Wrwer

Comprehensive
Paeds OSCE Notes

1st Edition

By: Dr. Minhal Khan (DMC ,
DUHS)

Reviewed by: Dr. Raja Shakeel Mushtaq
Dow Universsity of Health Sciences, Karachi.

Comprehensive Paeds OSCE Notes

Founder Comprehensive
Book Series: Dr. Raja Shakeel Musthaq
Dr. Idrees Muhammad Soomroo

Author: Dr.Minhal Khan

Reviewed & Edited
By: Dr. Raja Shakeel Mushtaq

Published by: Ali Publishers
03219214876
Price: Rs. 180/-
All rights reserved, no part of this publication may be reproduced
or distributed in any form without permission in writing from
authors.

MEDICAL STUDENTS FOUNDATION
VISION TO FUTURE:
It is a non political, nonprofit, volunteer organization founded by
DUHS graduates, for Electives rotation for students particularly
in Pakistan and all over the world.
Aims and objectives of this organization is to provide medical
students a platform where they can find everything they need
and provide them awareness for their career options. They can
join and start working with people who have research
experience and can aid medical science in future. They can read
about and meet medical students who have something to say for
their inspiration, can read clinical cases and improve their
knowledge. This platform is a complete one for medical students
and we hope they find it useful.

Founded by:
Dr. Muhammad Idrees Soomro
Dr. Raja Shakeel Mushtaq
Dr. Zubair Ali Khwaja
Dr. Khaliq Pirzada

Links: www.msfpakistan.com
And facebook page: www.facebook.com/msf.pakistan

This is series of books containing exam oriented books and this is founded by
Dr Raja Shakeel Mushtaq A Dr. Idrees Soomro.
Following are the books available under the tide of this series
Comprehensive BCQs in General Surgery
Comprehensive BCQs in Special Surgery
(Both Books have chapter wise and exam oriented BCQs edition of bailey
and love)
Comprehensive Clinical Skills in Medicine
(helpful in 3
rd
, 4
th
, final year and also to HOs)
Comprehensive Pediatrics Review
(helpful stuff for final year and beyond)
House Officers Manual
(useful for HOs and for anyone practicing medicine in any ward)
Comprehensive Surgery OSCE Notes
(comprises important OSCE notes for exam oriented surgery)

This Book Is Dedicated To:

My Creator, who gives me
courage to fulfill my dreams
against all odds.

Acknowledgements:

My special thanks to:
Dr Shakeel Mushtaq (batch
2011)
Dr Idrees Soomro (batch 2011)

How to Contribute:
Send us your valuable suggestions, queries & contributions to:
abeernisar.a@hotmail.com

comprehensivebcq_786@live.com

dowites.msf@gmail.com

Your name will be included in the list of contributors in the
next edition of this book.

Preface

Paeds OSCE, in the terms of scenarios is
usually regarded as tough by our seniors. So in
my semester 10
th
, I tried to collect as many
past OSCEs as I could but whole semester l
kept on thinking what exactly is there in OSCE
which makes it difficult. When l took my OSCE,
I realized that there was nothing hard in it,
just that you need to prepare yourself for an
exam where you will be asked about
everything, including history, the different
instruments, lab reports, examinations.
So I decided that I should help my juniors in
making a book of all Paeds notes I wrote and
all the past DMC/SMC OSCEs I had. Answers of
all the OSCE questions are taken from
authentic books.
I wish best of luck to all my juniors.

Dr. Minhal Khan (DUHS)

Content
Histories Page 1
Examinations Page 24
2010 semester IX Page 95
2010 semester X Page109
2011 semester IX Page122
2011 semester X Page138
2012 semester X Page 167
Figures Page 236


1

BASIC PRINCIPLES OF
PEDIATRIC HISTORY

Biographical information:
Name/preferred name, date of
birth, sex, ethnicity, contact
information for parent or
guardian, living situation and
home environment.
Presenting complaint:
A brief description by the
patient or parent of the
complaint(s) bringing the child
to see the doctor.
Is it the childs complaint or is it
the caregivers or a teachers?
History of present illness:
Timing of the problem: onset,
frequency, time of day, and
duration. Is it ongoing? Has it
happened before? If so,
characterize.

2

Pinpoint location of the
symptoms or pain as much as
possible, and ask about
position, quality, radiation, and
severity.
Aggravating and alleviating
factors: does anything seem
to make it better or make it
worse? Is the pain better with
food or worsened with
consumption of food? Bowel
movements? School
avoidance?
Associated symptoms: ask
about vomiting, character of
vomitus, colour of vomitus
(bilious? bloody?),
regurgitation, heartburn,
abdominal pain or discomfort,
abdominal distension, bowel
movement patterns, stool
character and colour (red,
black, brown,
steatorrhea/fatty), fever,
systemic symptoms. Are any
symptoms associated with
eating or bowel movements?

3

Use the FIFE acronym: ask
about Feelings, Impressions,
Function, and Expectations.
How do the symptoms affect
the child and the family? What
does the child or parent think is
causing the symptoms? How
have the symptoms affected
the childs appetite, sleeping
patterns, or ability to play?
What would you like to get out
of the visit today?
Past medical history:
Antenatal History: health of
mother during pregnancy (ask
about medications, vitamins,
diet, alcohol use, tobacco use,
illnesses, stresses, vomiting,
complications (for example,
polyhydramnios, toxaemia,
gestational diabetes,
hypertension, or eclampsia),
Rh serology, radiation
exposure, bleeding); mothers
previous pregnancy history.

4

Prenatal History: timeline of
prenatal care, onset of fetal
movement
Birth History: duration of
pregnancy, location and time
of delivery, type of delivery
(breach, cesarean section,
vaginal), length of labor,
amount/type of anesthetics or
analgesics used.
Peri- and Postnatal History:
APGAR score, onset of crying,
first breath, breathing
problems, birth weight, birth
length, head circumference,
presence of jaundice or
cyanosis, presence of
convulsions, fever,
haemorrhage or birth injury,
congenital abnormalities,
presence of meconium,
feeding history, number of
days in hospital, NICU
admission, discharge weight,
illness in first month of life.
Screening procedures (types,
such as sickle cell, G6PD,
lead, HIV, genetic or metabolic

5

screens, and results);
immunizations (ages, types,
presence of reactions,
seasonal influenza).
Infant nutrition: formula (type,
concentration, amount with
each feeding and within 24
hours, changes, duration,
problems, burping,
regurgitation); breast
(frequency, length, problems,
weaning how were they
weaned, and at what age),
introduction to solid foods
(when, how, what types, how
were they taken, what was the
reaction to the solid foods),
following Canada Food Guide.
Overfeeding can be a common
problem for new breastfeeding
mothers.
Childhood nutrition: vitamin
supplements (what types,
when were they started,
amount), appetite (likes and
dislikes), eating habits, food
variety, fruit and vegetable
consumption, protein, junk

6

food, food allergies (for
example, cow milk protein).
General childhood health
Past illnesses: infections (type,
quantity, severity, age), past
hospitalizations (age,
indication), past operations
(age, indication), allergies
(insulting agent; ask patient or
parent to specify the reaction;
if anaphylactic, ask if they
carry an EpiPen).
History of trauma. Is/was there
any lasting sequelae?
Developmental history:
physical growth (height/weight
growth charts is or has the
child been failing to thrive?),
time of milestones (age when
first held head up, rolled over,
sat up alone, crawled, walked
alone, said first word, toilet
trained, dressed without help,
tied shoes without help;
compare milestones to siblings
if applicable), dentition (age of
first teeth, loss/eruption of
teeth), development of

7

secondary sexual
characteristics (females
development of breasts,
axillary hair, pubic hair,
menarche; males
development of pubic hair,
voice changes, emissions).
Family history: age and health
status of immediate family
members, communicable
disease history, genetic
disease history, health status
of living children.
Current health status:
Allergies (food, medications,
environmental irritants,
eczema, asthma, allergic
rhinitis).
Current medications:
prescriptions (type, indication,
dose, frequency), over-the-
counter drugs (including
antipyretics, cough and cold
remedies, supplements), and
alternative medications/herbal
remedies.

8

Environmental risks/exposures
(for example, underprepared
meals or contaminated
drinking water).
Safety measures (car seats,
choking, falls, injury
prevention, drowning, bicycle
safety, seat belts, sexual
practices, violence)
Exercise (type, duration,
frequency)
Sleep: length of sleep at night,
naps, and character of sleep.
Does the child experience
nightmares? Sleep-walk?
Sleep-talk?
Elimination: urination patterns
(discomfort, blood, control).
Personal habits: nail biting,
thumbsucking, tobacco,
alcohol, caffeine, drug use.
Psychosocial history:
infant/child-parental
attachment, school (ability to
function,
strengths/weaknesses, special
classes), home situation
(marital status, type of home,

9

parent occupations, principal
caretaker), socioeconomic
status of family, support
systems, religious
beliefs/preference, personality
(anxiety, independence,
relationship with peers and
family, self-concept), stressors
(parental, body image,
substance use,
work/school/home
surroundings).
Review of systems:
Serves to obtain additional
symptoms or signs and to
probe further systems related
to the present illness.
General/constitutional
symptoms: unusual weight
gain or loss, fatigue,
temperature sensitivity,
mentality, growth pattern
(height/weight charts), timing
of puberty.
Skin: rashes (for example,
eczema or diaper rashes), hair,
skin texture, colour, hives.

10

Eyes: vision, crossed eyes,
foreign body, nystagmus,
colour, glasses.
Ears, nose, throat: sore throat,
post-nasal drip, frequent
infections, congestion, ear
infections, hearing, sneezing,
snoring.
Cardiorespiratory: chest pain,
cyanosis, edema, syncope,
tachycardia, dyspnea,
coughing, wheezing, sputum,
stridor, secretions, snoring,
sleep apnea.
Gastrointestinal: vomiting,
abdominal pain, type of stool
(diarrhea, constipation).
Genitourinary: urinary patterns
(dysuria, polyuria, enuresis,
frequency), toilet training, urine
character (hematuria, pyuria),
discharge, menstrual history,
abnormalities of genitalia,
precocious puberty.
Neuromuscular: headache,
anxiety, dizziness, tingling,
convulsions, seizures,
problems with movement (eg.

11

ataxia), muscle/joint pain,
exercise tolerance, gait.
Endocrine: liquid/solid food
intake, growth disturbances.


12

SPECIFIC SYPMTOMATOLOGIC
HISTORIES

The Danger Signs:
Inability to feed or drink
Vomiting
Lethargy/Unconsciousness
Convulsions/Fits

Fever:
Fever is perhaps the most common
symptom of disease in childhood and
infection localized or generalized are
the most common cause.

Ask about:
duration of fever
intensity (low or high grade)

13

pattern
Any other associated
symptoms.

In a child no localizing features of
infection malaria, UTI and enteric fever
are the likely possibilities. Do not
forget to examine the throat of a
febrile child.

Feeding:

Ask about any change in milk
intake (in case of young child)
or food and water intake (in
case of older child) since
illness started
Infants have difficulty in
feeding if their nose is blocked
or mouth is sore.

14

Refusal to feed is an important
symptom in children and
indicates the severity of illness.
Inability to feed or drink
anything may be due to severe
respiratory distress, persistent
vomiting or unconsciousness.

Vomiting:

It is very common in sick children.
Vomiting and diarrhea together - due
to gastrointestinal infections are one of
the most common pediatric problems
in third world countries. Vomiting is
often associated with sore throat
fever or cough. Persisted vomiting
accompanied by distension of
abdomen suggests intestinal
obstruction or paralytic ileus.

Ask about following details:
Frequency and force of
vomiting.
Relationship of vomiting with
feeding.

15

Color and contents of vomitus

Remember that effortless
regurgitation of milk is common in
normal newborn and infants and
should not be confused with true
vomiting

Bowel habits:

Normal bowel habits of an
infant vary from 5 to 6
times/day to one in a couple of
days.
Breastfed babies usually pass
feed after every feed
(gastrocolic reflex)
Diarrhea is very common in
infancy, often accompanied by
vomiting or/and fever.
Most likely cause in our
country is GIT infection.

Other causes are:

1. Infection elsewhere
2. Inappropriate feeding
3. Drugs.

16

Ask about:

1. Duration
2. Frequency
3. Consistency
4. Color
5. Relationship to feeding
6. Odor
7. Contents
8. Presence of blood
9. Presence of mucus

Convulsions (Fits or Seizures):

These can be of recent onset,
associated with other symptoms eg
fever or can be recurrent. If doctor
himself has not observed the
convulsions (or fits), detailed
description by an observer is the
main information on which the
diagnosis is based.

True convulsions should be
differentiated from restlessness,
jerkiness, hysterical psychoneurosis,

17

tics, involuntary movements and
breath holding spells.

Febrile convulsions - associated with
high grade fever are common in
children between six months and five
years of age. There may be previous
history of such convulsions in the
child or in the family. Meningitis
(pyogenic or tuberculous) and cerebral
malaria are the two disease which
must be suspected and excluded in
any child with acute onset of fits.

