OSCE: Nutrition & Dissorders


QUESTION 1

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This is the x-ray of a 2year old child who presents with anorexia, vomiting and poor weight gain.

  1. Write the findings on this x-ray.
  2. What is your diagnosis?
  3. What will be the presenting feature of this condition in an infant?
  4. Name the neurological complication that occurs in this condition.
  5. Mention one close differential radiological diagnosis.

ANSWER 1
  1. Cortical hyperostosis of ulna and tibia, absence of metaphyseal changes
  2. Hypervitaminosis A
  3. Bulging fontanel
  4. Pseudotumor cerebri
  5. Infantile cortical hyperostosis


QUESTION 2
  1. What is metabolic syndrome?
  2. What is adiposity rebound?
  3. Name 2 skin changes that is commonly seen in obese children.
  4. Name 4 common comorbidities seen in pediatric obesity.

ANSWER 2
  1. Central adiposity, hypertension, dyslipidemia, glucose intolerance, insulin resistance
  2. The point at which body fatness declines to a minimum/The point of maximal leanness/minimal BMI. Usually occurs at 5.5years. Early AR – increases risk of adult obesity
  3. Acanthosis nigricans – insulin resistance, Hirsuitism – PCOS
  4. Type 2 DM, Hyperlipidemia, hypertension, NAFLD.

QUESTION 3

Match the following

  1. Copper a) Hypocholesterolemia
  2. Selenium b) Osteoporosis
  3. Chromium c) Central Scotoma
  4. Manganese d) Cardiomyopathy
  5. Molybdenum e) Hyperglycemia

ANSWER 3
  1. Copper b) Osteoporosis
  2. Selenium d) Cardiomyopathy
  3. Chromium e) Hyperglycemia
  4. Manganese a) Hypocholesterolemia
  5. Molybdenum c) Central Scotoma

QUESTION 4

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  1. Identify the condition
  2. What is the mode of inheritance ?
  3. Give the key laboratory findings in this condition.
  4. What is the treatment ?

ANSWER 4
  1. Vitamin D Dependent Rickets – type II
  2. Autosomal recessive
  3. Calcium – Normal to low, PTH – Normal, 25-OHD – normal, 1,25-diOHD – very high, SAP - high
  4. Without alopecia – extremely high doses of vitamin D2, 25- D2 or 1,25 D. (partially functional receptor). If no response to high-dose Vitamin D – long term IV calcium, later high dose oral calcium.

QUESTION 5

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  1. What is your diagnosis?
  2. Name the common inciting agents for this condition.
  3. Name any 2 important predisposing conditions.
  4. Name the drugs used in the management of this condition.

ANSWER 5
  1. Noma – chronic necrotising ulceration of gingiva & cheek
  2. Fusobacterium necrophorum, prevotella intermedia
  3. Measles, malaria, TB, diarrhea, ulcerative gingivitis in a nutritionally compromised host
  4. Penicillin, metronidazole

QUESTION 6

A 6hrs old term neonate has prolonged bleeding from umbilical stump. PT is 24 seconds and PTT is 50seconds. Platelet count is 3lakhs/cumm. Sepsis screening is negative.
  1. What is the most likely diagnosis?
  2. Mention one important antenatal history that you will elicit.
  3. What is the treatment of choice?

ANSWER 6
  1. Vitamin K deficiency bleeding of the newborn
  2. Maternal intake of medications – warfarin, phenytoin, phenobarbitone
  3. 1mg of parenteral vitamin K

QUESTION 7

Answer the following regarding factors in breast milk:
  1. Kills bacteria ------
  2. Kills giardia -------
  3. Protects against malaria -------
  4. Inhibits E.coli --------

ANSWER 7
  1. Kills bacteria - Lipase
  2. Kills giardia - BSSL
  3. Protects against malaria - PABA
  4. Inhibits E.coli - Lactoferrin

QUESTION 8

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  1. Identify the condition.
  2. What are the X-ray findings seen in this condition?
  3. What are the skin changes seen in this condition?
  4. What is the treatment of choice?

