Year 5 Paeds End-Of-Posting SAMPLE OSCE


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Class of 2001, National University of Singapore
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Neonatology End-of-Posting Test (1 July 2000)

90 minutes written paper.

Define: Perinatal mortality rate
Ans:
Number of stillborn and neonatal deaths within the first 7 days per 1000 live births

Define: Neonatal mortality rate
Ans:
Number of neonatal deaths within 1 month after birth per 1000 live births

Define: Post neonatal mortality rate
Ans:
Number of infant deaths after 1 month from birth till 1 year of age per 1000 live births

Define: Infant mortality rate
Ans:
Number of deaths from time of birth till 1 year of age per 1000 live births

Define: Postterm
Ans:
Birth after 42 completed weeks of gestation

Define: Preterm
Ans:
Birth before 37 completed weeks (37+0) of gestation

Define: Small for gestational age
Ans:
Weight below 10th percentile of the population for that age.
Alt answer:(i)5th percentile(2 S.D). (ii)3rd percentile

Define: Low birth weight
Ans:
Birth weight less than 2.5kg

What are Singapore's current:
a)PMR b)NMR c)PNMR d)IMR
Ans:
a)1.2 b)2.1 c)1.9 d)4.0

Low birth weight:
a)Incidence b)Proportion of neonatal deaths
Ans:
a)7% b)60-80%

What is the range in a term infant of:
a)Length
b)Head circumference
Ans:
a)(43-45)-(53-56)cm
b)(30-32)-(36-38)cm

What may the following abnormalities in the maternal history
  result in or be associated with the newborn?
a)Oligohydramnios - give 3
b)Polyhydramnios - give 2
c)Mild diabetes - give 2
d)Severe diabetes
e)Graves disease
f)Hyperparathyroidism
g)Aspirin
h)Phenytoin
i)Naphthalene
j)Pethidine
k)Local anaesthetics entering blood
Ans:
   
a)Renal agenesis, Prematurity, Small for gestational age, Pulmonary hypoplasia
b)Oesophagial atresia, Hydrops fetalis
c)Hypoglycaemia,?macrosomia
d)?Congenital defects,?Sacral agenesis
e)Thyrotoxicosis, Drug-induced hypothyroidism
f)Hypercalcemia
g)Intracranial haemorrhage, early closure of PDA
h)Facial abnormalities
i)Jaundice in a G6PD baby
j)Respiratory depression
k)Convulsions,?arrhythmias

Name 6 common problems the intra-uterine growth retarded fetus
   can have during labour and the early newborn period
Ans:
Hypothermia, hypoglycaemia, IUD, Meconium aspiration, Birth Trauma, Polycythemia
NOT: Birth asphyxia(protected against!)

The fetus inspite of a low arterial PO2 is not anaerobic because:
Ans:
Fetal haemoglobin (HbF) has a greater affinity for oxygen, and is saturated at low PO2.

Name 4 mechanisms accounting for newborn heat loss:
Ans:
Conduction, Convection, Radiation, Evaporation
NOT: Poor thermoregulation, etc. etc.

Describe the natural history of respiratory distress syndrome.
Ans:
1)Presents before 6 hours
2)Maximum at about 48 hours
3)Remains static for about 24 hours
4)Improves on the 2nd or 3rd day
5)Baby can die of hypoxia at any time.

Name 3 ways respiratory distress syndrome be prevented?
Ans:
1)Prevent premature births.
2)2 does of steroids(dexamethasone) completed by 24 hours before delivery.
3)Prophylactic intra-tracheal surfactant before the first breath

What is the specific therapy for RDS?
Ans:
Direct delivery of surfactant (eg via ETT)

Name 5 ways a neonate with respiratory distress is monitored.
Ans:
a)Hourly HR,RR,BP, temperature
b)Hourly/3 hourly respiratory assessment
c)Transcutaneous O2/CO2
d)Daily fluid balance
e)6 hourly ABG if severe

Name 4 ways transient tachypnoea of the newborn differs from HMD(RDS)?
Ans:
a)TTNB in term infants, HMD in premature infants
b)TTNB usually just tachynpnoeic without retractions. HMD more severe with retractions.
c)TTNB self resolving, HMD usually requires intervention.
d)TTNB - lungs well expanded. HMD - atelectasis, collapse, whitewash, etc. XRay signs

What are the long term complications of mechanical ventilation? Give 3.
Ans:
a)Bronchopulmonary dysplasia
b)Subglottic stenosis
c)Hyperactive airway
d)Retinopathy of prematurity

The blood volume of a newborn is about:
Ans:
85ml/kg

The range of haemoglobin at birth is:
Ans:
14-20 g/dL

When does physiologic anaemia of the newborn occur?
Ans:
Between 2 and 4 months

Name 4 common causes of anaemia due to blood loss at birth:
Ans:
a)Feto-feto transfusion (twins)
b)Feto-placental transfusion
c)Vasa praevia
d)Placenta praevia
e)Intracranial haemorrhage/SAH/SDH

Haemorrhagic disease of the newborn is due a deficiency of:
Ans:
vitamin K dependant clotting factors 2,7,9,10

What method of feeding is associated with an increase in HDN?
Ans:
Breast feeding

What controversy exists in the prevention of HDN?
Ans:
One study showed that i/m Vit K is associated with an increase in adult tumors.
On the other hand, there is poor compliance when oral Vit K is given.