Cough:

Respiratory tract infections are very
common in children and cough is an
important presenting symptom.

Cough may be due to common cold,
pharyngitis, tracheobronchitis or
pneumonia. Long bouts of cough
associated with a whoop, cyanosis,
apnea or vomiting may indicate
whooping cough.


18

Ask the following questions about
cough:
1. Is it dry or wet (children usually
swallow the sputum)
2. Is it worse at a particular time
of the day (late night or early
morning cough may be due to
asthma)?
3. Is there any relation with
feeding (cough during feeding
may indicate inflamed throat or
incompetent swallowing)?
4. Is it accompanied by wheeze or
fever?

Difficult Breathing (Respiratory
Distress):

Difficult breathing may be acute (of
recent onset), or recurrent over a
period of time. Sometimes it may be
chronic and persistent.
Pneumonia, asthma and heart disease
(congenital or rheumatic) are the
important causes of respiratory
distress in children.

Ask about:

19

1. Age of onset
2. Duration
3. Relation with activity
4. Relation with feeding in young
infant
5. Pretence of cough, stridor,
wheeze or cyanosis.

Rashes:

Skin rashes are frequent in children.
Common causes of generalized
rashes are exanthematous fevers (eg.
measles, chicken pox, rubella).
Localized rashes may be due to
eczema, scabies, allergy and drugs.
Find out
Duration.
Site and distribution.
Type (macular, papular,
vesicular, pustular, purpuric)
Presence of itching.
Purpuric rashes are due to bleeding
disorders eg. thrombocytopenia.

Cyanosis:


20

It is the bluish discoloration of skin
and mucus membranes due to low
hemoglobin. In children it is either
due to congenital cyanotic heart
disease or a severe respiratory
disease.

Ask about:
1. Age of onset
2. Duration
3. Episodic or persistent
4. Associated symptoms

Jaundice:

In older children, viral hepatitis is an
important cause.

Jaundice developing after birth is a
different entity. It occurs in more than
50% of newborns. In case of
neonatal jaundice, THE TIME OF
ONSET AFTER BIRTH is very
important. If its on the the 1
st
day
then it can be due to hemolytic
disease of the newborn, while
appearing on 2
nd
or 3
rd
day, its
usually physiological. If it persists

21

beyond 2
nd
week of life then
consider:
1. Prolonged physiological
jaundice
2. Biliary obstruction
3. Neonatal hepatitis

Lethargy & Unconsciousness:

Its a sign of severe disease
particularly acute illness.
Unconsciousness is usually due to
severe metabolic or neurologic
disorders like:
1. Meningitis
2. Encephalitis
3. Cerebral malaria
4. Severe dehydration
5. Renal failure
6. Hepatic encephalopathy
7. Hypoglycemia

Posture and Gait:

Rickets, polio, cerebral palsy,
muscular dystrophies, hemiplegia.
paraparesis and congenital
abnormalities can affect the childs

22

gait and posture. Ask about the
duration and specific problems with:
1. Neck holding and sitting
2. Standing and walking
3. Usual body movements

Involuntary Movements:
Get the full description of involuntary
movements from parents or patient if
he is old enough. Obtain information
about:
1. Age of onset.
2. Duration.
3. Any relation with febrile illness
4. Progress since onset.

Hearing:

Hearing defects are frequent in
children Ash whether he responds
(by turning his face) to any voice out
of his field of vision, and whether he
has difficult] understanding your
commands. Hearing problem can be
due to congenital or acquired
diseases (
due to recurrent/persistent middle ear
disease)

23


24

EXAMINATION SKILLS
Inspection:
Shape
Movements with respiration
Symmetry
Visible peristalsis, pulsations,
stria, scars, veins, hernia
orifices.
Pubic hair distribution
Umbilicus
Palpation:
Guarding with or without pain
Tenderness
Mass
Spleen measurement notch
Liver upper border by
percussion lower border span
tenderness surface pulsatile
liver
Kidneys

25

Urnary bladder
Percussion
Liver upper border lower
border confirmation
Urinary bladder confirmations,
measurement
Percussion of mass
Fluid thrill
Shifting dullness
Auscultation
Gut sounds intensity and
frequency
Bruit aortic hepatic and renal
Friction sounds hepatic or
renal
INGUINAL REGION AND
GENITALIA:
MALE GENITALIA
Testicular descent
Inguinal hernia

26

Ambiguous genitalia
Hypospadias
Epispadias
Phimosis
Hydrocele
Scrotum
Ulceration
Testicular sensation
Testicular mass
Examination 1
FEMALE GENITALIA
ANUS
1: examine abdomen and genetalia
of child and describe positive
findings?
A.1:
Patency, fissure, prolapsed,
perianal dermatitis
Hepatomegaly and
splenomegaly

27

Examination 2
Examine liver?
Method:
Start from the right iliac fossa. Ask
the patient to breath deep. Press the
hand inwards and upwards during
expiration and keep it steady during
inspiration. At the height of
inspiration release inward pressure
and maintain upward pressure. If
liver is palpable its edge will descend
during inspiration and palpable, its
edge will descend during inspiration
and palpable In the right iliac fossa
move the hand gradually upwards
with each respiration till right costal
margin.
Q: what are different causes of
hepatomegaly?
Inflammation:
Viral hepatitis

28

Bacterial or amebic abscess,
sepsis, cholangitis.
Drugs
Auto-immune, SLE, sclerosing,
cholangitis, sarcoidosis.
Infiltration:
Pri: liver tumors
Sec: tumors
Storage disorder:
Lipid
Glycogen
Fat, obesity, D.M
Vascular:
CHF thalassmia, sickle cell anemia
Examination 3
1: Examine spleen?
Methods:
Place the right hand in the right iliac
fossa, fingers facing towards left

29

hypochondrium press the hand
during expiration and keep it steady
during inspiration (similar to palpation
of the liver ) release the pressure at
the height of inspiration so that
fingers slip over the edge of the
spleen if it is palpable. Move the
hand gradually towards left
hypochondrium.
2. What are different causes of
splenomegaly?
A.2: Infections:
Bacterial:
Thyphoid fever, septicemia T.B
Viral:
Viral hepatitis EBV CMV
Rubella herpes birus
Protozoa:
Malaria, Kalazar.

30

Rickettsiae:
Thyphus fever
Haematological Disorders:
Hemolytic Anaemia
Malignancy of blood elements
Extramedullary erthropoiesis
Examination 4
1: Palpate abdomen and tell
positive findings?
A1: Abdomen:
Palpation:
Guarding with or without pain
Tenderness
Mass
Spleen: measurement, notch
Liver: upper border by
percussion, lower border.
Span, tenderness, surface,
pulsatile liver
Kidneys

31

Urinary bladder
Findings:
Liver was palpable two fingers
below the sub costal margin.
Examination 5
1. percuse abdomen of child and
describe findings?
Percussion:
Liver: upper border, lower
border confirmation
Urinary bladder: confirmations,
measurement
Percussion of mass
Fluid thrill
Shifting dullness
Findings:
Fluid thrill and shifting dullness
positive.
Examination 6

32

1. examine Lymph nodes?
A.1: Method of palpation:
Stand behind the patiet, flex his neck
and push middle and ring fingers of
both hands under the chin move the
fingers backward to palpate
submental and submandibular
groups. Then palpate in front and
behind the auricle and over the
occiput . Move your fingers
downwards behind the sternomastoid
towards clavicle for lymph nodes of
posterior triangle for papation of
supravlvaicular fossa push your
fingers behind the clavicle finally
move the fingers upwards between
trachea and sternomastold for lymph
nodes of anterior triangle.
Note the following features if lymph
nodes are palpable.
Site
Size

33

Number
Consistency
Mobility with reference to each
other(matted or discrete). To
overlying skin and to
underlying structures.
Tenderness
Discharge or sinuses.
2. tell cause of : Generalized
lymphadenopathy?
A2: Infections:
Bacterial
Viral
Protozoa
Fungal
Malignanies:
Primary
Metastalic
Lipid storage disease
Auto immune disease
Drug reactions

34

Examination 7
1: Do general physical examination
and tell findings?
GENERAL PHYSICAL
EXAMINATION:
A.1;
Appearance
Behavior
Reponse to surroundings
Position
Cry
Facies
Head
Hair
Ears
Eyes
Nose
Lips
Tongue
Palate
Gums
Buccal mucosa

35

Teeth
Throat
Neck
Chin
Abdomen
Hands
Feet
Skin
Bones and joints:
Muscles
Gait
Congenital
Genitalia
Reflexes:
Moro
Rooting
Sucking
Grasping (palmar)
Grasping (plantar)
Examination 8

36

1. Examine respiratory system and
tell findings?
A.1: Inspection:
Shape
Symmetry
Chest movements
RR
Type of repiration: AT or TA
kussmal`s
Deformities: Pectus
carninatum pectus
excavatum,rickety rosary,
scorbutic rosary, Harrison`s
sulcus, barrel chest, kyphosis,
scoliosis, lordosis, pre-cordial
bulging localized bulging or
depression accessory muscle
use Nasal flarting supra-sternal
recessions, supra-clavicular
recessions, intercostals
retractions indrawing of ribs
(sub costal recessions)

37

Visible vein, pulsations, scare,
etc
Grunting stridor, wheeze,
sighing respiration.
Palpation:
Trachea
Apex beat
Chest movement
Chest expansion
TVF
Tenderness
Crepitus
Palpable sounds
Percussion:
Note on all intercostals spaces
Upper border of liver
Lower borders of liver
Comparison on both sides
Tidal percussion
Auscultation:

38

Breath sounds
Added sounds
Vocal resonance
Whispering pectoriloquy
Forced expiratory time
Findings:
Decreased air entry on right
side
Dull percussion note on right
side
Decreased breath sounds on
right side
Examination 9
1 examine front of chest?
A.1: Inspection:
Shape
Symmetry
Chest movements
RR
kussmal`s

39

Deformities: Pectus
carninatum pectus
etc
Palpation:
Trachea
Apex beat
Chest movement
Chest expansion
TVF

40

Tenderness
Crepitus
Palpable sounds
Percussion:
Tidal percussion
Auscultation:
Breath sounds
Added sounds
Vocal resonance
Findings:
side
side

41

right side
Examination 9
1. examine back of chest and tell
positive findings?
A.1: Inspection:
Shape
Symmetry
Chest movements
RR
kussmal`s
Deformities: Pectus
carninatum pectus

42

etc
Palpation:
Trachea
Apex beat
Chest movement
Chest expansion
TVF
Tenderness
Crepitus
Palpable sounds
Percussion:
Tidal percussion

43

Auscultation:
Breath sounds
Added sounds
Vocal resonance
Findings:
side
side
right side
Examination 11
1. percuss and ausultate back of
chest
A1: percussion:
Note all intercostals spaces

44

Comparision on both sides
Tidal percussion
Auscultation:
Breath sounds
Added sounds
Vocal resonance
2. describe two causes of resonate
percussion note?
A2:
Pneumothorax
Emphysema
3. tell causes of dull percussion
note?
A3:
Thick chest wall
Collapse consolidation

45

4. what are causes of stony dull
percussion note?
A4:
Pleural effusion
Emepye1ma
Examination 12
1. auscuitate chest?
A1: Auscultation:
Breath sounds
Added sounds
Vocal resonance
2. what are different types of
breathing pattern?
A2:
Bronchial
Vesicular
Bronchovesicular

46

3. what is stridor?
A.3; it is a high pitched respiratory
sound produced by turbulent airflow
Examination 13
1. examine CVS of child and tell
findings?
A.1: pulses:
Rate
Rhythm
Volume
Character
Radio-radial delay
Radio-femoral delay
Comparison
Condition of wall
Check for collapsing pulse
BP
JVP or neck Veins:
Level

47

Precordium:
Inspection
Chect deformity
Pulsations
Bulging
Prominent veins
Scar
Palpation
Trachea
Apex beat site character
Heave
Palpable heart sounds
Thrill site timing
Palpable pericardial rub
Auscultation o all 4 areas puls
neck left axillia and back
Heart sounds S1,S2,S3,S4,
splitting, intensity
Other sounds opening snaps
clicks prosthetic valve sounds
Murmurs timings intensity site
of max intensity radiation

48

character pitch effect of
respirations effects of posture.
Pericardial rub.
Findings:
Apex beat palbable in the sixth
intercostals space just lateral
to the mid clavicular line.
There is a pan systolic
murmur.
Examination 14
1. examine precordium?
A.1:
Precordium:
Inspection
Chect deformity
Pulsations
Bulging
Prominent veins
Scar
Palpation

49

Trachea
Apex beat site character
Heave
Palpable heart sounds
Thrill site timing
Palpable pericardial rub
Pericardial rub.
2. write causes of soft heart sounds
(any three)?
A.2:
Pericardial effusion
Emphysema

50

Thick chect wall
Examination 15
1 auscultate precordium?
A.1:
Pericardial rub.
2. what is thrill?
A.2: Palbable mrmur is known as
Thrill.
Examination 16
1. define pulse and examine pulse?

