Your 10-day strategy: 15 to 24 September

Daily non-negotiables

1. One long case, preferably a real ward patient.
2. Two short cases.
3. One OSCE-style topic: growth chart, vaccine, fluid calculation, X-ray, developmental assessment, prescription, counselling.
4. One 15-minute viva drill with a friend or senior.
5. Make a notebook called “Cases I can present”. Keep one page per case with:
   • Diagnosis
   • Key positive findings
   • Important negatives
   • Differentials
   • Investigations
   • Management
   • One complication
   • One parent-counselling point

Day-wise plan

The exact long-case presentation structure

1. Introduce yourself to parent and child. Ask permission.
2. State the child’s name, age, sex, residence, informant and reliability.
3. Present chief complaints with duration.
4. Present history in chronological order.
5. Include paediatric essentials:
   • Antenatal, natal, postnatal history
   • Feeding and dietary history
   • Immunization
   • Development
   • Past illness, admissions, transfusions
   • Family history, TB contact, similar illness
6. General examination:
   • Sensorium and comfort
   • Vitals
   • Anthropometry and nutritional status
   • Pallor, icterus, cyanosis, clubbing, edema, lymph nodes
7. Systemic examination in a disciplined sequence.
8. Give a one-line summary.
9. State provisional diagnosis, severity/complication, and 2-3 differentials.
10. Discuss investigations and management in priority order.

High-scoring summary template

“This is a ___-year-old, appropriately/immunized/partially immunized child with ___ for ___ duration, with examination evidence of ___, and no evidence of ___. My provisional diagnosis is ___ with ___.”

What examiners notice immediately

Do these

• Examine the child gently and keep them comfortable.
• Warm your hands and examine the painful area last.
• Ask the parent to hold the child where appropriate.
• Tell the examiner what you are looking for.
• Mention relevant negatives only, not a random list.
• Use correct growth and development terminology.
• Say “I would assess ABC and stabilize first” in any sick-child scenario.
• If you do not know, say: “I am not sure, but I would check the guideline/consult my senior and ensure immediate stabilization.”

Avoid these

• Declaring a murmur, hepatomegaly, dehydration, or developmental delay without demonstrating how you assessed it.
• Forgetting anthropometry in every child.
• Ignoring immunization and feeding history.
• Giving adult drug doses.
• Talking over the parent or frightening the child.
• Inventing findings or management when unsure.

High-yield practical topics

Examination

• Weight, length/height, head circumference, mid-upper arm circumference
• Plotting and interpreting growth charts
• Signs of severe acute malnutrition
• Dehydration assessment and plan
• Developmental screening and developmental quotient concept
• Respiratory distress signs
• Cyanosis, clubbing, pallor, edema
• Hepatomegaly and splenomegaly
• Cardiovascular examination and common murmurs
• CNS examination, tone, reflexes, cranial nerves, signs of meningitis
• Newborn examination and primitive reflexes

Common long cases

• Cerebral palsy/developmental delay
• Congenital heart disease
• Nephrotic syndrome
• Acute glomerulonephritis
• Severe acute malnutrition
• Chronic liver disease/hepatosplenomegaly
• Bronchial asthma
• Tuberculosis
• Seizure disorder
• Thalassemia/hemolytic anemia

Common short cases and spotters

• Rickets
• Marasmus/kwashiorkor
• Down syndrome
• Cyanotic heart disease
• Meningomyelocele
• Hydrocephalus
• Clubfoot
• Hepatosplenomegaly
• Facial dysmorphism
• X-rays: pneumonia, TB, congenital heart disease patterns, rickets
• Instruments: infantometer, MUAC tape, nebulizer, spacer, phototherapy unit
• Vaccines, vaccine schedule, cold chain
• ORS preparation, zinc, fluid calculations

Viva: prepare these “must-not-miss” areas

• National immunization schedule and catch-up principles
• Exclusive breastfeeding and complementary feeding
• ORS and zinc
• WHO dehydration classification
• SAM identification and initial management
• Developmental milestones
• IMNCI danger signs
• Common paediatric drug doses and weight-based calculation
• Maintenance fluid calculation
• Neonatal danger signs
• Jaundice differential in neonates
• Fever with rash
• Seizure management basics
• Asthma acute management basics
• Anemia approach
• Nephrotic syndrome complications

Mock-practical method that creates rank-level improvement

• Long case: 30-40 min examination and preparation, then 7-10 min presentation/viva.
• Short case: 5 min examination, 3 min discussion.
• OSCE/spotter: 1-2 min per station.
• Ask your mock examiner to interrupt you. Real examiners will.

• Rapport and consent
• History sequence
• Examination technique
• Finding interpretation
• Summary
• Differential diagnosis
• Management
• Viva clarity
• Confidence without arrogance
• Time control

On the examination day

• Arrive early with apron, stethoscope, pen, small notebook, watch, calculator if permitted.
• Eat and hydrate.
• Do not discuss rare cases outside the room.
• In the first 30 seconds, establish rapport with the parent and child.
• If the child cries, do not panic. Observe first, examine while on parent’s lap, and auscultate when calm.
• If you miss a finding, do not bluff. Continue systematically.
• End every management answer with monitoring, counselling, follow-up, and referral/escalation when indicated.