List 4 advantages of breast feeding over infant formula.
Ans:
a)Cheap
b)Secretory IgA protects baby
c)Less minerals which may overload the kidney
d)Maternal-infant bonding
e)Reduces risk of breast cancer
(Many more reasons possible)

True or false?:
a)A breast fed infant nurses 4 times a day
b)Breast feeding stools are yellow and loose
c)The stools are less frequent than in formula fed babies
d)Breast feeding is associated with higher levels of conjugated hyperbilirubinaemia
Ans:
   
a)F
b)T
c)F
d)F


Breast feeding is absolutely contraindicated in: (T/F)
a)Infants with jaundice
b)Maternal tuberculosis with sputum -ve for AFB
c)Maternal intake of antimetabolites
Ans:
   
a)F
b)F
c)T


Define total parenteral nutrition and list 2 diseases where TPN is indicated.
Ans:
a)Provision of calories, minerals and nutrients in amounts to prevent catabolism
and promote growth directly into the bloodstream without oral(enteral) feeding.
b)Necrotizing enterocolitis, massive gut resection, anastomotic leakage

The caloric density of the following are:
a)Breast milk
b)Humanised milk
c)Premature formula
Ans:
   
a)67-70 kcal/g
b)67 kcal/g
c)80 kcal/g


Name 3 ways in which premature formula differs from humanised formula
Ans:
a)More protein
b)More calories per gram
c)More vitamins
d)Less fat

What is the fluid requirements for:
a)Term infant Day 1
b)Term infant Day 7
c)Preterm infant Day 7
d)During phototherapy
Ans:
   
a)60 ml/kg/day
b)150 ml/kg/day
c)160 ml/kg/day
d)add 20 ml/kg/day


The following are indications of a fluid overload state:(T/F)
a)Hypernatraemia
b)Urine output <1 ml/kg/hr
c)Weight gain of 100g over 24g
d)Basal crepitations
e)Bradycardia
f)Periorbital edema
Ans:
   
a)F
b)F
c)T
d)T
e)F
f)T


A well term infant loses up to (A)% of birth weight in the first week of life;
Birth weight is regained by (B) and thereafter gains (C)g/day.
His caloric intake/requirement is (D)kcal/kg/day with (E)g/kg/day of proetin for cellular growth.
Ans:
a)10
b)10-14 day
c)30
d)100-120
e)2-5

List 4 features specifically suggestive of necrotising enterocolitis
Ans:
a)Bleeding GIT
b)Abdominal distension and gastric aspiration
c)Intramural or portal vein gas(aerobilia)
d)Systemic disturbance (eg Hypotension)

A 3 hour old term infant, delivered vaginally, presents with blood-stained gastric aspirate
Name a test you would do and describe the principle of the test.
Ans:
Apt test. Base is added to the aspirate, which will lyse any maternal(?) RBCs which are present,
which are less resistant than fetal(?) RBCs. This distinguishes swallowed maternal blood from
fetal GI bleeding.

The following may present with bilious vomiting:(T/F)
a)Tracheo-oesophageal fistula
b)Malrotation
c)Gastritis
d)Jejunal atresia
Ans:
   
a)F
b)T
c)F
d)T


List 5 clinical manifestations of neonatal hypoglycaemia:
Ans:
1)Jittery
2)Irritable
3)Poor suck
4)Seizures
5)Coma
etc.

Describe 3 mechanisms causing hypoglycaemia,
 and give 2 examples of diseases for each mechanism
Ans:
1)Hyperinsulinism - (a)Infant of diabetic mother (b)Nesidioblastosis(pancreatic tumor)
2)Low glucose stores - (a)Prematurity (b)IUGR (c)Sepsis
3)Decreased gluconeogensis - (a)Galactosaemia (b)Glycogen storage disorders (c)Cortisol def. (d)Panhypopit.