51

A.1: definition of pulse:
The pulse is a wave imparted
by the contraction of the left
ventricle to the blood column
Examination;
Consent
Right side approach
Introduction
Methods:
Pulse becomes impalpable
when systolic pressure falls
below 50mmHg in adults
Radial Pulse: it is the most
easily accessible and the most
commonly felt pulse. The
patient`s hand should be
slightly flexed and pronated.
Press the radial artery against
the head of the radius.
Brachial Pulse: Flex the
patient`s arm and feel for the

52

tendon of the biceps, press on
its medial side with the thumb
of your opposite hand.
Carotid Pulse: place the thumb
or fingers of your opposite
hand along the anterior border
of the sternomastoid, at the
level of laryngeal cartilage and
press backwards. Keep in
mind that carotid sinus
(present at the bifurcation of
common carotid artery) may be
stimulated and cah result in
bradycardia or syncopy. Don`t
palpate both carotids
simultaneously because blood
supply to the brain may be
critically reduced palpate the
right carotid from the right side
and the left from the left side.
Femoral Pulse: press with the
thumb/ finger halfway between
the anterior iliac spine and the
pubic lubercle along inguinal
ligament.

53

Popliteal pulse: popliteal artery
lies deep in the popliteal fossa
and is difficult to palpate. Flex
the knee at an angle of 120o
and push fingers of both hands
into the popliteal tossa.
Dorsalis pedis pulse: palpate in
the proximal part of the first
intermetatarsal space.
Posterior tibial pulse: palpate
behind the medial malleolus.
During the examination of pulse note
the following features:
Rate
Rhythm
Volume
Character
Comparision with other pulses
Condition of the vessel wall
2. what are different types of pulse?
A2:

54

Slow rising pulse
Collapsing pulse
Pulsus bisferiens
Jerky pulse
Pulsus paradoxus
Pulsus alternans
Pulsus bigeminus
Examination 17
1. Measure BP (blood pressure) of
child by different methods?
A.1: examination;
Consent
Right side approach
Introduction
Method:
(Pediatric cuff should be used)
Patient should be resting and
relaxed, sitting or lying. The
cuff should be wide enough to

55

cover about thirds of the arm
length.
Remove all the clothing from
the upper arm. Apply the cuff
closely to the upper arm in
such a way that its lower
border is not less than 2.5cm
(1) above the cubital fossa
and tubing is on the medial
side.
Palpatory Method:
Feel the radial pulse. Inflate
the cuff to a pressure above
the level at which the radial
pulse becomes impalpable
and then gradually deflate
it. The level at which the
radial pulse becomes
palpable again is taken as
the systolic pressure. It is
afew mmHg less than the
systolic pressure measured

56

by the auscultatory method
. define the cuff completely.
Auscultatory method:
Palpate the brachial artery
which lies on the medial
side of the tendon of the
biceps. Place the
stethoscope lightly over it
and inflate the cuff above
the systolic level
determined by the palpatory
method. Lower the pressure
in the cuff by 5 mmhg at a
time. The level at which the
krotokoff sounds are heard
for the first time is the
systolic pressure. The
character of the krotokoff
sounds varies as the
pressure is lowered frther
suddenly they become faint
(phase IV) and then
disappear (phase V) the
level at which sounds

57

disappear is the diastolic
pressure.
2. what is pulsepressure?
A2: it is the difference between
systolic and diastolic pressure.
(Normal range is 30-60 mmHg)
3. what do you mean by Silent Gap?
A.3: Normally krotokoff sounds once
become audible at the systolic
pressure, only disappear at the
diastolic pressure. Only disappear at
the diastolic pressure. In same
hypertensive patients these sounds
disappear for some time between
systolic and diastolic pressure. This
is called silent gap.
Examination 18
1. examine JVP
A.1: Exmination:
Consent

58

Right side approach
Introduction
Methods:
The patient should be propped
up at an angle of 45
o
if there is
slight increase in the right atrial
pressure, venous pulsations
will become visible is the neck
at this angle.
The head should be well
supported and slightly titled
towards left and be in line the
trunk
There should be enough light
Head end of the patient should
be elevated to an angle of 45
o

for examination of neck veins.
The internal jugular vein lies
deep with the carotid artery
and is not visible. But if venous
pulsations are present, they
can be seen along the anterior
border of the sternomastoid.

59

They are more easily visible
from the side.
2. define JVP?
A.2: A nearly accurate estimation of
right atrial pressure can be made
clinically by observing the upper limit
of venous pulsations in neck and
measuring its distance from sterna
angle.
3. what is normal right atrial
pressure?
A.3:5mmHg equivalent to 7cm hight
column of blood
4. what are different waves of JVP?
A.4:
Waves:
A
C
v

60

Descent:
X
Y
Examination 19
1 examine Motor system and
describe positive findings?
A.1: Exmination:
Consent
Right side approach
Introduction
Motor system:
Bulk and nutrition of muscles is
noted. Look for wasting or
hypertrophy
Muscle tone is assessed by
resistance to passive
movement, feeling muscles for
softness (hypotonia) or
stiffness (hypertonia), shaking

61

limbs and noting posture of
extremities.
Power in various groups of
muscles Is teated by asking
the patient to execute
movements against resistance.
2. what are positive findings?
A.2:
Bulk was normal
Tone was decreased on right
side leg
Power was 3/5 on right leg
Upgoing planter reflexes
dimmished on right side.
3. do grading of power?
A3: Grading:
Grade 0 complete paralysis.
Grade 1 A flicker of contraction
only
Grade 2 patient can move his
limb when graviy is excluded

62

e.g. moving limbs horizontally
on the bed.
Grade 3 patient can move
against gravity (can lift the limb
of the bed) but not against
resistance
Grade 4 patient can move
against resistance but power is
less than normal
Grade 5 normal power
Examination 20
1. examine Sensory system?
A.1: Exmination:
Consent
Right side approach
Introduction
Sensory system:
Touch:

63

Touch the skin with small point
of cotton wool or piece of
paper.
Ask the child to cose his eyes,
and raise his fingers say yes or
count when he feels the
touching object. He should
also tell whether sensations
are similar on both side of
different.
Pain: at first touch the child withboth
ends of the pin at a presumably
normal site to make him experience
what you mean by sharp and blunt .
then ask him to close the eyes, touch
him with sharp and bunt ends of the
pin in a random sequence and see
whether he can differentiate between
two or not. If patient can feel but
cannot distinguish between sharp
and blunt, it means his sense of
touch is intact but sense of pain is
lost.

64

Temperature: Take two test tube
containing cold and hot water and
apply to a healthy part so that child
experience the difference. Than
apply these tubes in random
sequesnce to the skin of the part to
be tested and ask him to indicate
whether its is hot or cold.
Sense of position and passive
movement:
There are number of ways of testing
sense of positin and passive
movements.
Ask the child to close the eyes.
After random movements in
different direction, place
patients limb in particular
position, making sure that it
does not touch body, and ask
him to imitate it with the other
limb. If sense of position is
intact he will bring the other

65

limb in exactly the same
position.
At first show child up and down
movements of the great toe.
Then stabilize the proximal
phalanx of the great toe by
grasping it between thumb
and index finger of your left
hand. Grasp the terminal
phalax of the great toe on its
lateral sides between thumb
and index finger of your right
hand. It should not be in
contact with the other toes.
Ask the patients to close the
eyes. Moe the terminal
phalanx gently and slowly up
and down in arandom
sequence so that patient
cannot guess and ask him to
identify the direction of
movement. Repeat the test on
contralateral side.

66

2. what are different types of
sensations, classify them?
A.2: sensations are of 2 types
Primary
Cortical
Primary:
Touch
Pain
Temperature
Position
Passive movement
Vibrations
Cortocol:
Localization
Two point discrimination
Stereognosis
Graphesthesia
Examination 21
1.Facial N examination?

67

A.1: Exmination:
Consent
Right side approach
Introduction
7
th
cranial nerve facial can
be tested by observing
during crying the symmetry
of face deviation of angle of
mouth to one side,
obliteration of nasolabilal
fold and inability to close
eyes. Also test for taste on
anterior two-third of the
tongue.
2. what is difference between upper
motor neuron and lower motor
neuron lesion?
A.2: there is sparing of face on the
affected side wrinkles will be present
when looking upwards.
3. what complications develop?
A.3:

68

Exposure keratitis
Corneal ulcers
4. what are causes of facial N palsy?
A.4:
Idiopathic
Infections (herpex simplex, GB
syndrome)
Otitis extrena, media
mastoidtitis
Intracranial Neoplasm
Examination 22
1 examine trigeminal N?
A.1:5
th
cranial nerve (trigeminal) has
two parts: sensor and motor.
Sensation should be checked on the
face and check corneal and
conjunctival reflex. Motor part
supplies muscles of mastication. Ask
the patient to clinch the jaws and feel
temporalis and masseter muscles. It

69

can also be tested by moving the jaw
from side to side also test jaw jerk.
2. what type of nerve is it?
A.2: it is a mixed nerve contains both
sensory and motor fibers.
3. sensory division of trignominal
nerve control which reflexes?
A.3: corneal and conjunctival
reflexes.
Examination 23
1. examine Accessory N?
A.1: 11
th
cranial nerve (accessory) is
teste by asking the patient to turn the
face to one side against resistance
and shrugging of shoulders.
2. which muscles will you examine
for assessing function of assessory N
?
A.2:

70

Sternocleidomastoid
Trapezius
Examination 24
1. examine reflexes?
A.1: Exmination:
Consent
Right side approach
Introduction
Bicep jerk (C5:6): flex the elbow at
right angle and place the forearm in a
semipronated position. Place the
thumb or index finger of your left
hand over the tendon of the biceps in
the cubital fossa and strike it with the
hammer. See contraction of biceps.
Triceps jerk (C6:7): place the forearm
on the patient`s abdomen elbow beig
flexed at right angle. Strike the
tendon of the triceps above the
olecranon. See contraction of the
triceps.

71

Brachioradialis jerk (C5:6): this is
also called supinator jerk. Flex the
forearm at elbow and place it in
semipronated position. Bend the
hand slightly towards ulnar side.
Strike the tendon of the
brachioradialis, proximal to the
styloid process of the radius. See
contraction of brachioradialis.
Ankle jerk (S1:2): patient should lie
supine. Flex the leg slightly and
place it in an externally rotated
position dorsiflex the foot with the left
hand and strike the achilies tendon
with the hammer. See contraction of
calf muscles.
Knee jerk (L3:4): Patient should lie
supine. Flex the knee and support it
with your left hand. Feel for the
tendon of the quadriceps and strike it
between the patelia and tibial
tuberosity with the hammer. See
contraction of the quadriceps.

72

2. what do you mean by upgoing
plantars?
A.2: upper motor neuron lesion
3. define clonus?
A.3: involuntary osceliatory muscular
contraction and relocation involved
by a sudden stretch of muscle
4. name different types of clonus?
A.4:
Ankle clonus
Patellar clonus
5. what is reinforcement
phenomenon?
A.5: reflexes are increased in
amplitude when muscles remote
from those being tested are
contracted forcefully. This is known
as reinforcement.
Examination 25

73

1. Examine cerebellum do cerebellar
signs?
A.1: Examination:
Consent
Right side approach
Introduction
Following are the signs of cerebellar
dysfunction:
Nystagmus
Scanning speech
Intention tremors
In coordination
Dysdiadochokinesia
Rebound phenomenon
Pendular knee jerk
Hypotonia
Ataxia
Drunken gait
Examination 26
1. Don signs of meningeal irritation?

74

A.1: Exmination:
Consent
Right side approach
Introduction
Signs of Meningeal irritation:
Neck rigidity: Flex the neck so that
chin touches the chest. Normally it
is possible but if meningeal
irritation is present. Neck
becomes stiff and rigid. Flexion is
not possible and causes pain.
Kerning`s sign: patient should be
lying flat with legs fully extended.
At first, flex the leg to be tested at
the hip and knee. If patient feels
pain in the hamstring muscles.
Kernig`s sign is positive.
Brudzinski sign: patient should be
lie supine. Flex the neck, if both
knees become flexed, sign is
positive. Another method is the
flex one leg at the hip and knee. If

75

other leg becomes flexed
automatically sign is positive.
2.what are signs of meingeal
irritation?
A.2:
Kernig`s sign
Brudzinksis sign
3. in which disorder they are
positive?
A.3: Meningitis.
4. if there is lesion of vermis what
signs will be positive?
A.4: truncal and gait ataxia
5. if there is lesion of cerebellar
hemispheres then what signs will be
positive?
A.5:
Finger nose test
Finger to finger test

76

Heel knee test
Intention tremors are present
Nystagmus towards the side of
lesion. There is
dysdiadokinesia.
Examination 27
1. Do neonatal examination (head to
toe)
A.1 Examination:
Wash hands properly before
examination.
Room temperature should be
appropriate
Remove all clothing.
Take antropometric
measurements (weight, length
and head circumference) and
plot on growth charts.
General inspection of the
newborn color activity posture
any gross congenital anomaly.