The mindset for a gold medal

• Consistent in common cases
• Safe with emergencies
• Gentle with children
• Precise in communication
• Honest about uncertainty
• Very strong in growth, nutrition, development, immunization, and newborn care

What to do from now until 25 September

Your daily template

• 1 complete long case from history to management discussion
• 2 short cases with a timed 5-minute examination
• 1 neonatal case or newborn examination
• One radiology/ECG/ABG/hematology/instrument viva session
• 30 rapid-fire viva questions
• 30 minutes of recent-guideline revision
• One mock presentation aloud, preferably in front of a senior or co-PG

---

Priority order for MD Paediatrics practical

1. Long cases: make these unbeatable

1. Cerebral palsy/developmental delay
   • Etiology, classification, developmental assessment, associated deficits
   • Nutrition, rehabilitation, seizure management, family counselling
   • Differentiate CP from progressive neurodegenerative disease
2. Congenital heart disease with heart failure/cyanosis
   • Functional class, saturation, heart failure signs, pulmonary hypertension
   • Differentiate common acyanotic and cyanotic lesions
   • Echo-based diagnosis, medical stabilization, timing of intervention
3. Chronic kidney disease/nephrotic syndrome/glomerulonephritis
   • Edema approach, hypertension, urine examination, renal function
   • Steroid-sensitive vs steroid-resistant nephrotic syndrome
   • AKI/CKD complications and renal replacement indications
4. Chronic liver disease/hepatosplenomegaly
   • Portal hypertension, ascites, encephalopathy, growth failure
   • Wilson disease, storage disorders, viral hepatitis, autoimmune hepatitis
   • Approach to massive splenomegaly
5. Thalassemia/hemolytic anemia
   • Transfusion history, chelation, iron overload, endocrinopathy
   • Differentiate anemia causes and interpret hemolysis work-up
   • Transfusion thresholds and long-term complications
6. Tuberculosis/chronic respiratory disease
   • Exposure history, nutrition, investigations, microbiological confirmation
   • Drug-resistant TB approach, adverse-effect monitoring
   • Differentials such as malignancy, chronic infection, ILD
7. Epilepsy/neurodisability
   • Seizure semiology, syndrome recognition, EEG/MRI interpretation
   • Drug choice, duration, breakthrough seizure and status epilepticus plan
8. Severe acute malnutrition with complication
   • Stabilization phase, feeding, electrolytes, infection, refeeding risk
   • Distinguish nutritional edema from renal/cardiac/hepatic edema

How to present a long case at MD level

“This is a ___-year-old child with ___, presenting with ___ for ___ duration. The illness appears to be acute/chronic/progressive, with severity markers including ___. Relevant background factors are ___. On examination, the key syndromic findings are ___. My problem representation is ___. My leading diagnosis is ___, with differentials of ___ and ___. I would first address ___, confirm the diagnosis using ___, and manage with ___ while monitoring for ___.”

1. Stabilization and emergency risks
2. Syndromic diagnosis
3. Etiological work-up
4. Definitive treatment
5. Monitoring
6. Complication prevention
7. Counselling, rehabilitation, follow-up

---

2. Short cases: speed, signs, and interpretation

Cardiology

• Tetralogy of Fallot and hypercyanotic spell
• VSD/PDA/ASD
• Rheumatic heart disease
• Heart failure
• Pulmonary hypertension
• Kawasaki disease
• Cardiomyopathy

Respiratory

• Severe pneumonia
• Wheeze/asthma
• Bronchiolitis
• Pleural effusion/empyema
• Interstitial lung disease clues
• Cystic fibrosis/bronchiectasis
• Foreign body aspiration

Neurology

• CP phenotype
• Spasticity versus dystonia
• Meningeal signs
• Peripheral neuropathy
• Muscular dystrophy
• Ataxia
• Neurocutaneous markers
• Raised intracranial pressure

Nutrition/endocrine/metabolic

• SAM
• Rickets
• Hypothyroidism
• Diabetes and DKA
• Short stature
• Precocious puberty/delayed puberty
• Obesity and metabolic syndrome
• Mucopolysaccharidosis/storage disease phenotype

Gastro-nephro-hemato

• Hepatosplenomegaly
• Ascites
• Chronic liver disease
• Nephrotic edema
• Hypertension
• Thalassemia facies
• Lymphadenopathy
• Bleeding manifestations

Neonatology

• Preterm examination
• Jaundice
• Neonatal sepsis
• HIE
• Respiratory distress
• Congenital anomalies
• Neonatal seizures

“The child has clinical features of ___. Severity is suggested by ___. Important associated findings I would actively look for are ___. My main differentials are ___. Immediate concerns are ___, and confirmation would require ___.”

---

3. Viva stations that decide ranks

A. Investigations

• CBC and peripheral smear
• Reticulocyte count, hemolysis profile
• ABG/VBG and acid-base disorders
• Electrolytes and anion gap
• LFT/RFT
• Urine routine, urine protein:creatinine ratio
• CSF analysis
• Thyroid profile
• Iron studies
• Bone marrow
• ECG
• Chest X-ray
• Pediatric neuroimaging
• Echo basics
• Growth charts, BMI charts, height velocity
• Developmental assessment tools

B. Emergencies

• Status epilepticus
• Shock
• DKA
• Severe acute asthma
• Anaphylaxis
• Acute heart failure
• Hypercyanotic spell
• Severe dehydration
• Severe hyperkalemia
• Raised ICP
• Acute liver failure
• AKI with fluid overload
• Neonatal resuscitation
• Severe neonatal jaundice

“I would call for help, assess airway, breathing, circulation, disability, exposure, establish monitoring and IV/IO access, check bedside glucose, and treat life-threatening instability simultaneously with targeted evaluation.”

C. Procedures and instruments

• Lumbar puncture
• Bone marrow aspiration
• Intraosseous access
• Pleural tap/chest drain
• Ascitic tap
• Endotracheal intubation
• Umbilical venous catheterization
• Exchange transfusion
• Nebulizer/spacer use
• Phototherapy
• CPAP and ventilator basics
• Growth measurement tools
• Vaccine cold-chain equipment

D. Drugs

• Indication
• Dose by weight
• Route
• Maximum dose
• Adverse effects
• Renal/hepatic adjustment
• Monitoring

---

9-day high-intensity schedule

---

How to score like a gold-medal candidate

Speak in clinical priorities

“I will first investigate the immediate threat and obtain samples that change management. Once stable, I will proceed to etiological testing.”

Give a reason for every test

“I would order echocardiography to define anatomy, assess ventricular function and estimate pulmonary pressures, as these findings determine the need and timing of intervention.”

