be changed in the following scenarios according to the respective ABG report.Also indicate the obvious acid base disturbance in each

6A ventilator setting PRE TERM HMD

FiO2 % 70Ti sec 0.4Te sec 0.6

FLOW L/mt 5PIP m.bar 17PEEP m.bar 5

Ph7.27

PaO2 mm Hg50

PaCO2 mm Hg44

ABG

33 weeks Preterm 20 Hrs in to ventilation following surfactant administration is clinically improving



•VENTILATOR SETTINGS

• ABG

Ph7.36PaO2 mm Hg86

PaCO2 mm Hg39



2kg infant with RDS 10 Hrs in to ventilationVentilator setting

Ph7.22PaO2 mm Hg65

PaCO2 mm Hg62

ABG

Ans6

1.met+resp acidosis Increase PIP2.NORMAL DECREASE PIP3.RESP ACIDOSIS DECREASE Te

• 8yr old boy admitted in shock following mild febrile illness.There is progressive visual loss and scholastic backwardness.His MRI brain is shown here.What is the most likely diagnosis?

7a

7A

• Adrenoleukodystrophy

7B

• This 10 month old infant presented with excessive irritability followed by seizures. He was born out of a non consanguineous parentage and was noted to have large head from early infancy. No h/o trauma.

• 1.What is your diagnosis?• 2.Mention 2 typical findings seen.• 3.Name 2 drugs specifically recommended for

this condition

7B

• Glutaric aciduria type1 • Subdural hemorrhage ,wide sylvian fissure

and brain atrophy• Carnitine ,Riboflavin

8• This is Hamna Fathima, 2 ½ years old.• She presented with pain & swelling of her right knee of 8 months duration, left knee and right ankle of 7months

duration & left ankle of 4months duration .She has persistent symptoms with exacerbations & remissions. She walks with a limp. For the last 2 weeks , she has pain & swelling of the small joints of her fingers & she has difficulty in holding a cup.She also finds it difficult to get up from sleep

• HB- 8.8 g/dl, TC-10,000 cells/cumm, P-61, L-37, M-2,• O/E She has mild pallor, no fever or rash, no lympoadenopathy or organomegaly.• MCV - 54.2, MCH- 21 , MCHC-31.9, RDW-17.3 Platelets- 3.99 L• Peripheral Smear- Microcytic Hypochromic Anaemia ESR – 55 mm/hr• SGPT- 32 RFT- Normal Antinuclear Antibody- Negative• • What is the most probable diagnosis? ( Write the full diagnosis)• What specific complication can occur at 2 months after disease onset?• Which investigation correlates well with this complication?• Presently, now what all complications can occur? • What treatment is recommended at 2 months after disease onset?• Presently, what treatment is recommended?• Name 2 drugs given in resistant cases.

8 Investigation

HB- 8.8 g/dl, TC-10,000 cells/cumm, P-61, L-37, M-2, O/E She has mild pallor, no fever or rash, no

lympoadenopathy or organomegaly. MCV - 54.2, MCH- 21 , MCHC-31.9, RDW-17.3 Platelets- 3.99 LANA-negative . Peripheral Smear- Microcytic Hypochromic

Anaemia ESR – 55 mm/hr• SGPT- 32 RFT- Normal • •

8• What is the most probable diagnosis? ( Write the full diagnosis)• What specific complication can occur at 2

months after disease onset?• Which investigation correlates well with this

complication?• Presently, now what all complications can

occur? • What treatment is recommended at 2

months after disease onset?

8

• 1.extended Oligoarticular JIA with iron deficiency anemia

• 2.uveitis /Iridocyclitis• 3.Antinuclear Antibody• 4.MAS, distruction of joints,Growth failure• 5.two months treatment Antiinflammatory

and Intraarticular steroid

• ECG of a 2 month old girl with H/O recurrent episodes of irritability,sweating,pallor and feeding difficulty.

•

9a

9A

• Alert.RR: 62/min Increased work of breathing +

• HR 150/min Chest:Bilateral wheeze+• CVS: Gallop rhythm+ No murmur• Abdomen :Liver span 6 cm• What is the most likely diagnosis?• What is the ECG finding?• What is the definite treatment

• ALCAPA• Deep and wide Q waves in leads 1,aVL and V2-

V6.• Surgical treatment consists of detaching the

anomalous coronary artery from the pulmonary artery and anastomosing it to the aorta to establish normal myocardial perfusion.

9a

9B• This is a rhythm strip of a 6 year old boy with

palpitation.