77

Rapid visual assessment of
gestational age.
Take vitals (respiratoy rate,
heart rate, temperature, and
blood pressure)
Skin examination (jaundice,
pallor, cyanosis, bruises,
rashes, any birth mark or
hemaginomas etc.)
Cardio-respiratory activity:
Central cyanosis
Tachypnea> 60/min
Grunting (it is sound produced
while expiration against
partially closed glottis)
Peripheral pulse and femoral
delay (if femorals are weakly
palpable always take four limb
blood pressure of rule out
coarctation of aorta)
Listen carefully for cardiac
murmur when baby is quite
and calm.

78

Listen for breath sounds or any
added sounds
Abdomen:
Look for shape of abdomen
(normally full, scaphopid in
case of diaphragmatic hernia)
Check umbilical cord for
presence of two arteries and
one vein
Palpate liver _up to 3 cm
below costal marging is
normal) and spleen (tip of
spleen is normally palpable in
newborn)
Palpate both kidneys
bimanually.
Palpate for any other
abdominal mass
Asucultate for bowel sounds
and look for passage of
meconium
Look for patency and (male,
female type or ambiguous, or

79

undescende tested and any
hypospadias, epispadias or
meatal stenosis or any
evidence of recto-vaginal
fistula)
Neurobehavioral activity:
Postures:
Neck retraction
Frog like posture
Hyper extension of limbs
Asymmetrical posture
Muscle tone:
Increased
Decreased
Tendon herks
Any abnormal movement
(jitters, convulsions)
Cry:
High pitched/shrill
Weak and un-sustained

80

Hoarse
Trunk and spine:
Meningo myelocele
Any sacral dimple or pit
Any lipoma or tuft of hair at the
spine
Neonatal reflexes:
Rooting reflexe
Sucking reflexe
Moro reflex
Grasp reflex
Peripheral nerve injuries (Erb`s and
klumpke`s paralysis)
Head, neck and face;
Dysmorphic features
Shape and size of the head
Shape and size of fontanellae
Over riding of sutures and
premature closure (cranio
synostosis)

81

Look for scalp vein ad texture
of hair
Any evidence of
cephalhermotoma, caput
succedaneum or craniotabes
Trans-illumination for evidence
of hydrocephalus
Any bruise or edema of face
Examine shape ad position of
eyes. Look for any evidence of
subconjunctival hemorrhage.
Check red reflex in both eyes
with ophthalmoscope to
watering and redness of eyes.
Look for the shape and
position of ears, any accessory
auricles or pre-auricle pits.
Check shape and size of nose,
check patency of nostrils.
Look for webbing orabnormally
snort neck, also palpate for
sternomastoid tumor and
fracture of clavicle
Limb and joints;

82

Look for any fixed deformities
like contractures band extra
digits and size of all limbs
proportionate to trunk and
body habitus
Especially examine both feet
for clubfoot deformity.
Screen every newborn baby
for congenital dislocation of hip
joint by performing barlow and
ortolani maneuvers.bu
Examination 28
1. do neonatal reflexes?
A.1; Sucking and swallowing reflex:
These are present in all the
newborns and are needed for
feeding. They can be assessed
during normal feeding process.
Sucking can be checked by placing a
clean finger in babies mouth.
Moro`s reflex: Buttocks back and
shoulders of the infants are

83

supported on one hand and arm or
on bed, and head on the other . if
head is lowered for an inch or so
arms and legs are abducted first and
then adducted.
Grasp reflex; For palmar grasp reflex
place a finger or pencil on infant`s
palm between thumb and forefinger,
he reflexly grasps it. For plantar
grasp reflex press heads of
metatarsals: there is flexion of toes.
Grasp reflex disappears at 2-3
months.
Rotting reflex: if light contact is made
with the infants`s cheek near the
angle of mouth, he turns his lips
towards that side.
2. name them
A.2:
Moro
Rooting
Sucking

84

Grasping (palmar)
Grasping (plantar)
3. till what age Moro`s reflex
persists?
A.3: 3-4 months age.
4. what is capul succedanum?
A.4; it is the baggy sweeling of the
presenting past of the scalp
developed during labor. It consist of
edema of subcutaneous tissue and
resolve in a few days.
5. what is physiological jaundice?
A.5: it is seen In more than 50% of all
the newborn it appears by day 2-3
and disappears by day 7-10 of life.
Examination 29
1. do FOC head circumference?
Do FOC head circumference.

85

1.What should be FOC of a child (at
different age groups)?
A.1: head circumference (FOC):
At birth 35.0cms
3 months 40.0cms
1 years 45.0cms
3 years 48.0cms
6 years 50.8cms
12 years 52.0 cms
2. what is normal FOC at birth?
A.2: 35cm
Examination 30
1. Do MAC?
A.1: method: Measure from
olecranon to acromion process take
mid of this and measure it by the inch
tape.

2. what is its importance?

86

A.2: it is used as screening test to
assess malnutrition in a community
3. what should be MAC is this child
(age could be mentioned)?
A.3:
Newborn 12cm
1 year 16cm
1-5 years 16cm
4. what should be FOC of this child
(age is 1 year)?
A.4: 45cm
Examination 31
1 Do PCM examination?
A.1 PCM Features:
Appearance: short stature in
vitamin D deficiency, marasmus
Face;

87

Old wise man look triangular
facies in Marasmus
Puffy moon face in Kwashiokor
Behavior:
Irritable, alert or lethargic in
Marasmus
Irritability in anemia
Skin;
Pallor in anemia
Petechial hemorrhages in
vitamin C deficiency
Flaky paints dermatitis is
kwashiorkor
Subperiosteal hemorrhages in
vitamin C deficiency
Fontanel`s: Anterior fontanelle large
and closure delayed in vitamin D
deficiency.
Head:

88

Frontal or parietal bossing or
caput quadratm /
quardrigeminum in vitamin D
deficiency
Large head in rickets
Craniotabes in rickets (before
1 year)
Hair:
Fine , straight brittle, spares
discolored hair in
kwashiorkor and mild to
moderate PCM
Aloperia in zinc deficiency.
Eyes:
Pale conjunctiva in iron, folate
and protein deficiency specially
anemia.
Coreal drying scarring hainess
ulceration opacity in vitamin A
deficiency

89

Bitot`s spots and night
blindeness in vitamin A
deficiency.
Mouth:
Psoriatic desquamating skin
lesions in zinc deficiency
Mouth ulcers cheilosis in
vitamin B deficiency
Gums: Bluish- purple, spongy,
swollen, bleeding gums in vitamin C
deficiency.
Teeth:
Delayed eruption in rickets
Defective enamel and caries in
rickets
Tongue: Glossitis (smooth tongue
with lose of papillae) in vitamin B
deficiency and anemia
Throat:
Palate:

90

Patechial hemorrhages in
vitamin C deficiency.
Pallor in anemia.
Cheeks: loss of buccal pad of
fat.
Neck:
Axillary folds:thin in PCM
Arms:
Tone decreased in PCm
vitamin D deficiency
Bulk decreased in PCM
Wrist; widened in vitamin D
deficiency
Hands:
Paloor in nails and skin in
anemia
Carpo-pedal spasm in
tetany
Chest:

91

Prominent rib cage in PCM
Rickety / rachitic rosary in
vitamin D deficienc
Harrison`s sulcus in Vitamin D
deficiency
Scorbutic rosary in Vitamin C
deficiency
Pigeon chest deformity in
rickets
Abdomen:
Distension in Pots`s diseased,
kwashiorkor
Hepatomegaly inkwashiorkor
Spine: kyphosis, scoliosos, lordosis
in vitamin D deficiency
Anus: Psoritic desquamating skin
lesion in inc deficiency
Legs:
Bow legs and knock knees
invitaminD deficiency

92

Generalized tenderness on
legs in vitamin C deficiency
Frog-like position in vitamin C
deficiency.
Ankle: ankle widening in vitamin D
deficiency.
DEVELOPMENT ASSESSMENT:
Vitals
Breasts
Nipples
Genitalia
Examination 32
1 examine patient of rickets?
A.1: look for:
Fontanelle
Frontal bossing
Rachitic rosary
Pot belly
Wrist widening
Bowing of legs

93

Examination 32
1 look for Anemia?
A.1 See the:
Conjunctiva
Tongue
Palmar creases
Nails
Skin
Mucous membrance
Examination 34
1 look for jaundice?
Look for:
Sclera
Tongue (ventral surface)
Hands
Nails
Skin
Mucos membranes
Examination 35

94

1. look for dehydration?
A.1: Look for:
Fontanelle
Eyes (sunken or shiny)
Tears present or absent
Mouth (dry or weight)
Skin turgor
Examination 36
1. Measure height of child?
A.1 Methods:
Make the child stand heel
buttocks and shoulder touching
the wall
Child should look straight.
2. what is difference between length
and height?
A.2: below 2 years length is taken
and after that height, when child is
able to stand.

95

PAPER 2010 (SEMESTER
IX)

Station 1:

A 5 years old child has history of
involuntary voiding of urine for the
last 1 month. He belongs to poor
socio economic group, his elder
brother also had some history.
1- What could be the best
possibility?
Ans: Nocturnal enuresis.
2- What treatment will you offer?
Ans: Through medical,
psychological and social
assessment:

96

Star chart maintain
Tri-cyclic drugs
Decompression (intranasal /
oral)
Bell and pad enuresis
alaram
Keeping a record or diary of
dry night.

Station 2:
An 8 years old child has history of
evacuation of faeces into clothes
repeatedly for last 15 days. On doing
examination and investigations, no
organic pathology is found.
1 what could be Diagnosis?
Ans: Differentials:
Encopresis
Overflow incontinence
Diseases of CNS

97

2 what are different types of
encopresis?
Ans: Types of Encopresis:
Primary
Secondary
3 what is treatment?
Ans: TREATMENT:
Behaviour therapy
Psychotherapy
Measure to control causative
emotional problem.

Station 3:
A 7 years old child gets out of bed
while asleep and walks around
without being luscious or aware of it.
There is no subsequent recollection
the next day for last 1 year.
1 what could be diagnosis?

98

Ans: sleeping walking
(somnambulism)
2 what is differential diagnosis?
A: Differentials:
Night terrors
Night mares
3 what is treatment?
Ans: Treatment:
Correction of manipulation of
family affairs.
Investigate any neurological
cause if it persists after
counseling.
Station 4:
A 15 days baby develops yellow
discoloration of skin, eyes for 10
days, otherwise baby is well and
gaining weight. There is history of
developing same discoloration of

99

skin and eyes of other siblings after
birth?
1 what is diagnosis?
Ans: Breast milk jaundice.
2 What investigation will you
conduct?
Ans:
Blood CP
ESR
Urine and stool sample for
color and D/R and culture
LFT`s
U/S abdomen
3 what should be treatment?
Ans:
Discontinue breast feed for 24-
36 years.
Ensure lactation by continuing
to express breast milk.

100

After 36 hours, restart breast
feed.
Station 5:
A 3 years old child having repeated
attacks of gastroenteritis, now
develops impained dark adaptation
followed by night blindness and hazy
comes and toad skin appearance for
the last 1 month.
Ans: Vit A deficiency
2 What complication can develop?
Ans:
Recurrent episodes of
diarrhea
Respiratory infections.
Night blindness
Recurrent skin infections
3 what should be management?

101

Ans:
Give 2 lac I.U of Vit: A on day
1,3 and 15.
Food rich in Vitamin A.
Station 6:
A 5 years old boy having 10kg
weight, admitted in CHK PAEDS-1
PCM ward for last 1 week. When
examined, there is frontal and
parietal bossing and open anterior
fontanels. Rib cage is prominent with
marked rickety rosary.
Ans: Rickets
2 what is the cause?
Ans: Vitamin D deficiency
3 how will you confirm diagnosis?
Ans:
Wrist radiography

102

Serum Ca
+
.
Serum phosphorous
AIK: phosphatase
4 how will you mange it?
Ans:
A single I/M infection of Vit: D
3

(6 lac units)
OR
Vit: D 2000 IU/day orally for 4
weeks and than 1000 I.U daily
for 4 months.
Station 7
Picture:
1. what is diagnosis?
Ans: Thyroid Goiter

103

2.Write down the common causes?
Ans:
Congenital goiter
Endemic goiter
Sporadic goiter
3. How will you treat it?
Ans:
Treatment is needed for
hypothyroidism (thyroxine)
For Hyperthyroidism treatment may
be Antithyroid drugs, surgery or
radioiodine therapy depending on the
type of Goiter
Beta blockers may be used for
symptomatic relief.