Mention uncertainty intelligently

“The leading diagnosis is ___. I would keep ___ as an important alternative because ___. I would distinguish them using ___.”

Always include family-centred care

• Prognosis
• Parent counselling
• Nutrition
• Development and rehabilitation
• Adherence
• Cost/availability
• Follow-up plan
• Need for multidisciplinary referral

Know your dissertation

• Why this topic?
• Research question and objectives
• Study design
• Inclusion and exclusion criteria
• Sample size
• Statistical tests
• Main result
• Bias and limitations
• Clinical relevance
• What you would do differently

---

Practical-day checklist

• Do not appear rushed.
• Obtain consent and build rapport with child and parent.
• Use age-appropriate examination technique.
• Warm hands, observe before touching, examine painful areas last.
• In a crying child, use observation, parent’s lap, and opportunistic auscultation.
• Never announce a finding that you have not demonstrated.
• Do not over-diagnose based on one sign.
• Present a concise problem representation before listing diagnoses.
• Give safe, phased management with monitoring.
• If corrected by an examiner, accept it calmly and incorporate the correction.

One final rule

What examiners expect in a CP long case

1. Is this cerebral palsy?
   • Permanent disorder of movement and posture due to injury/maldevelopment of the developing brain
   • Motor impairment is non-progressive, though functional problems and deformities can worsen with growth
2. What type is it?
   • Spastic: hemiplegic, diplegic, quadriplegic
   • Dyskinetic: dystonic/choreoathetoid
   • Ataxic
   • Mixed
3. What is the functional severity?
   • GMFCS level I to V
   • Mobility, hand use, communication, feeding, cognition, school participation
4. What are the associated impairments?
   • Epilepsy
   • Intellectual disability/developmental delay
   • Vision and hearing issues
   • Speech, language and communication impairment
   • Dysphagia, aspiration, malnutrition/constipation
   • Drooling
   • Hip displacement, contractures, scoliosis, pain
   • Sleep and behavioral/mental-health problems
   • Bladder/bowel dysfunction
5. What is the cause and are there red flags against CP?
   • Prematurity, HIE, neonatal seizures, CNS infection, hyperbilirubinemia, stroke, congenital infection
   • Red flags: loss of acquired milestones, progressive weakness/spasticity, diurnal fluctuation, positive family history of a neurodegenerative/metabolic condition, or an atypical MRI pattern.

---

Your examination sequence

1. Observe before touching the child

• Alertness, interaction, social smile, eye contact
• Head control, posture, asymmetry
• Spontaneous movements, dystonia/chorea/athetosis
• Drooling, speech/vocalization, feeding support
• Ability to sit, stand, walk, transfer
• Walking pattern if ambulant: toe walking, scissoring, crouch gait, equinus, circumduction
• Orthoses, wheelchair, walker, standing frame

2. General examination

• Anthropometry: weight, height/length, BMI or weight-for-height where appropriate
• Nutritional status
• Head circumference
• Pallor, rickets, contractures, pressure sores
• Spine: scoliosis/kyphosis
• Chest for recurrent aspiration signs
• Abdominal examination: constipation, hepatosplenomegaly if relevant
• Vision and hearing clues

3. Neurological examination

Higher functions/development

• Gross motor
• Fine motor/adaptive
• Language
• Personal-social
• Cognitive ability, appropriate to age and cooperation

“I would determine developmental age in each domain and identify whether delay is global or predominantly motor.”

Tone

• Spasticity: velocity-dependent increase in tone
• Rigidity: not velocity dependent
• Dystonia: sustained/intermittent involuntary contractions causing abnormal postures
• Ataxia: dysmetria, intention tremor, truncal instability

• Tone in all four limbs
• Adductors, hamstrings, gastrocnemius/soleus
• Ankle clonus
• Deep tendon reflexes
• Plantar response

Power and motor control

• Functional power is often more useful than formal MRC grading in young children
• Observe reach, grasp, pincer grip, transfers, rising from floor, squat-to-stand
• Check selective motor control

Reflexes

• DTRs, clonus, plantar response
• Primitive reflex persistence if relevant
• Protective responses and postural reactions in younger children

Musculoskeletal assessment

• Hip abduction, adductor tightness
• Thomas test for hip flexion contracture
• Popliteal angle for hamstring tightness
• Ankle dorsiflexion with knee flexed and extended
• Fixed equinus versus dynamic equinus
• Knee flexion contracture
• Upper-limb posture and hand function
• Spine and pelvic obliquity

---

How to classify in the final presentation

Model summary

“This is a ___-year-old child with static motor impairment since early infancy, characterized by delayed gross-motor milestones, bilateral lower-limb predominant spasticity, hyperreflexia, ankle clonus and equinus contractures, with no history of regression. The child has [associated epilepsy/intellectual disability/feeding difficulty/visual impairment]. Functionally, the child can ___ and is dependent for ___. This is most consistent with spastic diplegic cerebral palsy, approximately GMFCS level ___, with ___ associated comorbidities and ___ musculoskeletal complications.”

“Spastic quadriplegic CP with severe global developmental impairment, probable GMFCS V, feeding dysfunction, and high risk of aspiration, hip displacement, scoliosis, pain, and osteopenia.”

GMFCS: learn it perfectly

---

Essential history questions

Establish static encephalopathy

• When did parents first notice abnormality?
• Was there delayed attainment of milestones?
• Any loss of milestones? If yes, reconsider CP.
• Course: static, improving function with therapy, or progressive?