ANSWER 8
  1. Scorbutic rosary
  2. Calcified subperiosteal hematoma, pathological fracture with periosteal reaction, Pencil thin cortex, white line of frenkel, wimburger’s sign, Trumerfel zone of rarefaction, pelkan spur, subperiosteal hemorrhage
  3. Petechial hemorrhages in skin
  4. Vitamin C supplements 100 – 200 mg orally or parenterally, Daily intake of 3 – 4 oz of orange or tomato juice

QUESTION 9

Write the 10 steps for successful breast feeding.


ANSWER 9
  1. Have written breast feeding policy
  2. Training of health care staff
  3. Antenatal preparation – education about the benefits of breast feeding and nipple preparation
  4. Early contact – initiation of breast feeding with in 30minutes
  5. Guidance – how to feed and how to maintain lactation during separation
  6. No food or drinks other than breast feeds
  7. Rooming in – mother and baby together 24hrs
  8. Practice feeding on demand
  9. Avoid teats and pacifiers
  10. Continuing support through breast feeding support groups

QUESTION 10

Answer the following:
  1. Digestibility coefficient
  2. Biological value
  3. Net protein utilization
  4. Protein efficiency ratio
  5. Write the BV and NPU of egg and cow’s milk.

ANSWER 10
  1. DC = Absorbed nitrogen/Food nitrogen X 100
  2. BV = Retained nitrogen/Absorbed nitrogen x 100
  3. NPU = Retained nitrogen/Food nitrogen X 100
  4. PER = gain in weight of experimental animal per unit weight of protein consumed
  5. Egg – BV 96, NPU – 96, Cow’s milk – BV 90, NPU – 85

QUESTION 11

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This infant is under evaluation for chronic diarrhea.
  1. Describe the lesions
  2. What is your diagnosis?
  3. What is it due to ?
  4. How will you detect in its early stages?
  5. How do you treat ?

ANSWER 11
  1. Crusting dermatitis in periorificial regions
  2. Acrodermatitis enteropathica
  3. Zinc deficiency
  4. Serum thymulin levels can be used to detect early deficiency
  5. 50-150 mg of Zinc sulphate

QUESTION 12

A 8months old infant with history of recurrent diarrhea and poor weight gain is brought with complaints of loose stools for a day. On examination, infant is lethargic, pale, undernourished with weight of 4kg. Edema is present. Oral mucosa is dry. Pulses are feeble.
  1. What is the recommendation regarding initial fluid management in this infant?
  2. What is the recommendation regarding blood transfusion in this infant?
  3. What is the type of ORS that can be used in this infant and how to prepare it?

ANSWER 12
  1. 15ml/kg/hr of GRL or 0.45DNS
  2. 10ml/kg of whole blood transfusion over 3hrs if Hb <4gm/dl or <6gm/dl with respiratory distress
  3. ResoMAL (contraindication – cholera, profuse watery diarrhea). 1 sachet of standard WHO low osmolar ORS in 2litres+1 scoop of commercially available combined mineral & vitamin mix or 40ml of mineral mix solution + 50gm sugar

QUESTION 13

Write the RDA of the following

  1. Vitamin A
  2. Vitamin E
  3. Vitamin B 3
  4. Folic acid
  5. Vitamin B 12
  6. Vitamin C
  7. Calcium
  8. Phosphorus
  9. Magnesium
  10. Iron
  11. Iodine
  12. Zinc

ANSWER 13
  1. Vitamin A – 1500 IU
  2. Vitamin E – 5-15 IU
  3. Vitamin B 3 (Niacin)- 5-15 mg
  4. Folic acid – 50-150 mcg
  5. Vitamin B 12 – 0.5-1.5 mcg
  6. Vitamin C – 40 mg
  7. Calcium – 500- 1000 mg
  8. Phosphorus – 800- 1000 mg
  9. Magnesium – 200- 300 mg
  10. Iron – 10 – 20 mg
  11. Iodine – 50 – 150 mcg
  12. Zinc – 5 – 15 mg

QUESTION 14

A mother brings her 4months old infant to well baby clinic. How would you counsel her regarding complementary feeds?


