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Pediatrics- 2013 Internal OSCE StationsGroup 1:Counseling DM: Greet & introduce.Assess baseline knowledge.The pathophysiology of DM in lay language.Insulin therapy- types, duration and side effects.Home blood glucose monitoring. (Targets- FBS 70-150mg/dL, post-prandial <200 mg/dL)Dietary advice- 50 % carbs, 20 % protein and 30 % fatExercise- aerobic exercise at least 25 min/dayRecognition of hypoglycemia and hyperglycemia.Annual follow ups for eye, thyroid, foot and renal disease. Any questions or concerns? Thank you. Labs- identify microcytic anemia, probable cause and further investigationCauses- iron deficiency, thalassemia, chronic disease, lead poisoningTIBC, ferritin levels, peripheral smears, Hb electrophoresisCranial nerve examinationCN 1- smellCN 2- pupillary reflexes, visual acuityCN 3, 4, 6- EOMCN 5- sensations on face, muscles of masticationCN 7- facial symmetry, frown, smile, close eyesCN 8- HearingCN 9,10- gag reflex, check uvulaCN 11- shoulder shrug and SCMCN 12- tongue wasting, movementNeonatal resuscitationReceive baby in dry sheetLook ABC Suction, dry, stimulateInflation breathsVentilation breaths (40/min, 30-40 cm of H20, then 15 cm of H20 (how) (HR <60 , no breathing)Ventilation breaths and chest compressionsETT Vent. and chest compressionsDrugsSevere dehydration, signs of danger and initial managementRed flags:Lethargic/ unconsciousSunken eyesNot able to drink/drinking poorlySkin pinch goes back slowlyNot passing enough urine/anuriaManagement: IV fluids- 100 ml/kg Ringers Lactate or N/SInfants (< 1 yr) 30 ml/kg in 1 hour, 70 ml/kg in 5 hours> 2 yr, 30 ml/kg in 30 minutes, 70 ml/kg in 2.5 hoursReassess every 1-2 hours.Also give ORS as soon as child can drink (5 ml/kg/hour)Reassess an infant after 3 hours, child after 6 hours, classify dehydration and continue treatment as per clinical judgmentETT, identify uses and confirm its placement Uses:Provision of high flow oxygen in neonatal resuscitationAdministering drugs- epinephrine and surfactantSuctioning of airwaysPlacement confirmed by: chest auscultation, end tidal carbon dioxide, waveform capnographyDown syndrome- identify 2 cardiac and 2 GIT anomalies, chromosomal defectCardiac- VSDs, endocardial cushion defectsGIT- duodenal atresia, hirschspring disease, annular pancreasChromosomal defect- trisomy 21Low osmolarity ORS indication and composition, how to make homemade ORSStandard ORS osmolarity = 251.Indication: Avoid possible adverse effects of hypertonicity on net fluid absorption, in cases of hypernatremia.Home made ORS- 1/2 a teaspoon- salt6 level teaspoons of sugar1 liter water1 lemonPinch of baking sodaCompositionLow osmolarity ORSmmol/L (WHO)Standard ORSg/L (P.A)Standard ORS mmol/L (P.A)Sodium chloride753.590Glucose7520111Potassium201.520Trisodium citrate102.910Chloride65---80Total osmolarity= 245 Teratology of Fallot CXR, list findings, probable diagnosis, treatment of apneic spellsCXR- cardiomegaly, increased pulmonary vascular markings, right sided aortic archDx- TOFTet Spells-Oxygen inhalationPut child in knee chest position, decrease systemic vascular resistanceMorphine sulphate (0.1 mg/kg IV) to decrease anxiety and sympathetic overdrive.Sodium bicarbonate (1-2 mEq/kg) for acidosisPropranolol (0.1-0.2 mg/kg IV) to decrease infundibular spasm. Chicken pox image, describe the rash, diagnosis and complicationsVesicular rash- lesions in different stages of development- crusted, scabbed, blisters, vesicularDiagnosis- clinical or VZV FAMA or ELISAComplications- super-imposed bacterial infection, encephalitis, pneumonia, Reye’s syndromeGroup 2:Counseling a mother whose child has seizures – febrile seizuresGreet and introduce.Ask about baseline knowledge.Ask about family history.Explain the nature of the fits in lay language.Explain remedies to control these fits- treat underlying infection, no ant-epileptics needed.Explain the benign nature of these fits. Prognosis- good in simple febrile seizures. Increased risk of epilepsy or seizure disorder especially if young age or complex febrile seizure. In case of complicated seizures, prophylaxis can be given. Laryngoscopy and suction of meconium in a neonate in distress. Ambo bag was given to confuse the students. – Dr IffatStraight away suctionIf baby vigorous, HR > 100, ambu bag and normal resuscitation.If baby in distress, HR < 100, suction with laryngoscope, ETT, suction again, then normal resuscitation.Lab report with a mother and child with different Rh blood group. Management.Cord blood sampling- CBC, Retic count, Bilirubin, Coomb’s