Etiology

• Antenatal: maternal infection, diabetes, hypertension, reduced fetal movements, multiple pregnancy
• Perinatal: gestational age, birth weight, NICU admission, asphyxia/resuscitation, ventilation, neonatal seizures, jaundice/exchange transfusion
• Postnatal: meningitis/encephalitis, head injury, stroke, severe hypoglycemia
• Family history: developmental disability, similar illness, consanguinity

Functional assessment

• Head control, sitting, standing, walking
• Hand preference before 18 months can suggest hemiplegia
• Feeding time, choking/coughing, recurrent pneumonia
• Speech and communication method
• School attendance and learning
• ADLs, mobility aids, caregiver burden

Associated problems

• Seizures: semiology, frequency, drug adherence, rescue plan
• Vision/hearing assessment
• Sleep, irritability and pain
• Constipation, urinary symptoms
• Drooling
• Orthopedic surgery, botulinum toxin, serial casting, physiotherapy/occupational therapy

---

Management answer: give this in 6 headings

1. Define goals with the family

“Treatment is individualized. The goal is not to normalize tone, but to improve comfort, function, participation, ease of care, and prevent secondary complications.”

2. Multidisciplinary rehabilitation

• Physiotherapy: posture, range of motion, strengthening, gait and balance training
• Occupational therapy: hand use, ADLs, seating and adaptive equipment
• Speech and language therapy: communication and swallowing
• Orthoses, standing frames, walkers, wheelchairs, seating modifications
• School inclusion, special education and social support
• Family training and caregiver support

3. Manage spasticity or dystonia by functional impact

• Treat only when it causes pain, interferes with function/care, contributes to contracture/hip displacement, or affects participation
• Focal dynamic spasticity: botulinum toxin with goal-directed therapy, casting/orthoses where appropriate
• Generalized spasticity: oral medication may be considered, with careful monitoring for sedation and weakness
• Severe generalized spasticity/dystonia: specialist assessment for intrathecal baclofen
• Selected ambulant spastic diplegia: selective dorsal rhizotomy may be considered in an experienced multidisciplinary center
• Fixed contractures/deformities: orthopedic review for appropriate surgery

4. Treat associated conditions

• Epilepsy: characterize seizures, EEG/MRI if needed, appropriate antiseizure therapy, rescue plan
• Dysphagia/aspiration: swallow assessment, texture modification, nutritional plan, enteral feeding discussion if unsafe/inadequate intake
• Malnutrition: dietitian-guided energy and micronutrient plan
• Constipation: regular bowel regimen
• Drooling: posture/oral-motor approach, medication or botulinum toxin/specialist options when severe
• Vision/hearing: formal screening and correction
• Sleep/pain/behavioral issues: assess and treat causes

5. Surveillance for complications

• Serial growth and nutrition assessment
• Hip surveillance, especially in non-ambulant children and those with higher GMFCS level
• Monitor contractures, scoliosis, pain and bone health
• Dental review
• Puberty and menstrual counselling for adolescents
• Vaccination, respiratory infection prevention

6. Prognosis and counselling

• Explain that the brain injury is non-progressive, but function changes as the child grows.
• Avoid promising independent walking until you assess phenotype and functional level.
• Discuss realistic goals, rehabilitation duration, caregiver support, school, disability benefits, and transition planning.

---

CP viva questions you should answer without hesitation

1. Define CP.
2. Why is CP called non-progressive, yet deformity can progress?
3. Classification of CP by motor type and topography.
4. Difference between spasticity, dystonia, rigidity and athetosis.
5. Causes of spastic diplegia, hemiplegia and quadriplegia.
6. GMFCS levels and their relevance.
7. Gross Motor Function Measure versus GMFCS.
8. Early hand preference: why significant?
9. Red flags that suggest a CP mimic.
10. When will you order MRI brain and what patterns do you expect?
11. CP versus hereditary spastic paraplegia.
12. CP versus Duchenne muscular dystrophy.
13. Hip surveillance and risk factors for hip displacement.
14. Assessing equinus: dynamic versus fixed.
15. Indications and goals for botulinum toxin.
16. Indications for intrathecal baclofen.
17. Which child may be considered for selective dorsal rhizotomy?
18. Feeding assessment and indications for gastrostomy discussion.
19. Approach to drooling.
20. Common causes of pain in non-verbal CP.
21. Managing epilepsy in CP.
22. Common causes of sleep disturbance.
23. Why are non-ambulant children at risk of low bone density?
24. What is the prognosis for walking in spastic diplegia?
25. How will you counsel a parent who asks, “Will my child become normal?”

Your focused plan until the exam

• Examine one CP child fully or use a recorded/mock case if no patient is available.
• Present the same case in 7 minutes, then answer viva for 15 minutes.
• Practice identifying GMFCS from videos or ward patients.
• Spend 20 minutes on gait, contractures, hip assessment, and orthoses.
• Make a one-page sheet for:
  • CP classification
  • GMFCS
  • Spasticity management
  • Comorbidities
  • CP mimics/red flags
  • Multidisciplinary management

9-day MD Paediatrics practical timetable: 16 to 24 September

Fixed daily schedule

---

Day 1: 16 September

Build the CP long-case foundation

Main study, 4:30-6:00 pm

• Definition of CP
• Causes: antenatal, perinatal, postnatal
• CP classification:
  • Spastic, dyskinetic, ataxic, mixed
  • Hemiplegic, diplegic, quadriplegic
• Differentiate CP from progressive disorders
• Red flags for CP mimics

CP practice, 6:15-7:15 pm

1. Observation and gait
2. General examination and nutrition
3. Developmental assessment
4. Tone, reflexes, power, involuntary movements
5. Contractures and hip examination
6. Functional assessment and GMFCS
7. Associated comorbidities

Viva, 8:15-9:30 pm

• CP definition
• Causes by timing
• Classification
• Spasticity versus dystonia versus rigidity
• CP mimics
• MRI brain patterns in CP
• GMFCS levels I-V

---

Day 2: 17 September

Spastic CP, gait and orthopaedic examination

Main study

• Spastic diplegia, hemiplegia, quadriplegia
• Gait patterns:
  • Equinus/toe walking
  • Scissoring gait
  • Crouch gait
  • Stiff-knee gait
  • Circumduction
• Dynamic versus fixed deformity
• Hip displacement, contractures, scoliosis

CP practice

• Hip abduction
• Thomas test
• Popliteal angle
• Ankle dorsiflexion with knee flexed and extended
• Hamstring, adductor, hip-flexor and tendo-Achilles tightness
• Fixed versus dynamic equinus