ANSWER 14
  1. Duration of exclusive breast feeding and age of introduction of complementary feeds
  2. Maintenance of breast feeding – continue frequent, on demand breast feeding until 2years of age
  3. Responsive feeding – feed infants directly & assist older children, slowly & patiently, do not force, experiment different food combinations, avoid distraction, keep talking to the child
  4. Safe preparation and storage of complementary feeds – wash hands, clean utensils during preparation, clean cups, bowls for feeding, avoid feeding bottle
  5. Amount of complementary feed needed – start with small amounts and increase
  6. Food consistency – 6months pureed, mashed, 8months – finger food,
  7. 12months – whatever the family eats. Avoid foods that can cause choking
  8. Meal frequency and energy density – 2-3 times a day at 6-8months, after that 3-4times a day
  9. Nutrient content – rich in micronutrients, avoid drinks with low nutritive value, add nutritional snacks like fruits, bread in between. 30-45% fat content, add oil.
  10. Vitamin and mineral supplements or fortified products for infant and mother
  11. Feeding during and after illness – increased fluid intake during illness, frequent breast feeds.

QUESTION 15

As per WHO 2013 guidelines, mention the criteria for diagnosis of SAM in children <6months of age and in children between 6-59months of age.
  1. Name the diet that is recommended during the stabilization phase in SAM. Write the caloric and protein content.
  2. Name the diet that is recommended during the rehabilitation phase in SAM. Write the caloric and protein content.

ANSWER 15

<6 mo
Wt for length <3 Z score
Bilateral pitting edema
6-59mo
Wt for height </= 3 Z score
MUAC <11.5CM
Bilateral edema
Diet
F 75, 75kcal, 0.9gm protein/100ml
F 100, 100kcal, 2.9gm protein/100ml
Whole/skimmed milk, sugar, veg oil, water, mineral mix (cereal flour)
Ready To Use Therapeutic Food


Few things extra

Admission criteria
Medical complications
Severe edema
Failed appetite test
Danger signs of IMCI
Home environment not conducive
Recent weight loss or failure to gain weight

Discharge criteria
Discharge wt for Ht >2Z score and no edema for atleast 2 weeks
MUAC >12.5cm and no edema for atleast 2 weeks
Do not use percentage of weight gain
Good appetite
Weight gain >5gm/kg/day for 3 consecutive days

Vitamin A recommendation
Signs of deficiency – day 1, 2 and 15
Low dose 5000IU/day daily from admission to discharge
High dose – severe diarrhea, shigellosis

Antibiotic recommendation:
No apparent danger signs or no complications – oral amoxicillin
Parenteral antibiotic – septic shock, hypoglycemia, hypothermia, skin, respiratory infections, UTI

HIV and SAM
<1year – start ART irrespective of CD4 count or clinical staging
2-5years – WHO clinical staging 3 or 4, CD4 <750 or <25%


QUESTION 16

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This is the x-ray of a 4year old child who presents with easy fatiguability, easy bruising, limb pain and progressively increasing abdominal distension.
On examination, he has pallor, few petechiae and massive splenomegaly, moderate hepatomegaly
  1. What is the finding on this x-ray?
  2. What is the most likely diagnosis?
  3. What is the mode of inheritance?
  4. What will be the bone marrow finding in this child?
  5. What is the treatment of choice?

ANSWERS 16
  1. Erlenmeyer flask deformity
  2. Gaucher disease
  3. Autosomal recessive inheritance
  4. Gaucher cell – wrinkled paper appearance
  5. Enzyme replacement therapy


QUESTION 17

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  1. Identify the pattern of inheritance
  2. Write 4 examples

ANSWER 17
  1. Mitochondrial inheritance
  2. Leber hereditary optic neuropathy, MELAS, MERRF, Leigh disease, Pearson syndrome, Kearn sayre syndrome, Chronic progressive external ophthalmoplegia


QUESTION 18

This is the EEG of a child who is under evaluation for suspected Neurodegenerative disorder.
  1. What is the most likely diagnosis?
  2. At what stage of illness does this EEG pattern occur?
  3. Other than the compatible clinical course, what are the 3 supportive findings that are used in diagnosis of this condition.