test, Blood groupGive Rhogam to mother within 72 hours of deliveryAssess baby- if jaundiced- Phototherapy, exchange transfusion with Rh +ve bloodAbdominal examination of a child – palpate liver and tell findings.Down’s syndrome karyotyping- as above. Hemorrhagic diseases given in tabular form and were asked to identify if bleeding time, PTT, APTT will be raised, normal or decreased.Hemophilia A aPTT increased, factor 8 decreasedHemophilia B aPTT increased, factor 9 decreasedLiver disease PT increasedVon Willebrand Disease BT increased, aPTT mildly increased, factor 8 mildly decreasedA scenario of a child with Duchene muscular dystrophy, Gowers signCPK level > 500 unitsMuscle biopsy- absent dystrophinRx- supportive, physiotherapy, steroids have transient role. Group 3: Dehydration: grade, manage, list complications and red flags.Counsel the parents of a patient of type 1 diabetes.General physical examination:Greet, introduce, consent.General appearanceMention weight, height, temperature. Hands- pulse, pallor, wasting, sweating, marks, capillary refill, nails, widened wristsEyes- pallor, jaundiceHead- fontanelle, shape, head circumferenceNeck- goiter, lymphnodesMouth- oral hygiene, thrushFeet- pedal edema, peripheral pulses. Neonatal Resuscitation in a case of meconium aspiration.Nasogastric tube: identify, list indications and complicationsUses- feeding, administering drugs/fluids, gastric lavageComplications- minor- nose bleeds, sinusitis; major- aspiration, esophageal perforation, intracranial placement of tube (skull #)Tetrology of Fallot chest Xray: identify the abnormality, list management of a Tet spell and diagnose the disease.Meningococcal Rash picture: write down the organism, type of rash and complications of the disease.Neisseria meningitidesGeneralized purpuric rashComplications- waterhouse friedrichsen syndrome, deafness, blindness, learning disabilities, seizures, hydrocephalus Measles rash picture: Diagnose. What is the death rate of the disease in Pakistan. List the complications. Give the EPI schedule of measles vaccine.Death rate- Complications- pneumonia, encephalitis, myocarditis, thrombocytopenia Measles vaccine- 0.5 ml SC at 9 months, MMR 0.5 ml SC at 15 months- left deltoidDowns' picture: Diagnose. List CVS and GI complications associated with the disease. What is the genetic defect in this disease?CXR with a pleural effusion: Identify the problem, what clinical findings are expected in this patient on examination, what investigations would you want to do.Examination- asymmetrical chest expansion, absent vocal fremitus, stony dull percussion note, decreased breath soundsInvestigations- CBC, CXR, chest USG, PPD, pleural fluid aspiration- counts, cytology, culture.Group 4:Nephrotic Syndrome counseling- 8 month old child.Baseline knowledgeFamily historySigns and symptomsWork upManagementPrognosisScreening for congenital nephrotic syndrome in next babyLower limb examinationNeonatal ResuscitationCare of normal infant questions\Gower sign on LCDDiagnosisInheritance patternPancytopenia on blood report with reticulocyte count < 0.2 %Identify abnormality- pancytopeniaList 4 causes- Aplastic anemia, Leukemia, Megaloblastic Anemia, Drugs, RadiationWhat next diagnostic test? What will you see? Bone marrow biopsy, blast cells, hypocellular marrow, abnormal precursors.Celiac disease on LCDWrite points in history2 physical examination findings- buttocks wasting, protuberant belly, signs of vit A,D,E,K deficiency, dermatitis herpetiformisInvestigations? Anti-gliadin antibodies, endoscopy with biopsyPPD, how to do it and TB vivaPPDA standard dose is 5 tuberculin units (TU - 0.1 ml) is injected intradermally (between the layers of dermis) and read 48 to 72 hours later. This intradermal injection is termed the Mantoux technique.Results: < 5mm negative,5-10 mm doubtful, > 10 mm positiveFalse +ve: BCG, hypersensitivity, resolved TBFalse –ve: malnourished, immunosuppressed, military TB, steroids, cytotoxic drugs, faulty technique, viral illnessTB viva:Drugs in pulmonary TB, TBMOrganism causing TBParacetamolDosage: 10-15 mg/kg/doseUses:Toxicity: HepatotoxicityAsthma attack managementABCO2 100 % via face maskSalbutamol 0.5 mg/kg/dose at 20-30 min intervals (nebulizer)Adrenaline 0.01 mg/kg (subcutaneously)Tebutaline 0.01 mg/kg/doseAminophylline 5 mg/kg/dose IVHydrocortisoneAdequate hydrationAntibioticsVentilator supportRicket Xray- wristXray findings- widening of epiphysis, splaying, frayingDiagnosis- ricketsLabs- ALP, Vit D3 ................
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