1. What is the ECG finding?2. What are the diagnostic criteria?3. Mention the indications for further investigations

and possible treatment

9b ans 1) Ventricular trigeminy 2)Wide complex QRS,T wave opposite in polarity to

QRS3)(a) 2 or more ventricular premature beats in a row,

(b) multiform PVCs, (c) increased ventricular ectopic activity with exercise, (d) R on T phenomenon and (e) the presence of underlying heart disease, a history of heart surgery, or both

Q 111 yr old infant with h/o incessant cry since

previous night is brought with poor responsiveness, fast breathing and peripheral cyanosis.

His air way appears clear

Manage the child. You may assign specific tasks to the observer

and also ask for relevant clinical parameters

ANS Q 11• StartO2• Ask for a) RR – 60 b)HR-fast c)CFT-3Sec d)BP-difficult e)spO2-90 f)GRBS • Ask for monitor - give ECG• Should not delay for IV• Straight away cardio version• Energy dose • Sync• Paddles – position • Gel • Clear

Q 12

• A term male baby is just born to a 30 yr old primi with h/o APH. The baby is limp and not breathing. No meconium staining

• The warmer is on. You may ask for specific assistance an information from the observer.

• Now receive the baby and proceed to resuscitation

• Assume that you have taken sterile precautions

Ans Q121.Dries and removes the wet towel (1/2)2.Position – sniffing position (1/2)3.Suction – mouth first (1/2) -- asks for pressure (1/2)—asks for the catheter size (1/2)4.Stimulation (1/2)5.Reposition (1/2)6.Asks for status (1/2)7.Selects appropriate mask (1/2)8.No O2 (1/2)9. Connects pulse oxymeter (1/2)10.Correctly places and holds bag and mask (1/2)11.Correct rhythm (1/2)12.Asks for air entry/chest expansion (1/2)13.Ventilation correction steps-MR SOPA 14.Re-adjusts the mask (1/2)15.Repositions (1/2)16.Suctions (1/2)17.Ventilate with open mouth (1/2)18.Increases the pressure (1/2)19.Asks for HR, Breathing, and saturation (1/2)

Q 13Show the posture and area of percussion for the

postural drainage from following different segments of right lung of this child.

• Upper lobe: Apical Anterior Posterior• Lower Lobe: Superior Anterior Basal Posterior Basal

Q12A 3yrs old Veena was brought to the casualty by the

mother.Her father died in a road traffic accident 2wks back. Her mother was busy in packing as they were planning to shift the place when she saw Veena stumbling about with a flushed face & slurred speech. She was soon taken to the hospital & on the way to hospital she developed one episode of GTC seizure.

• Veena was the only child of her parents with normal growth &development. There was no history of fever, rash, headache or vomiting. Child never had convulsions before. There was no history of head trauma / vaccination in the recent past.

12In the ER,she responds to pain only HR 186/mt,• BP-120/78mmHg Rt UL, • RR-12/mt & shallow, SPo2 in room air-86% CFT-2sec Temp-103F

GRBS-178mg%• Pupils dilated &sluggishly reacting • Systemic examination revealed nothing abnormal except for a

distended bladder.• ECG showed QRS interval 0.1 sec& QTc0.49secs with frequent

unifocal ventricular ectopics.• Q 1.What is the most likely diagnosis?• Q2. Will you choose to treat this rhythm disturbance?• Q3.After supporting ventilation and oxygen what drug you will

administer?

• Tricyclic Antidepressant poisoning• yes• NaHco3

12

• What are the typical clinical features due to poisoning with fruits of this herb?

• What is the specific antidote?

12

• Dry like a bone,red as a beat,mad as a hen,hotas a hare,blind as a bat

• physostigmine

12

This is a 3.5yrs old girl• What is the diagnosis?• Mention any 2 complications this child is likely to develop• What is this peculiar appearance called?• What is the characteristic skeletal abnormality?

13a

• Mc-Cune albright syndrome• Hypothyroidism,hypoadrenalism,PCOD• Coast of Maine appearance• Polyostotic fibrous dysplasia

13a

• Spot the diagnosis• what would you expect in renal USG?

13b

• Ash leaf macules-Tuberous sclerosis• Renal Angiomyolipoma

13b

Q 14

• Advise this mother of 3 years old child, who is being discharged from your hospital following acute severe asthma regarding inhalational therapy.