ANSWER 18

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  1. Burst suppression episodes, SSPE
  2. Stage 2
  3. Measles antibody detected in CSF, Characteristic EEG findings, Typical histologic findings in/or isolation of virus or viral antigen from brain tissue obtained by biopsy

QUESTION 19

5 years old girl has presented with breast enlargement for the past 1 year. Her height has increased from 95 to 106 cm in the last 1 year. The SMR staging is breast stage 2, axillary hair- stage 1 and pubic hair stage 1. X-ray bone age is consistent with age standard of 8 years. Investigations show FSH 4.6 IU/L (normal < 1.6), LH 0.5 IU/L (Normal < 0.1 ) 17 β- estradiol 25 (normal < 10).
  1. What is the likely diagnosis?
  2. What further investigations are required to confirm the diagnosis?
  3. Name 5 clinical pointers to differentiate true precocious puberty from premature thelarche.

ANSWERS 19
  1. True precocious puberty
  2. Ultrasound pelvis, GnRH stimulation test, MRI brain
  3. Areolar darkening. Growth spurt. Estrogenised vaginal mucosa. Presence of axillary/pubic hair. Progression of pubertal signs. Presence of acne/adult odour. Age of presentation

QUESTION 20

10 weeks old male baby is admitted with seizures. Blood glucose at the time of admission was 22 mg/dl. Baby was treated with IV glucose infusion. Two subsequent blood glucose measurements are all less than 30 mg/dl.
  1. What immediate management is required?
  2. What investigations are required at the time of hypoglycaemia?
  3. Urine sample is negative for ketones. What could be the possible causes of hypoglycaemia in this child? (Name two)
  4. The insulin level is 27 (normal 0-10). Describe further management options.

ANSWERS 20
  1. Take critical sample and give IV glucose infusion of 200 mg/kg
  2. Insulin, c-peptide, cortisol, growth hormone, lactate, free fatty acids, ketones, alanine
  3. Hyperinsulinism, Fatty acid oxidation defect.
  4. Diazoxide, chlorthiazide, Octreotide, Subtotal or focal pancreatectomy

QUESTION 21

7 yr old girl from Delhi brought with complaints of FTT, recurrent diarrhea and pallor. Clinical examination reveals clubbing and generalized abdominal distension.
Hb 7.8
PS- Micro Hypo Aniso
Serum albumin 2.7 g/dl
Serum calcium 7.7 mg/dl
  1. Name 5 causes of chronic diarrhea and malabsorption in children
  2. Most probable diagnosis in this child?
  3. What serological tests may be useful?
  4. How to confirm the diagnosis?

ANSWERS 21
  1. Celiac disease, cow’s milk protein allergy, giardiasis, immunodeficiency, inflammatory bowel disease
  2. Celiac disease
  3. Serum IgA tTG, serum IgA Endomysial antibody
  4. Positive serology and duodenal biopsy showing villous atrophy while on gluten and clinical improvement on gluten free diet

QUESTION 22

An 8 mth old female infant. Referred for evaluation of large head size. She is the first born of second degree consanguinous parents.
On examination, she has Macrocephaly, normal vision & hearing & normal neurological examination
MRI brain revealed- macrocephaly,dilated lateral ventricles,cortical atrophy & atrophy of striatum.
  1. What is the diagnosis ?
  2. What special diet will you advice ?
  3. What is the estimated average life span of this condition ?

ANSWER 22
  1. Glutaric Aciduria Type I
  2. Low protein diet (restricted in Lysine & Tryptophan ), High dose Riboflavin (200-300mg/day) & L Carnitine(50-100mg/kg)
  3. 10 yrs

QUESTION 23

Arrange the following common Indian food items in to any of the 3 groups – low/medium/high glycemic index
  1. Cornflakes
  2. Orange
  3. Potato (boiled)
  4. Brown rice (boiled)
  5. Watermelon
  6. Whole wheat bread
  7. French fries (potato)
  8. Banana
  9. Chocolate
  10. Milk (full fat)
  11. Honey
  12. Lentils

QUESTION 24

Counsel parents of a 2months old infant with meningomyelocele.


ANSWER 24
  1. Congenital defect of spinal cord
  2. Need for neuroimaging (hydrocephalus/arnold chiari)
  3. Risk of intracranial infection
  4. Prognosis with or without surgery
  5. Seizures, paraparesis, UTI, need for CIC
  6. Post surgery multidisciplinary follow up and physiotherapy
  7. History whether mother was on AED or had IDDM
  8. Risk of recurrence
  9. Folate supplementation during next pregnancy. 1month prior to conception till the end of first trimester.
  10. Regular USG during next pregnancy.
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