Station 8

104

Picture:
1. Identify it?
Ans: Graves disease
(Hyperthyroidism)
2. What is lab diagnosis?
Ans:
Serum T
4

Free T
4

Serum T
3

Free T
3

TSH
BMR
Thyroid peroxidase antibodies
TRS ab (TSH receptor
stimulating antibodies)

105

3. What is the treatment?
Ans:
For symptomatic relief Beta blocker
Anti thyroid drugs
Surgery
Radioiodine therapy.
Station 9
Radiograph:
1. What is diagnosis?
Ans: Pneumothorax
2. Write Differential diagnosis.
Ans:
COPD

106

Pulmonary embolus
Emphysema
3. What are the causes of
Pneumothorax?
Ans:
Spontaneous
Laterogenic / truma e.g pleural
tap, transbronchial, biopy,
central venous line insertion,
mechanical ventilation.
Obstructive lung disease, e.g
asthma, COPD
Infection e.g pneumonia,
tuberculosis
Cystic fibrosis
Connective tissue disorders,
e.g Marfan`s EHLERS-
DANLOS.
Station 10
Lab Assessment:

107

A 6 years old girl has vomiting
headache and irritability. She does
not appear to be dehydrated. But
when reviewing her vitals you notice
her weight is up 3 kg from just 3
weeks ago. Laboratory findings are:
Na+ 112meq/L K
+
4.0 meq/L CI
-
75
meq/L HCO
3
19 meq/L BUN
10mg/dL and creatinine 0.4/Dl. A
spot urine sodium concentration is
100 meq/L.
1. what is your diagnosis?
Ans: Increased ADH secretion.
2. How will you manage this
condition?
Ans:
Fluid restriction
Treat the underlying cause of SIADH.
Investigate to locate any tumor
secreting ADH

108

Head CT scan
Station 11
History ( refer to history section)

Station 12
History Viva (refer to history
section

Station 13
Examination
Refer to Examination section
Station 14
Examination
Station 15
Examination Refer to Examination
section

109

PAPER 2010 (SEMESTER X)

Station 1
A 1 year old child with bleeding
tendency resulting in recurrent
bruises. Petechiae over limbs,
trunks, bleeding from gums and
sometimes minor bleeds for 3 days.
There is also H/O hemarthrosis and
pseudoparalysis?
1 What is diagnosis?
Ans: Scruvy
2 What is the cause of bleeding?
Ans: Defects in collagen formation in
capillaries.
3 How will you manage it?
Ans:
Intake of Vit; C (10-500mg)
daily for few days.

110

Fresh citrus fruits and
vegetables.
Spinach and other leafy
vegetables.
Station 2
8 month old child admitted in PCM
ward for 1 month having H/O
anorexia, lethargy, apathy or
irritability. When examined angular
stomatitis, smooth red tongue along
with candidiasis was seen
Ans: Vitamin B complex deficiency.
2 Name three common diseases of
B-complex deficiency?
Ans:
Beri-beri
Pellagra
Pernicious anemia

111

Ans:
Oral Vitamin B complex (multi
vitamins)
Adequate diet rich in B
complex
Station 3
1.5 years old child brought by her
mother to OPD with H/O diarrhea
and failure to gain weight from 1
month. Child diet includes goat milk
due to insufficient milk of mother. On
examination he is anemic and
irritable?
Ans: folic acid deficiency.
2 Name investigations?
Ans:
Blood CP.
Bone marrow examination

112

3 How will you manage the
condition?
Ans:
Supplementation with 0.5
1mg/day folic acid for a month.
1 dietary intake of folic acid
rich foods.
Station 4
4 years shahbaz resident of Gilgit
having swelling in neck region and
delay in physical growth was brought
by parents to OPD. He has above
mentioned complains in that village
toddlers.
Ans: Iodine deficiency.
2 What treatment will you offer?
Ans:
Supplemental iodine

113

Thyroxine - 4g/kg/day
Lipoidal capsules 1cap for 1-
2 years
3 What investigations will you
conduct?
Ans:
Base line investigations
Serum iodine level
T
3
, T
4
, TSH
Station 5
3 months old child brought by
parents having H/O severe
malnutrition during head to toe
examination there was a typical rash
at the muco-cutaneous junction in
the oral and anogenital area. There
is also H/O repeated infections?
Ans: Zinc deficiency.
2 How will you manage it ?

114

Ans:
ZnSO
4
150mg/day
Local application of Zn paste
Station 6
2 years old child admitted in paeds
ward PCM ward for 5 days. She is
severely malnourished, during
examination she was restless and
irritable. There is loss of bucal,
axillary and gluteal pads of fat while
no other features are found here.
Height, weight are very much low
according to her age.
Ans: Marasmus
2 How will you confirm it?
Ans:
By putting child parameters into
various classification of PCM

115

3 Write down the appropriate
management?
Ans:
Treat hypoglycemia
Treat hypothermia
Prevent dehydration
Restore electrolyte balance
Start to feed child (kichri,
yougurt and banana)

Station 7
Picture
1. What this diagram shows?
Ans: Thalessemia

116

2. Write its mode of inheritance?
Ans: It is inherited as an autosomal
recessive disorder.
3. What would be the lab findings?
Ans: Labs:
Blood CP
Serum iron
TIBC
Serum ferritin
Serum Transferrin saturation
HB electrophoresis
Station 8
Picture:
(hypochromia + microcytosis)
1. What does this diagram shows?

117

Ans: Iron deficiency anemia
2. Write down the etiology?
Ans: Etiology:
Decreased iron stores
Inadequate intake
Impaired absorption
Excessive demands for iron
Blood loss
Intolerance to cow milk
3. How will you diagnose this
condition?
Ans:
MCV
MCH
RDW
Serum ferritin level
Serum iron level
TIBC (Total iron Binding
Capacity)
Red cell Protoporphyrin level

118

Serum ferritin (most reliable
and sensitive index)
Station 9
Radiograph:
Tetralogy of Fallot`s (boot shaped
heart)
1. What does this chest X-ray
shows?
Ans:
Boot shaped heart
Oligaemic lung fields
2. What is your diagnosis?
Ans: Fallot tetralogy
3. What do you mean by tetralogy of
fallot?

119

Ans:
Pilmonay infundibular stenosis.
VSD
Over-riding of aorta
Right ventricular hypertrophy
Station 10
Lab Assessment:
A 6 days old male infant is brought to
the ER with complaints of poor
feeding and lethargy for 2 days. On
physical examination the infant is
hypotonic and responds poorly to
painful stimuli. The initial Dexgtrostix
is 30 mg%. Two mL/kg of D25W are
administered in addition to 20 mL/kg
of normal saline initial laboratory
evaluation includes sodium 128
meq/L potassium 8.4 meq/L
bicarbonate 8 meq/L and chloride
104 meq/L?
1. The next intervention should be
to?

120

Ans:
Obtain plasma for 17-OH
progesterone level and administer
10mg/kg hydrocortisone.
2. What is most likely diagnosis?
Ans: Congenital Adrenal hyperplasia.
3. Which enzyme is deficient?
Ans: 21 hydroxylase.

Station 11
History (refer to history section)

Station 12
section)
Station 13

121

section
Station 14
Examination
Station 15
section


122

PAPER 2011 (SEMESTER IX)

Station 1
5 years old Jamal admitted to paeds
ward for 15 days has features of
severe PCM . O/E he is edematous.
There is hepatomegaly and
dermatitis?
1 what is your likely diagnosis?
Ans: Kwashiorkor
2 What investigations will you order?
Ans:
Blood CP
ESR
RBS
Urine D/R, C/S
Blood smear for malaria
Stool D/R
Stool C/S
Chest X-ray

123

3 How will you manage this case?
Ans:
Treat hypoglycemia
Treat hypothermia
Prevent dehydration
Restore electrocyte balance
Treat Vit: Deficiency severe
anaemia and heart failure.
Station 2
2 years old child who is diagnosis
case of insulin dependents DM, now
brought to ER with confusion, stupor
and smell of ketones in breath.
Dehydration is severe with rapid
breathing. Nausea and vomiting is
also present
1 what is the diagnosis?
Ans: Diabetic Ketoacidosis
2 How will you confirm diagnosis?
Ans:

124

Blood glucose via dipstick and
lab confirmation
CBC
ABG`s
Urine for ketones
Chest X-ray
Blood urea, serum creatinine
and electrolytes
Ans:
Fluid
Electrolyte replacement
Insulin
Control of acidosis (NaHCO
3
)
Central of infection
Control of complication.
Station 3
1.5 years old Avinash brought to
OPD clinic by parents with H/O
polyuria, polydipsia, polyphagia and

125

weight loss. There is also H/O bed
wetting for last 1 month.
1 What is the diagnosis?
Ans : Juvenile Diabetes mellitus

2 What should be possible causes?
Ans:
Genetic predisposition
Viral infections
Auto antibodies production
3 What investigations you will order?
Ans:
Fasting and random blood
sugar
Urine analysis
Glucose tolerance test
HbAC
4 How will you manage this case?

126

Ans:
Insulin
Diet control
Exercise
Routine blood and urine
examination
Family and child education
5 What complications can develop?
A5:
Bacterial infections
Slow linear growth
Nephropathy
Neuropaltry
Station 4
1 month old baby is brought to ER
with H/O irritability, abnormal
hyperactive purposeless movements,
seizures, abnormal posturing and
brisk tendon like reflexes. There is
severe vomiting and amuse like odor
is emitted from the body and urine?

127

1 How will you diagnose?
Ans: Screening Feric chloride test
on the urine
2 What is the confirmatory test?
Ans:
Blood phenyl-alanine and
tyrosine level
Urine for phenyl pyruciv acid
Phenyl alanine loading test
3 Write the treatment plan?
Ans:
Diet containing low
phenylalanine with added
tyrosine.
Phenyl alanine levels should
be maintained between 6-
9mg%
Station 5

128

A 4 years old child is brought to OPD
with H/O strabismus. There is hypo
pigmentation of skin, hairs and
choroids on further examination there
is visual acuity and red reflex are
seen in the eye?
Ans: Albinism
2 what are the different clinical
forms?
Ans:
Tyrosinase positive form
Tyrosinase deficiency form
Ovular
Localized form
3 How will you confirm diagnosis?
Ans:
Tyrosinase enzyme level at
the last of a plucked hair.

129

Station 6
A 3 years old child is brought to
PAEDS OPD with clinical features of
dark discoloration of cheeks, sclera
and ears pinna. There is also black
discoloration of urine on standing?
Ans: Alkaptonuria
2 What is mode of inheritance?
Ans: Autosomal recessive
inheritance.
3 How will you investigate the
condition?
Ans:
Black coloration of urine on
prolonged standing.
Positive reaction with
benedict / fehling reagent
or the urine.

130

Urine levels of
homogentistic acid.
X-ray joint.
4 Write down treatment plan?
Ans: Nitrosonine.
Station 7
Picture:
Ans: Megaloblastic anaemia.
2. Write the common etiology?
Ans:
Vitamin B12 deficiency
Folate deficiency
3. What other system is involved in
vitamin B12 deficiency?

131

Ans: Peripheral neuropathy and
combined spinal neuropathy.
4. What is the peak age group
affected?
Ans: 4-7 months of age.
Station 8
Picture
1.What is the most likely diagnosis?
Ans: Cushing syndrome
2. What are main clinical features?
Ans:
Weight gain
Lethargy
Hirsuitsm

132

Acne
Purpulish skin
Striae/Hper pigmentation
Obesity is evident with a
characteristic buffalo hump
and moon face
3. Write down the investigations?
Ans:
1
st
phase investigation:
Serum cortisol
Urne free cortisol
Low dose dexamethasone
suppression test
Overnight dexamethasone
suppression test.
2
nd
phase investigation:
High dose dexamethasone
suppression test
Pituitary imaging
Inferior petrosal sinus sampling

133

Station 9
Radiograph:
Pleural effusion.
1. Idenity the given CXR.
Ans: Massive pleural Effusion
2. Write down the findings of xray.
Ans:
Homogenous opacity involving
the entire right side of lung
Shifting of mediastinum and
trachea away from effusion.
3. What are the different types of
Effusions?
Ans: Transudate < 30g/I protein

134

Heart failure e.g congestive
cardiac failure pericardial
effusion.
Liver failure e.g cirrhosis.
Protein loss e.g nephritic
syndrome protein losing
enteritis
Reduced protein intake e.g
malnutrition
Latrogenic e.g peritoneal
dialysis
Exudate>30g/I protein
Infection.g pneumonia,
tuberculosis
Infarction
Malignancy e.g bronchial
carcinoma mesothelioma
metastasis.
Collagen vascular disease e.g
rheumatoid arthritis, SLE.
Abdominal disease, e.g
pancreatitis subphrenic
abscess.

135

Trauma / surgery
Station 10
Lab Assessment:
A 2 month old female presents with a
4 day history of coughing spells that
last at least 30s. After the coughing
spells she vomits. She is otherwise
well laboratory evaluation reveals a
peripheral white blood cell count of
42,000/mm
3
with 86% lymphocytes.
1. What prophylaxis family and day
care contacts of this child could
receive?
Ans: Erythromycin
2. What is the diagnosis?
Ans: Pertussis
3. For how many days erythromycin
is recommended for prevention and
treatment of Pertussis?