15•Rajat 3.5 yr old boy only child of non consanginous marriage

brought for the evaluation of FTT. Both the parents hailing from Uttar Pradesh were of adequate height & weight. His birth weight was 3Kg &length 52 cm. He was thriving normally till 1 year of age when his father's job

•demanded a transfer to Kerala .•There was no history of significant illness or c/c medication

in the past. But he was not growing normally & was the smallest child in his class. Examination revealed an active child with stable vitals General examination was not contributory except for pallor & mild abdominal distention.

Systemic examination was normal . •

15• .But he was not growing normally & was the smallest child in

his class.•Examination revealed an active child with stable vitals.General

examination was not contributory except for pallor & mild abdominal distention. Systemic examination was normal

•Weight-11Kg Height-88cm US:LS-1.25:1Head circumference-50cm MAC14cm Investigation

• Platelet-1.34L/mmHb-9.2gm% MCV-106fl•TC-6700cells/mm3 DC-N45,L50, E2 M3

•ESR-12mm/hr •Urine & stool examination-normal TFT-normal

•A serologic information confirmed the •diagnosis

15

• Q1.What is the most likely diagnosis?•Q2.What is the characteristic pathologic

finding?•Q3.How will you treat the anemia?

•4 .Best serological test ?

15

1.Celiac disease•2.villous atrophy & hypertrophy of crypts

3.folic acid-1mg/day4. TTG

mannedDevelopmental assessment

• Assess the developmental age of this child using the the materials provided

• This is the CXR of a 2yr old girl who is being evaluated for recurrent respiratory infection. What is your diagnosis?

16A

16a

• Nodular prominence of costochondral junction consistent with rickets

16B

• These are the chest Xray & peripheral smear of a 10 mo old infant. What is your diagnosis?

• Right Isomerism• Asplenia, Howell Jolly bodies

16B

16C

• This is the xray of one month old child who has been evaluated for neonatal cholestasis . What is your diagnosis?

• Celery stalk appearance• Congenital rubella syndrome

16C

16D

• This is the ray of the child who presented with short stature

• What is the diagnosis?

• Small Sqare iliac wings,• horizontal acetabular roof,• narrow sacrosciatic notches,• decreasing inter peduncular distance L1 to L5

16D

19 Akhil 2 month old male child was brought to

casualty with poor feeding,lethargy,vomiting, cold extremities and pallor

• Antenatal period was uneventful except for last trimester AFI-25

• O/E PR-100/mt BP-76mm Hg• Afebrile• Wt-2 Kg Length-54cm HC-35cm• Systemic Examination Chest –clear• Liver span 12 cm

19Hb-9gm% TC-5600 , DC-P46 L50 M4ABG-pH: 7.48 , pCO2: 49mmHg, HCo3 : 36meq/lSerum Na: 132, K-2.5meq/l, urine Na-25meq/l• Urine chloride-30 meq/l • Give 2 important differential diagnoses.• How will you differentiate them?• What is the abnormality in each?

19ANS• Bartter Syndrome, Gitelman syndrome• Bartter syndrome - Hypercalciuria• Gitelman Syndrome -Hypomagnesemia and hypocalciuria• B syndrome - Autosomal recessive inborn defect Na K 2Cl-

cotransporter in thick ascending limb of loop of Henle lead to Na ,Cl and water wasting.

• G syndrome- defect in distal tubule Na+cl-co transporter

• e

20A• What is the diagnosis?• What is this peculiar appearance of the cells

due to?• What is this peculiar appearance called?• Mention the characteristic radiological

finding.

Ans20A

• Gaucher cell• Due to accumulation of glucocerebroside• Crumpled tissue paper appearance• Erlen meyer-flask appearance of femur

This the CBC of child What abnormality in the psmear will give clue to diagnosesWhat is the diagnosesWhat specific test you will order to diagnose What are the drugs of choice

20b

ANS20b

• Macrocytic Anemia ,Increased RDW• Megaloblastic Anemia• B12,Folicacid Assay• B12,Folic Acid

21• Advise regarding immunization in the following

situations 1. 12 Yr old child is a case of sickle cell disease

fully immunized as per the national immunization schedule. He had also received MMR , hepatitis-B and pneumococcal polysaccharide vaccine at the age of 2.5 yrs.

2. 2.5 yr old girl child had underwent hematopoietic stem cell transplantation 2 months ago . She is fully immunized with HepB,Hib and MMR vaccines.