Give 3 reasons for jitteriness in an infant of a diabetic mother.
Ans:
1)Hypoglycaemia
2)Hypocalaemia
3)Hypothermia

With respect to hypocalcaemia, indicate (T/F):
a)Asymptomatic hypocalcaemia should always be treated
b)May present with seizures
c)Is defined by an ionised calcium level < 6mg/dL(2 mMol/L)
d)is seen in DiGeorge syndrome
Ans:
   
a)F
b)T
c)F
d)T


The following are true of rickets of prematurity: (T/F)
a)May result in pathological fractures
b)Doesn't affect growth in length
c)Causes a decline in serum alkanline phosphatase
d)Is never due to phosphate deficiency
Ans:
   
a)T
b)F
c)F
d)F (Always is)


Describe how you would symptomatic hypoglycaemia in a term newborn.
Ans:
1)Early feeding
2)i/v 10% dextrose 2-4ml/kg over 5 mins
3)maintenance drip of 10% dextrose 6-8ml/kg
4)Check blood sugar level in 30 minutes
5)Observe for hypoglycaemic signs
6)Consider glucagon/hydrocort

Give 4 reasons why preterm infants are more prone to infections.
Ans:
1)Weak immune system
2)Frequently breached physical barriers (Invasive procedures)
3)Nosocomial infections (during prolonged hospital stay)
4)Antibiotic treatment removes commensal organisms

Describe 4 methods used in the NICU to decrease the incidence of infection.
Ans:
1)Handwashing
2)Aseptic technique
3)Personal medical equipment
4)Barrier and reverse barrier nursing

Name 3 risk factors in infants for early onset sepsis
Ans:
1)Chorioamnionitis
2)Heavy Group B Strep colonization
3)Prolonged rupture of membranes

List 6 tests your would do when investigating a newborn for early onset sepsis.
Ans:
Chest X Ray, Neutrophil count, Platelets, ESR/CRP, Blood C/S, CSF, Torch serology

The commonly used first line of antibiotic treatment for newborns is:
Ans:
Penicillin/Amoxycilin + Gentamycin

Match the following features with the appropiate aetiological agent:
1)Cutaneous scarsa)Parvovirus
2)Blue berry muffin rashb)Syphillis
3)Metaphysitisc)Rubella
4)Non-immune hydropsd)Toxoplasmosis
5)Intracranial calcificatione)Varicella
Ans:
1)Cutaneous scarse)Varicella
2)Blue berry muffin rashc)Rubella
3)Metaphysitisb)Syphillis
4)Non-immune hydropsa)Parvovirus
5)Intracranial calcificationd)Toxoplasmosis


Varicella zoster immune globulin must be given to infants whose mothers
developed chicken buring during the time from:
Ans:
5 days before to 2 days after birth

Seizures seconday to asphyxia usually occur ____ hours after the hypoxic episode.
Ans:
6.

Are they(post-hypoxic seizures) controlled easily or with much difficulty?
Ans:
Much difficulty

How may seizures be clincially distinguished from tremors? (3 ways)
Ans:
1)Uprolling of eyes in seizures
2)Seizures not controllable by flexing/holding arms
3)Baby may not be alert or respond to mother
4)Not brought on by simple stimuli
5)Coarse infrequent tremors in seizures.
6)Seizures last longer

Name 3 signs of subtle seizures
Ans:
1)Uprolling of eyes or staring
2)Baby stops moving
3)Abnormal posture
4)Apnoea

Name the 3 common sites of intracranial haemorrhage
Ans:
1)Subdural
2)Subarachnoid
3)Intraventricular

Why is periventricular haemorrhage common in the preterm? (2 reasons)
Ans:
1)Pressure passive cerebral blood flow (Poor BP control)
2)Poorly supported vessels of germinal matrix (weak blood vessels)

Name 2 clinical states which predispose a preterm to periventricular haemorrhage
Ans:
1)Birth asphyxia
2)Hypotension

What pathological changes occuring after PVH are associated with a poorer long-term prognosis?
Ans:
1)?Hydrocephalus
2)?Periventricular leukomalacia

Describe the pupillary and tone disturbances associated with the following stages of HIE.
Stage 1Stage 2
Muscle tone  
Pupils  
Ans:
Stage 1Stage 2
Muscle toneNormalDecreased
PupilsDilatedConstricted

What Apgar scores are associated with a high probability of poor long-term prognosis?
Ans:
Apgar 5min < 3 or 10min < 3

Name 4 Anatomical Sites and 4 examples of diseases where decreased tone at birth may originate
Ans:
1)Cerebrum: HIE/Drugs
2)Spincal cord: Trauma
3)Anterior horn cell: Spinal muscular atrophy
4)Muscle: Muscular dystrophy (eg Duchenne's)

Current survival rates in Singapore of newborns by birth weight grouping are about:
1)400-500g: ____
2)750-1000g: _____
3)1.0-1.5kg: _____
4)> 2.5kg: _____
Ans:
1)< 50%
2)70-80%
3)75-80%
4)> 99%

1)Most infants with cerebral palsy are either preterm or term infants with low 1' Apgar scores (T/F)
2)Disability rates in survivors with birth weights below 1.5kg is: (a)5-10% (b)10-20% (c)20-30%
Ans:
1)False
2)(b)




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