Viva

• Hip surveillance
• Reimers migration percentage concept
• Risk factors for hip displacement
• Contracture prevention
• Orthoses: AFO, KAFO, seating systems, standing frame
• Indications for orthopedic referral and surgery

---

Day 3: 18 September

Functional assessment and developmental evaluation

Main study

• Developmental assessment in CP
• Global developmental delay versus isolated motor delay
• Functional assessment:
  • GMFCS
  • Manual Ability Classification System
  • Communication Function Classification System
• Gross Motor Function Measure versus GMFCS
• ADLs, school participation, caregiver burden

CP practice

• Mobility, transfers, self-care, hand use
• Feeding, communication, schooling
• Assistive devices
• Family goals and caregiver concerns

Viva

• Meaning and use of GMFCS I-V
• Prognosis for walking
• Early hand preference
• Prognostic factors in CP
• Static brain injury versus changing functional impairment
• Disability certification, school inclusion, social support

---

Day 4: 19 September

Spasticity and dystonia management

Main study

• Goal-directed management of tone
• Physiotherapy, occupational therapy, speech therapy
• Botulinum toxin: role, goals, limitations, adverse effects
• Serial casting and orthoses
• Oral antispastic medications
• Intrathecal baclofen
• Selective dorsal rhizotomy
• When to refer for surgery

CP practice

1. Family goal
2. Rehabilitation
3. Tone management
4. Comorbidity management
5. Orthopedic surveillance
6. Follow-up

Viva

• Indications for botulinum toxin
• Focal versus generalized spasticity
• Intrathecal baclofen indications and complications
• Selective dorsal rhizotomy: appropriate candidate
• Why tone reduction can worsen function in some children
• Difference between treating impairment and improving participation

---

Day 5: 20 September

Associated comorbidities: the rank-deciding day

Main study

• Epilepsy
• Intellectual disability and behavioral concerns
• Vision and hearing impairment
• Speech and communication impairment
• Dysphagia and aspiration
• Drooling
• Malnutrition
• Constipation
• Sleep difficulty and pain
• Bladder dysfunction

CP practice

• Seizures
• Feeding and aspiration
• Nutrition
• Communication
• Sleep/pain
• Bowel/bladder
• Vision/hearing

Viva

• Causes of recurrent pneumonia in CP
• Swallow assessment and aspiration prevention
• When to consider enteral feeding/gastrostomy discussion
• Causes of pain in a non-verbal child
• Drooling management
• Constipation plan
• Why epilepsy is common in severe CP

---

Day 6: 21 September

Neonatology and CP etiology

Main study

• HIE and CP relationship
• Prematurity and periventricular leukomalacia
• Neonatal seizures
• Hyperbilirubinemia and dyskinetic CP
• CNS infection, stroke, hypoglycemia
• Basic MRI correlation:
  • Periventricular white-matter injury
  • Basal ganglia/thalamic injury
  • Cortical injury
  • Malformations

CP practice

“What is the most likely etiology in this child, and how will you establish it?”

Viva

• Neonatal encephalopathy
• HIE staging basics
• Neonatal seizures
• Kernicterus phenotype
• Prematurity-associated CP
• When MRI/genetic/metabolic evaluation is needed
• CP red flags requiring re-evaluation

Additional 30-minute revision

---

Day 7: 22 September

Short cases, emergencies and procedures

Main study

• Developmental delay
• Microcephaly/hydrocephalus
• Muscular dystrophy
• Peripheral neuropathy
• Neurocutaneous syndromes
• Rickets
• Thalassemia
• Hepatosplenomegaly
• Nephrotic edema
• Cyanotic congenital heart disease
• SAM
• Short stature

CP practice

• 30 minutes examination/history
• 7 minutes presentation
• 20 minutes viva

Viva and procedures

• Status epilepticus
• Anaphylaxis
• Shock
• Acute severe asthma
• DKA basics
• Lumbar puncture
• Bone marrow aspiration
• Intraosseous access
• Pleural tap/chest drain
• ABG interpretation

---

Day 8: 23 September

Investigation, imaging and drug viva

Main study

• CBC and peripheral smear
• Iron studies and hemolysis profile
• LFT/RFT
• Electrolytes and acid-base disorder
• CSF
• Urine routine and urine protein:creatinine ratio
• Chest X-ray
• ECG
• Neuroimaging
• Growth chart

CP practice

• Relevant investigations
• Explanation for each test
• MRI interpretation
• Management based on findings

Drug viva

• Benzodiazepines and antiseizure drugs
• Antibiotics used in common paediatric emergencies
• Adrenaline
• Salbutamol
• Steroids
• Insulin
• Fluids and electrolyte correction
• Baclofen and common CP-related drugs

---

Day 9: 24 September

Full dress rehearsal, then calm revision

Morning or ward hours

1. CP long case
2. Two short cases
3. One neonatal case
4. One radiology/ECG/ABG station
5. One procedure station
6. Rapid viva, including dissertation questions

Afternoon, 4:30-6:00 pm

• Your error notebook
• CP classification
• GMFCS
• Comorbidity checklist
• Spasticity-management ladder
• CP mimics
• Emergency algorithms
• Your unit drug doses

Evening, 6:15-8:00 pm

“This child has a non-progressive motor disorder with delayed motor milestones, [spastic/dyskinetic/mixed] motor phenotype, [topographical] involvement, functional limitation corresponding to GMFCS level ___, and associated ___ . There is no history of regression. My diagnosis is ___ cerebral palsy, likely related to ___, with ___ complications. My management will be family-centred and goal-directed, involving rehabilitation, tone management, treatment of associated comorbidities, musculoskeletal surveillance, nutritional support, and long-term follow-up.”