• One dose of PCV13• One dose of PPV23 ,8wks later

23 doses of DPT,IPV, Hib, HepB at 12mo, 14mo,

24mo post transplant2 doses of PCV & 1dose of PPV23 at 8wks intervals,

beginning 12mo post transplantRestart influenza vaccine 6 mo post transplant &

continue lifelongMMR& Varicella vaccine at 24mo post transplant, if the

child is adjudged immunocompetent

You are called in to resuscitate a newborn going to be delivered by emergency LSCS for fetal distress evidenced by fetal bradycardia When delivered you find an actively crying term baby. But the heart rate remained less than 60. Baby started feeding normally when put to breast after 4 hrs.

• What is the most likely diagnosis?• What general examination findings you will look for?• What is the treatment?• What is the prognosis?• What is the pathogenesis of this disorder?•

21

1.Congenital heart block-neonatal lupus2.Neonatal lupus3 .Cardiac pacing4 .Excellent prognosis after pace maker implantation .Future auto immune reaction is rare.If not corrected later exercise intolerance arrythmia and death 5. Due to passive transfer of maternal anti-Ro(SSA) and anti-La(SSB)antibodies to fetus

21

22 A 9 month old infant was admitted with a history of fast

breathing,cough and fever of 5 days duration.There was history of paternal death two months back.Examination revealed oral thrush,cyanosis, chest retractions and bilateral crepitations.SpO2 was 85% in room air. LDH was 1000mg/dl. X Ray showed a ground glass pattern.

• 1. What is the most probable cause for the present symptoms?• 2.What is the drug of choice and dosage needed to treat this

condition?• 3.What underlying condition will you suspect and what definitive test

will you do?• 4.Outline any longterm medications this child will require if

the diagnosis is confirmed?

22

1.PCP pneumonia2.Cotrimoxazole 20 mg/kg/day3.HIV infection. DNA PCR4. Anti retroviral therapy zidovudine,

lamivudine, nevirapine with cotrimoxazole prophylaxis

232yr old Rajat, who was screaming like anything , was

brought to the casualty. He was keeping his right hand in pronated position & was not allowing any one to touch it.

He was attending a party along with his parents. Child was perfectly alright & playing with his friends. All the problems started when the mother stopped him by holding his Rt hand as he was running to the pool side.

Q1 .What is the most likely diagnosis?Q2. How will you manage?

1.Nursemaid’s elbow/pulled elbow

2.Rotate the hand & forearm to a supinated position with pressure over the radial head

23

• What is the diagnosis of this child who presented with fever , pallor and bleeding manifestation

• What is the specific genetic abnormality commonly associated with this disease

• What is the Drug of Choice and what is its mechanism of action

24a

• Hypergranular AML M3• t 15;17 • ATRA(all - trans Retinoic Acid)• Able to bind to the PML/RAR alpha fusion

protein & allow subsequent transcription and gene expression

24a

24a

24 BThis is a platelet Histo gram

What is the abnormality and mention four common causes this

• Increase in Mean Platlet Volume• Schistocytes • Microcytes • Giant platelets• Platelet clumps

24 B

Answer

1.Rapport2. Grading of asthma3.What is asthma?4. Need for inhaler5. Proper technique demonstration6. Doubts

26• A couple, husband 30 years and wife 24 years

comes to your clinic. Their first child has clinical features of Down syndrome and karyotyping report is shown. The wife has missed her periods and is anxious to know whether the same problem will be repeated in this pregnancy also.

• What is the karyotypic abnormality• What is the relevant investigation at this stage?• How will you stratify the risk as per the

investigation result

26

• 14, 21 translocation• Parental karyotyping indicated• Risk- if father is carrier risk is 2-3%, if mother

is carrier, risk 10-15%, if both have normal karyotype, the risk is low but more than 1%

30

• 9 yr old boy is brought in coma with h/o high grade fever of 2 days duration and seizures. LP is deferred since he is unstable

• His peripheral blood smear is given • What is your diagnosis• Mention the 2 specific drugs of choice• Name 4 important complications

30

• Cerebral Malaria• Quinine sulphate i/v• Artemisine derivative• Anemia,Hpoglycemia,Shock(algid

malaria)Metabolicacidosis,seizures,Jaundice,

• Prostration,Acute renal Failure,Infection

31• This is the growth chart of a 8 yrs old male child. His

height is 110cm & weight is 18 Kg. Q1. What is his height age? Q2. What is his weight age? Q3.What is his bone age as per the chart? Q4. Height of the father is 170cm & that of mother is 160cm. What is the MPH? Q5.His height after 4mo is 112cm. What is his

height velocity?•

Ans31

1) 5 yrs2) 5yrs3) 4yrs4) (170+160+13)—171.5cm5) 6 cm/yr

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