OSCE Sir Ganga Ram Hospital

1. OSCE
Centre for Child Health
Sir Ganga Ram Hospital

2. STATION 1
This 9-month-old
infant was cyanosed at
birth and had a cardiac
operation at 3 months
of age.
What condition is
shown here?
Name all features of
this condition?

3. Answer 1
• left sided Horner’s syndrome
• It results in ptosis (drooping upper eyelid),
miosis (constricted pupil), and occasionally
apparent enophthalmos (the impression
that the eye is sunk in) and anhidrosis
(decreased sweating ) on one side of the
face

4. STATION 2
A 14-year-old boy from Uttarakhand was seen in the Accident &
Emergency Department of Sir Ganga Ram Hospital with a generalised
convulsion. His parents said that he had complained for two weeks
previously of mild headaches, which had occurred at different times of
the day. At the age of 12 he was found to be sniffing glue but
subsequently told his parents he had discontinued the practice. His
progress at school was good and his behaviour had been normal.
On the afternoon of admission he had complained of a sudden
generalised headache; despite this he had gone to see some friends but
returned home with the headache. His mother had given him
paracetamol. As he was sitting down to watch television, he became
stiff and had a generalised convulsion.The family called an ambulance
and rectal diazepam was administered. He continued to fit and on arrival
at the hospital, intravenous lorazepam was required to terminate the
convulsion. He remained very drowsy and non-responsive.

5. STATION 2
On examination, there was some resistance to flexion of his
neck but he was afebrile. His respirations were laboured,
he was not cyanosed and was well perfused peripherally.
His blood pressure was 160/90 mmHg. Examination of his
heart, respiratory system and abdomen were normal.
His pupils were of equal size and both reacted sluggishly
to light. Examination of the fundi showed no
abnormalities; there was a generalised increase in tone in
his limbs but no focal abnormal neurological signs.

6. STATION 2
• What is the most appropriate investigation
to establish the diagnosis?
• What are the two most appropriate forms of
immediate management?
• What is the most likely diagnosis?

7. ANSWER 2
• CT scan
• administer intravenous mannitol and
arrange for intubation and ventilation
• subarachnoid haemorrhage

8. STATION 3
A 14-year-old boy presented with an 8 weeks history of occasional vomiting, weight loss,
listlessness and increasing pallor.
During this period he complained intermittently of headache, pain in the lower chest
anteriorly, and episodes of feeling hot and breathless. He had been short of breath on
exertion. He had been drinking more water and passing more urine than previously. He
complained of pains in his hands and feet and his family doctor arranged for an x-ray
(Q9).
His parents reported that since the onset of the illness his heart rate had become rapid and
his heart beat unduly forceful.
He had a long history of episodes of fever, abdominal pain and vomiting which had been
diagnosed as “abdominal migraine”. Both parents and his 4-year-old brother were
healthy.
His father was a factory worker and the family lived in a modern two-bedroomed flat.

9. STATION 3
On examination his weight was 30kg and his height was 138cm (growth charts Q11). He
was alert and afebrile. His respiratory rate was 40/minute and his pulse rate was
130/minute. There was some pitting oedema over the dorsum of each foot. Jugular venous
pressure was 5cm above the sternal angle. The apex beat was in the fifth interspace in the
anterior axillary line and was thrusting in character. The first and second heart sounds were
normal; the third heart sound was heard in the apical and left parasternal regions. The
femoral pulses were readily palpable.
The blood pressure was 160/110 mmHg. Fine crepitations were heard at both lung bases.
The appearance of the fundus is shown (Q10). The liver edge was palpable 3cm below the
costal margin. Neither bladder nor kidneys could be palpated and there was no abdominal
tenderness. Urinalysis was positive for protein (+) and negative for both glucose and blood.

10. • Hb 9.2 g/dl •urea 78 mg/dl
• MCV 73 fl • creatinine 3.4mg/dl
• MCH 23 pg • total protein 70 g/l
• MCHC 31 g/l • albumin 38 g/l
• WBC 8.0 x 109/l •S.calcium 2.1 mmol/l
• •S. phosphate 2.7 mmol/l
neutrophils 5.20 x 109/l
(normal range 0.99-1.57)
• lymphocytes 2.64 x 109/l
•alkaline phosphate 496 IU/l
• monocytes 0.08 x 109/l
(normal range for age 71-234)
• eosinophils 0.08 x 109/l •Chest x-ray normal
• Na-133 /K-4 •Abdominal ultrasound: Kidneys
• S. chloride 97 mmol/l small with increased echogenicity
• S. bicarbonate 20 mmol/l •No bladder abnormality

11. STATION 4
What is the most important
abnormality on the radiograph
of the hand shown of the boy
in St 3?
A delayed bone age
B osteomalacia
C osteoporosis
D splayed epiphyses
E subperiosteal erosions

12. ANSWER 4
E subperiostial erosions

13. STATION 5
What is the most likely pathogenesis of the abnormality
shown in X-ray shown in STATION 4?
A chronic ill health
B hypophosphataemia
C poor dietary calcium intake
D primary hyperparathyroidism
E secondary hyperparathyroidism
F vitamin D deficiency

14. ANSWER 5
E secondary hyperparathyroidism

15. STATION 6

16. STATION 6
What are the two most important features demonstrated on
the growth chart?
A bone age: advanced
B bone age: delayed
C bone age: normal
D height: high
E height: low
F height: normal
G pubertal staging: advanced
H pubertal staging: delayed
I pubertal staging: normal
J weight for height: high
K weight for height: low
L weight for height: normal

17. Answers 6
E Height: low
H pubertal staging: delayed

18. STATION 7
What is the best
interpretation
of the appearance
of the optic
fundus ?

19. ANSWER 7
Hypertensive retinopathy
Group I: minimal narrowing of the retinal arteries
Group II: narrowing of the retinal arteries in conjunction
with regions of focal narrowing and arteriovenous nicking
Group III: abnormalities seen in groups I and II, as well
as retinal hemorrhages, hard exudation, and cotton-wool
spots
Group IV (i.e., malignant hypertension): abnormalities
encountered in groups I through III, as well as swelling of
the optic nerve head.