---

Daily scorecard

Gold-medal habits for the practical

• Be systematic but not robotic.
• Observe the child before touching them.
• Explain your findings and their functional significance.
• Present a problem representation, not a list of signs.
• State immediate safety issues before definitive therapy.
• Set goals with the family.
• Include nutrition, aspiration, seizures, pain, sleep, communication, schooling, and caregiver burden every time.
• Never bluff doses or examination findings.
• Correct yourself calmly if an examiner challenges you.

Cerebral Palsy Long Case: Complete Practical Guide

1. Confirm that this is likely CP.
2. Identify the motor phenotype and distribution.
3. Grade functional severity.
4. Find associated disabilities and secondary complications.
5. Exclude red flags for a CP mimic.
6. Give a goal-directed, multidisciplinary management plan.

---

1. Opening at the bedside

“Good morning. I am Dr ___. I would like to ask you a few questions about your child’s development and examine them. I will ensure the child is comfortable and stop if there is any distress. Is that alright?”

What to observe immediately

---

2. History

A. Identification data

• Name, age, sex
• Residence
• Informant and reliability
• Parents’ education and occupation
• Socioeconomic background
• Who is the primary caregiver?

Why?

---

B. Chief complaints

• “What was the first concern you noticed?”
• “What are your major concerns now?”
• “Is the main problem delayed walking, stiffness, abnormal movements, feeding, seizures, poor speech, or difficulty in school?”

Why?

Example

“Delayed attainment of motor milestones since 8 months of age, inability to walk independently at 4 years, and stiffness of both lower limbs for 3 years.”

---

C. History of present illness

1. When was the abnormality first noticed?

• “At what age did you first feel the child was different from other children?”
• “Was there poor head control, delayed rolling, inability to sit, stiffness, floppiness, abnormal posturing, or asymmetry?”
• “Did the child use one hand much earlier than expected?”

Why and interpretation

---

2. Was development delayed from the beginning or was there regression?

• “Did the child gain skills and then lose them?”
• “Could the child previously sit, stand, walk, speak, feed themselves, or use both hands better than now?”
• “Has stiffness, weakness, or loss of function progressively worsened?”

Why?

Interpretation

“There is no developmental regression, which supports a static encephalopathy rather than a progressive neurodegenerative disorder.”

---

3. Milestone history

“The child had head control at 7 months, sat with support at 18 months, never achieved independent walking, can use a spoon with assistance, speaks single words, and understands simple commands.”

How to interpret pattern

---

D. Antenatal history

• Was pregnancy supervised?
• Maternal fever, rash, TORCH-type illness?
• Hypertension, diabetes, thyroid disease?
• Bleeding, trauma, drug/alcohol exposure?
• Reduced fetal movements?
• Multiple gestation?
• Placental problems?
• Consanguinity?

Why?

---

E. Natal history

• Term/preterm/post-term?
• Mode of delivery: vaginal, instrumental, caesarean?
• Birth weight?
• Did the baby cry immediately?
• Any need for resuscitation, ventilation, NICU stay?
• Was there neonatal seizure?
• Was there meconium-stained liquor?
• Any birth trauma?

Why and interpretation

---

F. Postnatal history

• NICU admission duration and reason
• Sepsis, meningitis, encephalitis?
• Severe jaundice or exchange transfusion?
• Hypoglycemia?
• Seizures?
• Head injury, near drowning, stroke?
• Prolonged ventilation or severe respiratory failure?

Why and interpretation

---

G. Seizure history

• “Has the child ever had seizures?”
• Age at onset?
• Description: staring, eye deviation, stiffening, jerking, focal onset?
• Duration, frequency, triggers, status epilepticus?
• Current anti-seizure drug, adherence, adverse effects?
• Is there a rescue plan?

Why?

Interpretation

• Focal seizures can correlate with focal cortical injury.
• Frequent uncontrolled seizures suggest need for EEG, medication review, adherence review, or epilepsy specialist input.
• “Episodes” without clear semiology may be dystonia, behavioral events, reflux, or sleep phenomena.

---

H. Feeding, swallowing and nutrition history

• How long does a meal take?
• Does the child cough, choke, gag, or turn blue during feeds?
• Any wet voice, recurrent fever, recurrent pneumonia?
• What texture can the child tolerate?
• Who feeds the child and how?
• Is weight gain adequate?
• Any vomiting, reflux, constipation?
• Any prior swallow assessment or feeding tube?

Why?

Interpretation

---

I. Vision, hearing, speech and communication

• Does the child fix and follow objects?
• Squint, nystagmus, bumping into objects, poor visual attention?
• Has formal ophthalmic assessment been done?
• Does the child respond to name and everyday sounds?
• Any hearing test?
• Does the child speak? Use gestures, pictures, sign language, or a device?
• Do parents understand the child’s needs?

Why?

Interpretation

• Visual impairment may follow periventricular injury or cortical visual impairment.
• Hearing impairment is particularly relevant with kernicterus and some congenital infections.
• Limited speech can be due to dysarthria/oro-motor dysfunction rather than poor comprehension.

---

J. Functional history and GMFCS

• Can the child sit independently?
• Can the child stand, transfer, walk indoors/outdoors?
• Does the child walk with an AFO, walker, crutches, or support?
• Is a wheelchair used for distance?
• Can the child use a powered wheelchair?
• What can the child do in school, home, and community?
• Can they feed, dress, toilet, and bathe themselves?
• What help is needed daily?

Why?

Practical GMFCS interpretation

---

K. Musculoskeletal and pain history

• Hip pain, especially during diapering/perineal care?
• Pain on movement or sitting?
• Difficulty spreading the legs?
• Fixed bent knees, toe walking, shoe wear problems?
• Back deformity, sitting imbalance?
• Prior botulinum toxin, serial casting, orthoses, hip surgery, tendon-lengthening surgery?
• Any fracture after minor trauma?

Why?

Interpretation

---

L. Bowel, bladder, sleep and behavior

• Constipation, hard stools, painful defecation, frequency?
• Urinary urgency, retention, incontinence, recurrent UTI?
• Sleep onset problems, frequent waking, snoring, apnea?
• Irritability, unexplained crying, self-injury, behavioral difficulties?
• Is there pain and how is it recognized?