136

Ans: 14 days
Station 11
History (refer to history section)

Station 12
section)

Station 13
Examination
Refer to Examination section)


137

Station 14
Examination

Station 15
Examination


138

Station 1
A 5 years old child presents to OPD
with complaints of genu-valgum,
pes-Cavus, arychodactyli and
umbilical hernia. O/E there are
abnormal heart sound on mitral and
aortic areas. There is a peculiar
malar rash. There is +ve
homocystine test on freshely void
urine too.
1 what is the likely diagnosis?
Ans: Homocystinuria
2 What are different types and above
mentioned scenario relates to which
type?
Ans:
Type-I,II,III
Type i

139

conduct in this case?
Ans:
Positive hemocytive test
Methionine and
homocystine in plasma and
urine.
Liver biopsy
Enzyme Assay
Ans:
Administration of large
doses of pyridoxine
(500mg)
Folic acid
Diet low in methionine and
cystine supplement
Betain
Station 2

140

A 5 months old child brought to OPD
by parents with the complain that
baby`s diaper turns blue by urine
stasis. O/E his mental status is
normal.
Ans: Hartnup disease (blue diaper
syndrome)
2 How will you diagnose it?
Ans:
Selective amino aciduria
Indole derivatives in urine
3 How will you treat the case?
Ans: Nicotinic acid or nicotinamide
(50-30mg/day) high protein intake.
Station 3
A 5 days old child is brought to ER
with vomiting lethargy, convulsions
and coma. O/E hypertonia, rigidity

141

and opisthotonus are found. There is
hypoglycemia and metabolic
acidosis-urine has the odor of maple
syrup.
Ans: Maple syrup urine disease.
2 What is the cause?
Ans:
Deficiency of pyruvate
dehydrogenase and alpha
keto glutarate
dehydragenase
3 What will be treatment?
Ans:
Peritoneal dialysis
A diet low in branched
chain amino acids.
Ans:
Peritoneal dialysis

142

A diet low in branched
chain amino acids.
Ans:
CBC
Blood sugar
Urine D/R
Serum electrolytes
Valine
Urine
Iso-urine and aldolase
levels.
Station 4
A 3 week old Khayam is brought to
ER with complains to feed, failure to
thrive and dehydration. Reducing
substance (galactose) is deleted in
urine by benedict`s reagent.
1 what are the causes?
Ans: Galactosemia

143

2 How will you investigate it?
Ans:
Three enzymes are involved in the
causation of the disease.
Golactase 1-PO
4
uridyl
transferase deficiency
Golactokinase deficiency
UDP galactose 4
epimerase deficiency
3 How will you diagnose it?
Ans:
Reducing substance
(galactose) is detected in
the urine by benedict`s
reagent.
Blood galactose and
galacticol levels
Assay of enzyme glucose-1
PO
4
uridyl transferase in
erythrocytes
Beutler test

144

Ans:
Diet exclude galactose
from the diet. (No milk or
dairy products)
Soya based formulae are
given as on alternative
Follow-up though out
childhood and adult life.
Station 5
A 8 months baby is brought by
parents to paeds OPD with
complains of lethargy , progressive
deterioration of motor functions and
vision. O/E there was hyperacusis.
There was also hyperreflexia. On
fundoscopy, characteristics cherry
red spot is seen at macula.
Ans: Tay sachs Disease.

145

2 What is maximum age of patient of
the disease?
Ans: 4 years of age.
3 How will you diagnose this
conditions by which la test?
Ans:
Brain biopsy
Hexosaminidase A level
serum plasma WBC`s and
cultured fibroblasts
4 How will you treat?
Ans:
No specific treatment
Supportive therapy is
emplayed
Station 6
1 year old child is brought by parents
to OPD with complain of bone pain,
myoclonic seizures history for last 1

146

week. O/E there is
hepatosplanomegaly bone marrow
examination show Goucher cell
Ans: Goucher`s disease
2 What are different types and which
type is lethal?
Ans: 3 types, type II is lethal
Ans:
-glucosidase activity is
WBC`s or cultured
fibroblasts.
Bone marrow examination
Long bone X-ray
Blood CP
Ans:

147

Correction of blood
cytopenios
Surgery for joints is
indicated
Enzyme therapy
coenzyme administration
safe and effective
Station 7
Picture:
Ans: Microcephaly

2. Write down the clinical features?
Ans: Forehead is slanting, vertex is
pointed, flat occiput.
3. What are the causes of
Microcephaly?

148

Ans:
Craniosynostosis
Chromosomal abnormalities
Cerebral anoxia
Intrauterine infections
Drugs
Malnutrition
Phenyl ketonuria
Station 8
Picture:
1. What is the diagnosis?
Ans: Henoch-Schonlein
2 Write down the etiology?

149

Ans:
It is secondary to deposition of
immune complexes in the small
blood vessels, most commonly found
in infants and children under 5.
3 What are clinical features?
Ans:
A maculopapular rash that becomes
hemorrhagic and abdominal pain are
the most common manifestation.
Station 9
Radiograph:
Egg on side, Transposition of Great
Arteries(TGA)
1. Write down the findings of CXR?

150

Ans:
Cardiac enlargement
Pulmonarphy plethora
Nanow pedicle (egg on side
shaped heart)
2. Write investigations to confirm the
diagnosis?
Ans:
ECG
Echo
3. Write the management?
Ans:
IV Prostaglandins
Cardiac Catheterization
Fluid replacement
Mechanical ventilation
Surgical or Palliative repair.
Station 10

151

Lab Assessment:
A 5 years old well female presents to
your emergency department with
episodic headache and hypertension.
During the episodic she is sleepy,
complains of headaches, vomits and
becomes sweaty. Her current vital
signs are T 101oF Hr 150 bpm BP
220/130 mmHg. She is diaphoretic
sleepy but arousable and clutches
her head. Pupils are reactive and
papilledema is present. There is no
organomegaly and femoral pulse is
normal.
1. The first course of action should
be?
Ans: Administration of an
antihypertensive medication
2. What are symptoms of HTN?
Ans:
Headache

152

Altered mental states
Papilledema
3. Write down the causes of severe
HTN?
Ans:
Renal artery stenosis
Malignant Hyperthyroidsm
Aldosteronism
Pheochromocytoma
Coarction of aorta

Station 11
History Refer to history section

Station 12

153

History Viva refer to hiatory
secrion

Station 13
Examination
Refer to examination section

Station 14
Examination
Station 15
Examination


154

Station 1:
A 7 months old Zareena is brought to
ER by her parents with presenting
complain of progressive CNS
deterioration. Lymphadenopathy,
yellow brown discoloration of skin
and seizure are noted. Bone marrow
shows foam cells
Ans: Neimann pick disease
2 How will you investigate the
condition?
Ans:
Bone marrow shows typical
foam cells
X-ray chect and longbones
Serum cholesterol levels
Biopsy of affected viscera

155

Sphingomyelinase is
WBC`s and cultured
fibroblasts
Ans: Activity of enzyme
sphringomyelinase is responsible
for abnormal collection of
sphingomyclin.
Station 2
A 5 years old child is brought to OPD
by parents having characteristics
faces. The skull is large, with heavy
eyebrows and supra orbital ridges
broad thick nose, cloudy (opaque)
corneas, short neck, lumbodorsal
kyphosis. Large abdomen, umbilical
hernia, hepatosplenomegaly and
broad hands. Mental deficiency is
also present.
Ans: Hunter syndrome

156

2 What complication causes death?
Ans: Cardiomegaly
3 How will you diagnose this
condition?
Ans:
X-ray films
Urine for muco-
polysaccharides
Enzyme in leucocytes/
cultured fibroblasts
Station 3
A 6 years old Arshad is admitted in
Paeds ward with history of abdominal
pain, jaundice and other feature of
acute hepatitis. During routine
workup, KF ring was seen with a slit-
lamp.
Ans: Wilson disease

157

2 When CNS manifestations develop
in Wilson disease?
Ans: Usually in 2
nd
and 3
rd
decade
3 How will you work this patient
(investigations)?
Ans:
Serum copper
Serum ceruloplosmin
Urinary copper level
LFT`s
KF ring
Liver Biopsy
4 What is treatment?
Ans:
Avoid high CU
+
foods
Chelating agents like D
penillamine
Zinc acetate 50mg TDS
maintaince treatment
Liver transportation

158

Station 4
28 years old Aqsa gave birth her 2
nd

baby via SVD at 11:00 am. There
was failure of baby to cry and
establish adequate respiration one
minute after birth.
Ans: Birth Asphyxia.
2 How will you prevent and manage
this condition?
Ans:
Anticipation
Assessment action
Aftercare
3 What are different kinds of
Asphyxia? Which is more
dangerous?
Ans:
Asphyxia livida

159

Asphyxia pallid (more
dangerous)
Station 5
1 What is Apgar scare. What is its
significance?
Ans: A1 It is used for assessment of
condition of the new born infant after
birth it offers a quantative estimate of
birth asphyxia.
2 At which time Apgar scare is
calculated? And what do they
indicate?
Ans:
At 1,5 and 15 minutes after
birth.
Apgar scare at 1 minute
indicates that a baby needs
resuscitation while the later
scores at 5 and 15 minutes
are a better guide to

160

prognosis of neuro
developmental outcome.
3 in Asphyxia livida, what is Apgar
scar?
Ans: A3: Between 4 and 7
4 In Asphyxia pallid, what is Apgar
scare?
Ans: 0-3
Station 6
1 In management of birth Asphyxia
action component includes what
things?
Ans: Airway breathing and circulation
2 If breathing is irregular, than what
intervention should be done?
Ans: Mask and Bag with O
2
3 How you are going to assess
circulation?

161

Ans: Check heart rate if heart rate is
below 100, Excardiac compression
alongside bag and mask ventilation,
if heat rate is over 100 assess the
color i.e blue or pale if pale and
Apnoeic it suggest severe asphyxia,
imidiate prompt resuscitation with
respiratory and cardiac support.

Station 7
Picture
Ans: Mumps infection.
2. What is common age affected?
Ans: 5-15 years of age

162

3 Write down the differential
diagnosis.
Ans:
Parotitis due to other causes
Suppurative parotitis
Salivary calclus
Tumor of parotid gland
Station 8
Picture:
1. What does this diagram show?
Ans: Chicken Pox infection.
2. How will you diagnose it?
Ans:

163

Blood CP (leucopenia in first
72 hours)
Multinucleated giant cells on
sezank smear
Virus isolation
Viral antigen detection in
vesical fluid using immune
fluorescent antibody.
Station 9
Radiograph:

Ans: Lobar pneumonia.

164

2. Write down the findings of the
CXR?
Ans:
Consolidation
Fibrosis
Infiltrative condition
Collapse
3. What investigations will you
conduct?
Ans:
Blood CP
Sputum D/R. culture
Blood culture
Station 10
Lab Assessment:
A 7 years old girl presents with a 3
week history of fatigue, 5-lb weight
loss, and listlessness. Examination is
significant for a thin girl who appears
tired, petechiae and ecchymoses are

165

present over her trunk and
extremities. The complete blood
count reveals a white blood cell
count of 85,000/mm
3
the differential
reveals 80% blasts and 20%
lymphocytes. She is febrile to 103
o
F
and has a BP of 90/50 mmHg?
1. What is diagnosis?
Ans: Most likely Leukemia
2. Appropriate empiric antibiotic
therapy would begin with?
A.2: I/V ceftazidime

Station 11
History Refer to historysection


166

Station 12
History Viva Refer to history
section

Station 13
Examination
Station 14
Examination
Station 15
Examination


167

Station 1
A new born baby was referred to
paeds for review. There was diffuse
edema over the presenting part of
scalp which was bilateral.
Ans: Caput Succadaneum
2 How will you treat it?
Ans: It is a self limiting condition and
requires no treatment.
Station 2
A new born baby was admitted in
paeds ICU due to prematurity. After 5
days of birth baby developed
swelling on one side of head. There
was also yellowish tinge of eyes.
1 what could be the possibility?
Ans: Cephalhematoma

168

Ans: It result from haemorrhage
under the periosteum of the cranial
bone
Ans: Usually no treatment is required
unless complications are present
resolution may takes 3 -4 weeks.
Station 3
Regarding intra cranial hemorrhage
(ICU)
1 What are the different types?
Ans:
Sub Arachmoid
Sub-dural
Intra Ventricular
2 Which is the most common type?
Ans: Sub arachnoid hemorrhage

169

3 What is the source of bleeding is
sub-arachnoid hemorrhage?
Ans: Bridging vein of sub-arachnoid
space
4 What are common neurological
signs?
Ans: Irritability and seizure (well baby
with seizures).
Station 4
Regarding subdural hemorrhage
Ans: Trauma of precipitate delivery
or mid cavity forceps application or
delivery of a large baby.
2 What is the clinical presentation?
Ans:
Signs are those intra-
cranial pressure

170

Bulging anterior fontanelle
head circumference
letharf=gy or irritability
3 What is the treatment?
Ans: Sub dural tap or open
evacuation.
Station 5
Regarding intra-ventricular
hemorrhage
1 In which age group it is common?
Ans: In premature babies (esp <32
weeks) with associated problems
such as birth Asphyxia or respiratory
distress.
2 What are the different grades?
Which is most severe?
Ans:
Grade I IVH IV IVH

171

Grade IV is severe one all
grades
3 What does IV indicate?
Ans: When bleeding occurs into peri-
ventricular brain tissue as well.
Station 6
New born with H/O birth trauma. The
baby`s affected arm is adducted and
internally related with the elbow
extended. The form arm is pronated
and the wrist is flexed.
Ans: Erb`s paralysis
Ans: Injury to brachial plexus ( V
+n

and Vi
+n
cervical spinal roots)
3 What reflexes will be absent?
Ans: Moro`s biceps and radial
reflexes on affected side.