20. STATION 8
What is the most likely cause of his breathlessness?
A anaemia
B left ventricular failure
C metabolic acidosis
D myocardial ischaemia
E raised intracranial pressure
F right ventricular failure

21. Answer 8
B - Left ventricular failure

22. STATION 9
What is the most likely cause of his renal
impairment?
A acute tubular necrosis
B chronic glomerulonephritis
C hypertensive nephropathy
D hypovolaemia
E reflux nephropathy

23. ANSWER 9
E - reflux nephropathy

24. STATION 10
Which of the following renal investigations should now be
performed?
A abdominal CT
B DMSA isotope scan
C MAG 3 isotope scan
D micturating cysto-urethrogram (MCUG)
E renal arteriogram
F renal biopsy

25. ANSWER 10
DMSA istope scan
micturating cysto-urethrogram (MCUG)

26. STATION 11
What is the best
description of
this lesion?

27. Answer 11
cavernous haemangioma

28. STATION 12
What are the two most
important
abnormalities present?

29. Answer 12
left pleural effusion
mediastinal shift

30. STATION 13
This is the face of a
boy aged five years.
What is the most
likely diagnosis?

31. Answer 13
• Stevens-Johnson syndrome
• Both Stevens-Johnson Syndrome and Toxic Epidermal
Necrolysis can start with non-specific symptoms such as
cough, aching, headaches, and feverishness. This may be
followed by a red rash across the face and the trunk of the
body, which can continue to spread to other parts of the
body. The rash can form into blisters, and these blisters
can form in areas such as the eyes, mouth and vaginal area.
The mucous membranes can become inflamed, and with
Toxic Epidermal Necrolysis layers of the skin can also
come away with ease and often the skin peels away in
sheets. The hair and nails can also come away in some
cases, and sufferers can become cold and feverish.

32. STATION 14
An 8-month-old male infant is referred because of
non-bilious vomiting. His general practitioner
(GP) had seen him frequently for constipation
over the last few months. Examination reveals a
thin, non-dysmorphic infant weighing 6.8kg (1st
centile). He has a scaphoid abdomen and his
capillary refill time is three seconds. General
examination was otherwise unremarkable.

33. STATION 14
Hb 12.2 g/dl Urine microscopy
WBC 13 x 109/l - no red cells
neutrophils 9.4 x 109/l
- no white cells
lymphocytes 3.6 x 109/l
Platelets 373 x 109/l
- no casts
plasma sodium 154 mmol/l Urine osmolality
plasma potassium 3.8 mmol/l -180 mOsm/kg
plasma urea 6.0 mmol/l

34. STATION 14
1.What is the most likely diagnosis?
2 .What would be the most appropriate test to
confirm the diagnosis?

35. Answer 14
1. diabetes insipidus
2. response to DDAVP

36. STATION 15
This is an x-ray of the
abdomen in a 12-year-
old girl who attended a
school for children
with learning
difficulties and
complained of
recurrent abdominal
pain.
What abnormality
can be seen on the
plain abdominal
film?

37. ANSWER 15
• Nephrocalcinosis

38. STATION 16
A 2-week-old male infant,
Blood gases:
previously well,
pH 7.33 (plasma hydrogen
presented with vomiting.
ion concentration 47
Hb 12.9 g/dl nmol/l)
WBC 18.5 x 109/l
PaO2 6.7 kPa (50 mmHg)
neutrophils 10.0 x 109/l
PaCO2 4.5 kPa (34 mmHg)
lymphocytes 7.8 x 109/l
monocytes 0.7 x 109/l plasma bicarbonate 17.3
mmol/l
platelets 604 x 109/l
blood glucose 4.2 mmol/l Base deficit -7.8 mmol/l
Na- 123/K-6.2
BUN-12 mg/dl

39. STATION 16
What is the most likely diagnosis?

40. ANSWER 16
Congenital adrenal hyperplasia
(21-hydroxylase deficiency)

41. STATION 17
• The dentist reported this
incidental finding in a 16-
year-old female.
• What is the diagnosis?
A aberrant parathyroid
B cavernous haemangioma
C cystic hygroma
D lingual thyroid
E lymphoma
F mucus retention cyst
G peri-tonsillar abscess
H rhabdomyosarcoma

42. Answer 17
D – Lingual Thyroid

43. STATION 18
• What two
abnormalities are
seen on the CT scan
with IV contrast of
a 4 yr old boy?
• What is the likely
diagnosis?

44. Answer 18
1. -displaced right kidney
- solid tumour of the right kidney
2. Wilms' tumour

45. STATION 19
• What are your
findings on
this smear?

46. Answer 19
• Malarial parasite

47. STATION 20
• What are your
findings on this
smear?

48. Answer 20
• Sickle cell anemia

49. STATION 21
• What are your
findings on this
smear?

50. Answer 21
• Blasts seen- most likely lymphoblasts

51. STATION 22
• What are your
findings on this
smear?

52. Answer 22
• Band cell –Immature neutrophil

53. STATION 23
• What are your
findings on this
smear?

54. Answer 23
• Micro Hypo Anemia

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