Why?

• Constipation
• GERD
• Hip subluxation/dislocation
• Contractures
• Dental pain
• Urinary infection
• Pressure sores
• Poor seating/orthoses

---

M. Treatment and rehabilitation history

• Physiotherapy frequency and goals
• Occupational therapy
• Speech/swallow therapy
• Special school or inclusive education
• Orthoses, walker, wheelchair, seating system
• Botulinum toxin: muscles injected, benefit, duration
• Oral medications: baclofen, trihexyphenidyl, anti-seizure medicines
• Surgeries and outcomes
• Follow-up with neurology, rehabilitation, orthopedics, ophthalmology, ENT, dietician

Why?

---

N. Family history

• Consanguinity?
• Similar illness, delayed development, progressive stiffness, ataxia, seizures, early childhood deaths?
• Family history of neuromuscular disease or metabolic disease?

Interpretation

---

3. Examination

A. General physical examination

• Vitals if relevant
• Weight, height/length, BMI or appropriate anthropometry
• Head circumference, especially in younger children
• Nutritional assessment
• Pallor, rickets, skin lesions, pressure areas
• Dysmorphism/neurocutaneous markers
• Spine and posture
• Drooling, dentition and oral hygiene
• Respiratory signs of aspiration if symptomatic

Interpret carefully

---

B. Higher functions and developmental examination

• Alertness and interaction
• Eye contact
• Response to name
• Understanding simple and complex commands
• Speech or non-verbal communication
• Play
• Fine-motor manipulation
• Social reciprocity

“I would assess development in gross motor, fine motor-adaptive, language, and personal-social domains, while recognizing that impaired speech and hand control can underestimate cognition.”

---

C. Observe movement and gait

• Ask them to walk toward and away from you.
• Observe with and without shoes/AFO if feasible.
• Ask them to turn, run, climb steps, squat, rise from floor.

Gait patterns

• Observe sitting balance, head control, transfers, rolling, reaching, wheelchair positioning and involuntary movements.

---

D. Tone examination

First identify the tone phenotype

How to examine spasticity

• Child relaxed if possible.
• Move joints slowly and then quickly.
• Examine shoulders, elbows, wrists, hips, knees, ankles.
• Look especially at adductors, hamstrings, gastrocnemius-soleus.
• Compare both sides.
• Demonstrate ankle clonus and test reflexes.

---

E. Power, selective motor control and reflexes

• Reach and grasp
• Pincer grip
• Bimanual play
• Hand opening
• Rise from floor
• Sit to stand
• Squat and recover
• Transfers
• Stair climbing if appropriate

• Deep tendon reflexes
• Ankle clonus
• Plantar response
• Asymmetry
• Primitive reflexes if relevant

Interpretation

---

F. Musculoskeletal examination: do not miss this

Hips

1. Observe hip posture and pelvic symmetry.
2. Assess hip abduction with hips flexed and extended.
3. Look for pain or asymmetry.
4. Assess flexion contracture with Thomas test.
5. Check leg lengths and pelvic obliquity.

Knees

• Popliteal angle for hamstring tightness
• Knee flexion contracture
• Patella position if relevant

Ankles

• Passive dorsiflexion with knee extended and then flexed.
• If dorsiflexion improves when knee flexes, gastrocnemius tightness predominates.
• If it remains restricted, soleus/Achilles involvement or fixed contracture is more likely.

Spine

• Inspect sitting and standing.
• Look for scoliosis, kyphosis, lordosis.
• Assess seating balance.

Upper limbs

• Shoulder internal rotation
• Elbow flexion
• Forearm pronation
• Wrist flexion/ulnar deviation
• Thumb-in-palm posture
• Hand opening and functional grasp

---

4. How to give your final diagnosis

“This is a ___-year-old child with non-progressive motor impairment from early infancy, delayed gross-motor milestones and no developmental regression. On examination, the child has bilateral lower-limb predominant spasticity, brisk reflexes, ankle clonus, extensor plantar responses, adductor and tendo-Achilles tightness, and an equinus gait. Functionally, the child mobilizes with ___ and is dependent for ___. The child also has ___ such as epilepsy, intellectual disability, dysphagia, malnutrition, visual impairment, or speech impairment.

My diagnosis is bilateral spastic cerebral palsy, diplegic distribution, GMFCS level ___, with ___ musculoskeletal complications and ___ associated comorbidities.”

“This is spastic quadriplegic cerebral palsy, GMFCS V, with severe global developmental delay, epilepsy, feeding dysfunction, malnutrition, probable aspiration risk, and contractures. The child requires assessment for hip displacement, scoliosis, bone health, safe feeding, communication support, and caregiver support.”

---

5. Differential diagnosis and CP mimics

“The diagnosis is clinically consistent with CP because the motor impairment began early, is static, and there is no regression. However, I would reconsider the diagnosis if there were red flags for a progressive neurological disorder.”

---

6. Investigations: what to order and why

---

7. Management answer in the viva

“Management is individualized, family-centred and goal-directed. The aim is not simply to reduce tone. It is to improve comfort, function, participation, ease of care, communication, nutrition, and quality of life while preventing secondary complications.”