172

Ans: Physiotherapy and wrist
splintage.
Station 7
Picture:
1. What does the diagram shows?
Ans: Meningococcemial rash
2. Which organism causes this
condition?
Ans: N Meningitidis
3. What is common age group
affected?
Ans: Children under 10 years of age
(80% of cases)

173

Station 8
Ans: Herpes gingivostomatitis
2. How much time is required for
resolution of lesion?
Ans: 2.6 weeks
3. What is the treatment?
Ans: No specific therapy other than
oral acyclovir.
Station 9

174

Radiograph:
1 What is likely diagnosis?
Ans: Brochial asthma
2 What are the findings on CXR?
Ans:
Lungs appear blocker and
larger in volume than normal.
Hemi-diaphragms are flattened
Pulmonary arteries are large
centrally
What investigations will you conduct?
Ans:
Blood CP
Sputum D/R (Oesonophilia)
ABG`s (respiratory acidosis)

175

IGE levels

Station 10
Lab Assessment:
A 12 years old child is admitted
because of the sudden onset of
coma. The child had been well until
about 6 hours prior to admission,
when he began to complain of a
headache became more severe and
the child lapsed into coma. Physical
examination reveals a temperature of
38.2
o
C. The child is flaccid and
comatose. The remainder of the
physical is unremarkable. A lumbar
puncture reveals grossly bloody
spinal fluid after centrifugation. The
fluid appears xanthchromic. There
are 3000 RBC`s and 7 WBCs/mm3.
The protein concentration is 400
mg/dL and the glucose is 62 mg/dL.

176

1. The most likely etiology of the
coma is?
Ans: subarachnoid hemorrhage
2. Which of the following underlying
structural abnormalities would most
likely have led to the above events or
condition?
Ans: Cerebral arteriovenous
malformation
3. The most appropriates nest step at
this would be to?
Ans: Obtain a CT of the head
Station 11
History refer to history section

Station 12
History Viva refer to history
section

177

Station 13
Examination
Station 14
Examination
Station 15
Examination


178

Station 1
New born baby with H/O of birth
trauma. Intrinsic muscles of hands
are affected. Grasp reflex is absent,
while biceps and radial reflexes are
present.
Ans: Klumpko`s paralysis
Ans: Brachial plexus injury (7
th
, 8
th

cervical 1
st
thoracic spinal root).
Ans:
Physiotherapy
Wrist splintage


179

Station 2
New born baby is admitted with the
H/O birth trauma. There is
asymmetric crying facies angle of
mouth is drawn to the normal side,
facial wrinkle are deeper. The
paralyzed side is smooth angle of
mouth is lower than normal side.
Ans: Facial N injury.
Ans:
Lids are kept close with a
patch + - moistening eye
drop.
Supportive care.
3 What is most common cause?
Ans: Application of forceps
Station 3

180

A new born baby is referred to
paeds surgery as a result a birth
trauma. There is swelling at site of
clavicle. Crepitus is also felt over the
lesion.
Ans: Fracture of clavicle
Ans: Breech delivery or shoukder
dystocia
Ans:
Pining the sleeve to the
shirt
Gentle handling until calus
forms
Station 4
Regarding Neonatal reflexes

181

1 What are the different types of
neonatal reflexes?
Ans:
Moro`s reflex
Grasp reflex
Righting reflex
Stepping reflex
Sucking reflex
Withdrawal reflex
Asymmetric tonic neck
reflex
Gailant reflex
2 Why we go for checking these
reflexes, what is their significance?
Ans: They help in assessing maturity
and development of an infant and the
integrity of the new born system
3 If at birth Moro`s reflex is absent,
what does is indicates?
Ans: It indicates poor function of
CNS Absence in one limb indicates

182

local disease such as nerve trauma
bone fracture
4 If Grasp reflex persists beyond 5
months of age, what it indicates?
Ans: it indicates cerebral palsy.
Station 5
25 years old Nomaira gave by birth
to a baby at 34 weeks gestation
weighing 4.5kg C/section, baby
plump with pink color and rounded
Moon face giving a false
appearance of being healthy.
Ans: Macrosomic baby (infant of
diabetes mother)
2 What is cause of large size baby?
Ans: It results from transfer or large
amounts of glucose through placenta
from the mother with consequent

183

high insulin levels and fat deposition
in the baby.
3 What are different complications
that develop?
Ans:
Hypoglycemia
Hypocalcemia
Hyper billribiremia
Resp distress syndrome
Birth trauma
Birth Asphyxia
Conhenital anomalies.
4 What is the management?
Ans:
Appropriate management of
pregnant diabetic woman
Early feeling to avoid
hypoglycemia
I/V glucose for infants with
early hypoglycemia.

184

Station 6
Regarding pre-term new born
1 When we call a baby pre-term?
Ans: Neonates who are born before
completing 37 weeks of gestation
and their birth weight is between 10
th

and 90 percentile for the gestational
age.
2 What are different complications
that develop in pre-term new born?
Ans:
Hyper billrubinemia
Hypothermia
Hyaline membrane disease
Cerebral haemorrhage
Anaemia of prematurely
Hypoglycemia
Apnoic attacks
Infections
Neutralizing enterocalitis
Retinopathy of permaturity

185

Station 7
Picture:
1. What does this picture show?
Ans: Down syndrome.
2. What chromosomal abnormality
causes it?
Ans: Trisomy 21
Ans:
Characteristics facial
appearance
Flat occiput
Microcephaly

186

Upward slanting eyes
Low set ears
Single plamar crease
Broad short neck
Small maxilla and palate

Station 8
Picture:
Ans: Facial N Palsy of right side.
2. What are the causes?
Ans:
Idiopathic

187

Infections (herpes simplex GB
syndrome)
Otitis externa, media and
mastoiditis
Intracranial neoplasm
3. What are the complications?
Ans:
Exposure keratitis
Cornal ulcers
Permanent deformity
Station 9
Radiograph:
Myocarditis (cardiomegaly)
1. Write the positive findings?

188

Ans:
Evidence of pulmonary edema
cardiomegaly
2. Write the investigations to confirm
diagnosis?
Ans:
ESR
Creative kinase MB
ECG
ECHO
Enomycardial biopsy
3. What is the etiology?
Ans:
Viral
Bacterial
Fungi
Rickettsial
Spirochetal
Idiopathic

189

Station 10
Lab Assessment:
A 37 month old male with failure to
thrive ingests 175 cal/kg per day
during 2h of hospitalization, but does
not gain weight laboratory value are
serum Na+ 138 meq/L, K
+
3.5 meq/L
CI
-
111 HCO
3

12 meq/L BUN 2
mg/dL CR 0.2 mg/dL, glucose
112mg/dL serum pH 0.30 and urine
pH 8.0 (under oil). The serum
phosphate level is 2.4meq/L.
Ans: Renal tubular acidosis.
2. What are the classic findings?
Ans:
Amino acidosis
Phosphaturia
Glycouria

190

3. Write down the common causes.
Ans: Inborn errors of metabolism.
Acquired forms from:
Heavy metal toxicity
Drug toxicity

Station 11
Station 12
section
Station 13
Examination Refer to examination
section
Station 14
Examination

191

Station 15
Examination


192

Station 1
1 When we label a baby in a
respiratory distress?
Ans: If baby has one or more of
following clinical signs.
When respiration rate is
excess of 60/min
Cyanosis
Chest wall retraction on
inspiration
Expiratory grunt
Flaring of Nostrils
Use of accessory muscles of
respiration
2 What are different causes?
Ans:
Meconium aspiration
Surfactant deficiency

193

Choanal atresia
Congenital diaphragmatic
hernia
Pneumo
Station 2
A 33 years old lady at 42 weeks of
gestation gave birth to a baby with
meconium staining present on the
nails, skin and umbilicus. There is
general lung over-inflation along with
diffuse rales and ronchi and
respiratory difficulty.
1 What is your diagnosis?
Ans: Meconium aspiration syndrome.
2 How will you investigation it?
Ans: X-ray chest
3 What x-ray chest shows?
Ans: It reveals coarse hilar shadows
with streaky shadowing and patchy

194

Atelactasis. Pneumothorax and
pneumo mediastinum may develop
Ans:
Nose, mouth and pharynx
should be cleared and trachea
should be shakeout either
throught an ETT or a wide bore
situation catheter to avoid
further aspiration into lungs
Humidified O
2
and mechanical
respiratory support.
I/V feeding
Broad spectrum antibiotics
5 What complications can develop?
Ans:
Pneumothorax and
pneumomediastinum
Pulmonary HTN.
Station 3

195

A 27 years old Zubaida aapa
delivered baby at 34 weeks of
gestation via C/Section. There was
respiratory distress with in the first 4
hours after birth. There is tachypnea,
cyanosis, apnoeic attacks. PO
2
is
reduced below 50mm Hg and PCO
2

rises.
Ans: Respiration Distress syndrome
(RDS)
2 How will you further investigate?
Ans:
Chest x-ray
ABG`s
Blood CP
RBS
Serum electrolytes
3 what is management?
Ans:

196

Gluco corticoid
betamethason Ante nately
Repiratory support
If higher concentration of O
2
is
needed assisted ventilation is
required.
CPaP
PPV
Monitoring heart rate
respiratory and temperature.
Surfactant therapy
Supportive therapy
Station 4
A new born baby is in respiratory
distress during examination , there is
hyper resonant note and absent
breath sounds.
Ans: Pheumothroax
2 How will you investigate it?

197

Ans: Chest radiographs erect right
lateral decubitus and left lateral
decibitus position.
Ans: A needle attached to a 3-way
stop cock or syringe inserted in 2
nd

left intercostal space anteriorly and
air removed immediately in large
pneumothorax, catheter is left in the
pleural space and attached to an
underwater seal.
Station 5
Miss jasmeen A 30 years old
European gave birth at hospital. Her
baby has microcephaly, internal
hydrocephalus micropothalmia,
blindness, chorioretinitis, squint and
convulsions.
Ans: Congenital Toxoplasmoxis
2 How will you further investigate it?

198

Ans:
Sabin Feldman Dye test
Toxoplasma lgG and LgM
antibodies in maternal and new
born serum
Intracerebral calcification on
skull X-ray
3 What is the treatment?
Ans:
Pyrimetthamine (daraspsim)
Sulpha diazine
Spiromycin therapy (3-6
months) improves outcome.
Station 6
Miss Sidra 32 years old gave birth to
her 5
th
baby but with congenital
complications. Deafness,
microcephaly, mental deficiency,
cataracts, glaucoma, microopthalmia,
retinmophathy, blindness, PDA,
VSD, Anemia, jaundice and

199

hepatosplenomegaly is there. During
lab work there was isolation of
rubella virus.
Ans: Congenital rubella infection.
2 How you investigate it?
Ans:
Isolation of rubella virus
(orophraynx, urine)
Detection of rubella specific
LgM in the cord or neonatal
blood.
Persistent rubella specific titers
overtime.
Ans:
No effective treatment
Congenital rubella can be
prevented by administering

200

rubella vaccine to non-
pregnant young females.
Station 7
Picture:
Diagram of a PCM child.
Ans: Marasmus
2. Write the features of marasmus.
Ans:
Gross loss of sub-cutaenous
fat loss of buccal pads of fat
Prominent rib cage
Accompanying micronutrient
deficiency

201

Station 8
Diagram of PCM child.
Ans: kwashiorkor
2. What are the major clinical finds?
Ans:
Edema
Light colored / depigmented
hairs
Dermatitis (crazy pavement)
Enlargement liver
3. Why is it an emergency?

202

Ans: sudden cardiac arrest can result
due to malfunctioning of Na-K ionic
pump at the cellular level.
Station 9
Radiograph:
Pericardial effusion
Ans: Pericardial effusion
2. Write the abnormal findings in this
chest X-ray?
Ans:
Heart shadow enlargement
and globular in shape
Heart shadow covers both hila

203

3. Write the causes of pericardial
effusion.
Ans: Transudative:
Congestive cardiac failure
Exudative:
Post myocardial infarction
Neoplastic infiltration
Collagen vascular, e.g
rheumatoid arthritis SLE
Latrogenic e.g post cardiac
surgery
Endocrine myxoedema
Blood:
Trauma
Neoplastic infiltration
Aortic dissection
Bleeding disthesis e.g
anticoagulation, leukaemia.
Station 10
Lab Assessment:

204

A 2 and half month old male
presents with failure to thrive and
dehydration. Lab evaluation reveals
a serum Na of 159 meq/L and a urine
specific gravity of 1.001. The urine
was negative for glucose.
1. which of the following may be
beneficial in the long-term
management of this patient`s
condition?
Ans: Thiaizide diuretics
2. What are symptoms of this
disorder?
Ans:
Fever
Vomiting
Constipation
Hypertriemia
Polyuria
Polydipsia
Failure to thrive

205

Station 11
Station 12
section
Station 13
Examination
Station 14
Examination
Station 15
Examination


206

Station 1
A 24 years old samina gave birth to
a baby of 24kg 4 months ago. There
is failure to gain weight , fever,
repeated infection, Anaemia,
jaundice, lymphoma adenopathy,
hepatosplenomegaly. There is
positive VDRL test of mother and
baby born.
1 what is your diagnosis?
Ans: Congenital syphilis
2 what investigation should be done?
Ans:
Radiography of long bones
UDRL test of mother and baby
Bark field examination of Nasal
discharge, spinal film.
3 what treatment should be given?

207

Ans:
Penicillin 1 lac unit 6 baby for
2-3 weeks
Follow up for 2 years.
Station 2
Four week old Salma brought
parents to paeds OPD with complain
of cough, low grades fever (evening
rise) lymphadenopathny, irritability
and poor feeding, ear discharge her
mother also had H/O T.B.
Ans: Tuberculosis in new born
2 write any 4 investigations?
Ans:
Chest X-ray
PPD skin testing
Acid fact stains / cultures
Tissue from lymph node, lung
liver and bones marrow

208

3 what is the treatment?
Ans: Give ATT for 9 months
according to its protocol.

Station 3
4 weeks baby is brought by parents
to a paeds OPD with complain of
yellow discoloration of skin sclera
and mucous membranes.
Ans: Jaundice in the new born
2 At what level of bilirubin manifests
in new born?
Ans: 4-6mg/dl
3 Write the types of jaundice in new
born.
Ans:
Physiological jaundice

209

Breast milk jaundice
Pathological jaundice
Conjugated
Unconjugated
4 what treatment will you offer?
Ans:
Photo therapy
Exchange transfusion
Drugs Phenobarbital
Station 4
A 3 weeks old baby is brought by
parents to paeds OPD with the
complain of yellowish discoloration of
face, eyes, lethargy, fever, vomiting.
O/E hepato splenomegaly was
present. Urine is dark and stool color
is pale. Serum direct bilirubin, ALT,
AST, GGT are deranged.
Ans: Neonatal hepatitis.

210

2 What is the likely cause?
Ans:
Viruses: Hep: B virus herpex
simplex, rubella, cmv protozoa
toxo, mosis.
Bacterin Gram negative bacilli
(esp, klebslella), staph syphilis.
Meta bolic defect-
1
-
antitrypsin deficiency
Idiopathic.
Ans:
LFT`s
PT, APTT
Serum albumin
Viral markers
Urine D/R
Abdominal U/S
Liver Biopsy

211

Ans:
Supportive and symptomatic
measures
A low fat high protein diet with
medium chain/ triglycerides
and water soluble reparations
of Vitamin A,D and E are
recommended
Regular Vitamin K
administration.
Station 5
A 3 weeks old baby was brought by
parents to OPD with C/O progressive
jaundice, dark yellow urine and clay
colored stool. O/E there was
hepatomegary. Child was admitted to
ward TCC
99
scan shows failure of
dye to be excreted by the intestine
Ans: Congenital biliary atresia.

212

2 Write one important differential
diagnosis?
Ans: Neonatal hepatitis.
conduct?
Ans:
Technetium 99 scan
Liver biopsy
Serum cholesterol
4. What treatment should be done?
Ans:
Surgical intervention (kasar
operation)
Within the first 8 weeks of life
Fat soluble vitamins and ply-
unsaturated fats.
Liver transplantation.

Station 6

213

4 weeks old child brought by parents
to ER with fever, Apnoea, seizures,
irritability refusal to feed. Child was
hypothermic and jaundiced. CBC
done, WBC`s > 20,000, ESR
increased.
Ans: Neonatal sepsis
2 What is the most common
organism causing this
condition?
Ans: E-coil
conduct?
Ans:
CBC, ESR, C-reactive protein
Hepatoglobulin
Blood culture
4. How will you manage this
condition?

214

Ans: Supportive:
I/V fluids
Electrolyte support
Nutritional support
Thermal environment
Antibiotics
Immunoglobulin (IgG and IgM)

Station 7
Picture:
Diagram of PCM child

215

1. What this diagram shows?0
Ans: PCM (rickets)
2. What is the etiology?
Ans: Deficiency of vitamin D
Ans:
Delay in closure of anterior
fontanelle
Frontal and parietal bossing
Hot-cross bun appearance
Craniotabes
Rickety rosary
Pigeon chest
Kyphosis
Bow legs
Knock knees
Station 8

216

Picture:
Ans: Maculo popular rash of measles
2. What are the common causes?
Ans: Paramyxoviral infection
transmitted by droplet spread
3 What is the incubation period of
this infection?
Ans: 10-14 days

Station 9

217

Radiograph:
1. What are the findings?
Ans:
Enlargement of hilar lymph
nodes
Parenchymal pulmonary
lesion. (cavitation)
2. What are the differentials?
Ans:
Tuberculous pneumonia
Collapse of segment or lobe
Pleural effusion
3. Write any 5 tests to diagnosis this
disease?
Ans:

218

Tuberculous (Mantoux test)
Diagnostic BCG
Ziel neilson staining
Sputum for AFB
Sputum culture(LJ medium)
Histology of biopsy specimen.
Station 10
Lab Assessment:
A 8 month old boy had been well
until 6 weeks prior to admission
when vomiting and poor appetite
were noted. On the morning of
admission the child had a
generalized convulsion and was
brought to the emergency room
where the seizure was controlled
with intravenous medication. A
second seizure occurred about 1
hour later and again responded to
intravenous medication. Physical
examination revealed a pale, listless
infant, poorly nourished, but in no
acute distress. The anterior fontanel

219

was full but not bulging. There were
no focal neurologic signs. The
remainder of the examination was
within normal limits.
1. What is the most likely diagnosis?
Ans: Subdural hematoma
2. A fundoscopic examination
performed after one pupil is dilated
with atropine reveals diffuse retinal
hemorrhages. The most likely
diagnosis now is?
Ans: Subdural hematoma
3. Which is the most important first
step in the management of this
case?
Ans: CT scan of the head

Station 11

220

Station 12
section
Station 13
Examination
Station 14
Examination
Station 15
Examination


221

Station 1
A 22 days old baby brought to ER
with high grade fever, septic look,
seizures, high pitched cry
irritability and a bulging fontanelle.
There were neck rigidity signs
positive.
Ans: Meningitis
2 Write the relevant
investigations?
Ans:
Blood CP
ESR
RBS
Serum electrolytes
Fundoscopy
CSF examination (Lumbar
puncture)

222

Ans: Support management:
I/V fluids
Electrolyte support
Nutritional support
Treat seizures
Antibiotics
Immunoglobulins
Station 2
A 28 years old shaista delivered her
first baby at home by dai at Quetta
village. Baby at birth was dyspneic,
cyanosed. She didnt take feed, baby
was feverish parents brought her to
paeds emergency (R/R -60b/min)
Ans: Pneumonia


223

2. What are predisposing factors?
Ans:
Prolonged rupture of
membranes (over 2 hours)
Home delivery with prolonged
labor
Excessive manipulations
Infected birth canal
Un-hygienic conditions of
delivery
Biological agents
3. Write the relevant
investigations?
Ans:
CBC
ESR
RBS
Serum electrolytes
Chest X-ray

224

Ans:
O
2

Tube feeding
Anti-biotics for 2-3 weeks
Station 3
A 4 weeks old child is brought by
parents to OPD with C/O
lethargy, vomiting, diarrhea, fever
investigation were done and urine
culture shows E-coli.
Ans: Urinary Tract Infection.
2. Write the relevant investigations?
Ans:
Blood CP
Urine D/R
Urine Culture

225

Ans: Ampicillin and gentamicin are
recommended for 14 days.
Station 4
A new born baby of 15 days is
brought to ER by parents with H/O
refusal to feed, lathery, look jaw, high
temperature, seizure, risus
sardonicus, abnormal muscles
rigidity, arching of back.
Ans: Neonatal tetanus
2. What complications may lead to
death?
Ans: Bronchopneumonia or
abdominal distention.
3. What will be first line treatment?
Ans: Specific:
Antibiotics
ATS

226

Tetanus immunoglobulin
Supportive:
Reduction of stimuli
Control of fits
Close watch
Involve mother for feeding
and nursing
Assisted ventilation/nasal
cpap.
Station 5
4 hours baby of diabetic mother is
jittery, tremulous and may sweat
excessively, baby is also
hypothermic.
Ans: Hypoglycemia
2. What is hypoglycemia?
Ans: Blood glucose levels of
<40mg/dl in the neonate.

227

3. Write the appropriate
management.
Ans:
Anticipate monitor blood
glucose
Prevention feed early avoid
hypothermia
Blood glucose level should be
kept above 40mg% in the
neonate if low a bolus I/V
injection of 2m;/kg of 10 %
dextrose solution should be
given followed by I/V drip of
10% dextrose
Oral milk feeds
Hydrocortisone 5mg/kg/day
Somatostatin in refractory
cases
Station 6

228

A 5 days old neonate is brought by
parents to emergency with H/O
apnea, irritability, convulsion,
jittesiness and cyanosis-serum Ca
++

level is 5mg/dl.
Ans: hypocalcemia
2. Define hypocalcemia?
Ans: serum Ca++ level of <5mg/dl in
fil term and below 7mg/dl in the
preterm
3. Write the relevant investigations?
Ans:
Serum Ca++ level
ECG
Serum electrolyte
4. What would be the firstline
treatment?
Ans:

229

Ca
++
- gluonate 10% I/V may
be given
Oral Ca
+
glunate 400-
800mg/kg/24hrs
Chole calciferol- 2f serum
Ca++ remain conc
Station 7
Picture:
Ans: Cervical adenopathy
2 Write the relevant investigations?
Ans:
Blood CP.
U/E

230

LFTs
Thyroid profile

Station 8
Picture:
A.1: Henoch-Schonlein
2 What is the etiology behind this
condition?
Ans: It is secondary to deposition of
immune complexes
3 What are clinical features?
Ans: A maculopapular rash that
becomes hemorrhagic and

231

abdominal pain are the most
common manifestation.
Station 9
Radiograph:
1. What this chest x-ray shows?
Ans:
Homogenous opacity involving
the left side of the lung
Shifting of trachea and
mediastinum to opposite side.
2. What are the differential
diagnosis?
Ans:
Pneumonectomy (absence of
lung)
Massive pleural effusion

232

Pleural CA
3. Write the relevant investigations to
reach diagnosis?
Ans:
CT scan of lung
Lung biopsy
Station 10
Lab Assessment:
A 6 year old previously healthy boy
presents with 2 days of scrotal
swelling and thinks his eyes are
puffy. Examination reveals an
afebrile child with a blood pressure of
90/50 mmHg. He is alert with
significant bilateral peri orbital
edema. His abdomen has ascites
with no organomegaly . His scrotum
and lower extremities have tense
pitting edema.
1. What is the most likely diagnosis?

233

Ans: Minimal change disease
2. What is initial lab test most likely to
point to etiology of his illness?
Ans: Urine analysis for protein
Station 11
History
Refer to history section

Station 12
History Viva Refer to Examination
section

Station 13
Examination

234

Station 14
Examination Refer to examination
section

Station 15
Examination

235


236

Figures

Station 7
(2010 sem IX)

Station 8
(2010 sem IX)

Station 9
(2010 sem IX)

Station 7
(2010 sem X)


237

Station 8
(2010 semX)

Station 9
(2010 sem X)

Station 7
(2011 sem IX)

Station 8
(2011 sem IX)


238

Station 9
(2011 sem IX)

Station 7
(2011 sem X)

Station 8
(2011 sem X)

Station 9
(2011 sem X)


239

Station 7
(2012 sem IX)

Station 8
(2012 sem IX)

Station 9
(2012 sem IX)

Station 7
(2012 sem X)


240

Station 8
(2012 sem X)

Station 9
(2012 sem X)

Station 7
(2013 sem IX)

Station 8
(2013 sem IX)

241

Station 9
(2013 sem IX)

Station 7
(2013 sem X)

Station 8
(2013 sem X)

Station 9
(2013 sem X)

242

Station 7
(2014 sem IX)

Station 8
(2014 sem IX)

Station 9
(2014 sem IX)

Station 7
(2014 sem X)


243

Station 8
(2014 sem X)
Station 9 (2-14
sem X)

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