1. Establish goals with child and family

• Independent sitting
• Safer feeding
• Better hand function
• Less pain
• Easier dressing and hygiene
• Better walking endurance
• School participation
• Reduced caregiver burden

2. Multidisciplinary rehabilitation

• Physiotherapy: posture, strength, range of movement, gait, balance
• Occupational therapy: hand function, ADLs, adaptive equipment
• Speech and language therapy: communication and swallowing
• Orthoses, seating, standing frame, walker, wheelchair
• Special educator/inclusive school planning
• Social worker, disability support and caregiver training

3. Tone management

• Focal dynamic spasticity: botulinum toxin with therapy and orthoses/casting where indicated
• Generalized spasticity: carefully selected oral therapy, with monitoring for sedation or weakness
• Severe generalized spasticity/dystonia: specialist consideration of intrathecal baclofen
• Selected ambulant bilateral spastic CP: consideration of selective dorsal rhizotomy at an experienced centre
• Fixed contracture/deformity or hip displacement: paediatric orthopaedic referral

4. Treat associated comorbidities

• Epilepsy
• Dysphagia/aspiration
• Malnutrition and GERD
• Constipation
• Drooling
• Vision and hearing impairment
• Sleep disturbance, pain, behavior
• Communication disorder

5. Surveillance

• Growth, nutrition and feeding safety
• Hip displacement, contractures and scoliosis
• Pain and seating
• Bone health, especially non-ambulant child
• Dental care
• Puberty and menstrual issues in adolescents
• Respiratory health and immunization

6. Counselling and prognosis

• Brain injury is non-progressive, but musculoskeletal problems can progress.
• Prognosis depends on phenotype, cognition, trunk control, associated epilepsy, vision, feeding and GMFCS.
• Explain realistic goals and need for long-term follow-up.
• Give family support and school/social inclusion advice.

---

8. Final 10-point CP long-case checklist

1. Did I establish no regression?
2. Did I find likely etiology from antenatal, natal and postnatal history?
3. Did I classify the motor type?
4. Did I state distribution: unilateral/bilateral, diplegic/quadriplegic?
5. Did I assign GMFCS based on usual function?
6. Did I assess development and cognition without underestimating non-verbal communication?
7. Did I ask about seizures, feeding, aspiration, speech, vision, hearing, sleep, constipation and pain?
8. Did I examine hips, contractures, spine, gait and upper-limb function?
9. Did I look for CP mimics/red flags?
10. Did I make a family-centred management plan with clear goals?

1. Identify a possible antenatal cause or risk factor
2. Establish gestational age, fetal growth, and quality of antenatal care
3. Look for clues to a genetic, congenital infection, teratogenic, or metabolic condition that may mimic or contribute to CP

Top part of your sheet

---

Antenatal history

1. Duration of married life

Ask

“How long have the parents been married?”

Why?

Interpretation

• Assisted reproduction/infertility treatment may be associated with multiple gestation and prematurity.
• Otherwise, it has no direct causal relationship with CP.

---

2. Non-consanguineous marriage

Ask

“Are the parents related by blood, for example first cousins?”

Why?

Interpretation

Practical line

“Parents are non-consanguineous, reducing but not eliminating the possibility of a recessive neuro-metabolic disorder.”

---

3. Mother’s age at marriage and conception

Ask

“What was the mother’s age at conception?”

Why?

Interpretation

• Advanced maternal age: greater risk of chromosomal anomalies and pregnancy complications.
• Very young maternal age: possible poor antenatal nutrition, anemia, prematurity, and limited antenatal care.
• This is a background risk factor, not proof of CP causation.

---

4. Order of the child

Ask

“Is this the first, second, or later child? Are there any previous abortions, stillbirths, neonatal deaths, or children with similar illness?”

Why?

Interpretation

---

5. Pre-pregnancy weight and total gestational weight gain

Ask

“What was the mother’s approximate weight before pregnancy? Was there documented poor or excessive weight gain?”

Why?

Interpretation

Exam point

---

6. Booked or unbooked pregnancy

Ask

“Was antenatal care taken regularly? Where was she followed up? How many visits were there?”

Why?

• Maternal medical history
• Blood pressure and urine records
• Hemoglobin
• Ultrasound reports
• Fetal growth monitoring
• Complications identified during pregnancy

Interpretation

---

7. Maternal immunization

Ask

“Were routine antenatal vaccines received, especially tetanus-containing vaccination? Was there any infection during pregnancy?”

Why?

Interpretation

• Adequate tetanus immunization: appropriate antenatal care, protection against maternal/neonatal tetanus.
• No vaccination history: does not diagnose CP, but may indicate poor antenatal care.
• Maternal rubella-like illness despite no immunization history: raises concern for congenital infection.

---

First trimester history

8. Pregnancy confirmation by UPT and dating scan

Ask

“When was pregnancy confirmed? Was an early dating scan done? What was the estimated due date?”

Why?

Interpretation

---

9. Folic acid use

Ask

“Did the mother take folic acid before conception and in early pregnancy?”

Why?

Interpretation

Practical point

---

10. Thyroid screening or thyroid medication

Ask

“Did the mother have thyroid disease or take thyroid medication during pregnancy?”

Why?

Interpretation

---

11. Excessive vomiting

Ask

“Was there severe vomiting requiring IV fluids, admission, weight loss, or reduced food intake?”

Why?

Interpretation

---

12. Fever, rash, and neck swelling

Ask

“Any fever with rash during pregnancy? Any lymph node swelling, jaundice, genital ulcers, or known infection?”
“Any neck swelling or thyroid disease?”

Why?

• Rubella
• CMV
• Toxoplasmosis
• Varicella
• Syphilis
• Other significant maternal infections

Interpretation

---

13. Other scans and X-rays

Ask

“Did the mother undergo any scans, CT scans, X-rays, or radiotherapy during pregnancy? If yes, when and why?”

Why?

Interpretation

---

14. Drug intake

Ask

“Did the mother take any prescribed medicine, over-the-counter medication, herbal preparation, antiepileptic drug, alcohol, tobacco, or other substance during pregnancy?”

Why?

Important examples

• Antiseizure medicines, especially valproate
• Warfarin
• Retinoids/isotretinoin
• Certain cytotoxic/immunosuppressive drugs
• Alcohol
• Tobacco
• Illicit substances
• Unregulated herbal medication

Interpretation

---

What is essential versus routine in the practical?

Ask these definitely

• Consanguinity and similarly affected siblings
• Previous abortions/stillbirths/neonatal deaths
• Multiple pregnancy
• Maternal fever/rash/infection
• Maternal hypertension, diabetes, thyroid disease, seizures
• Drug/substance/radiation exposure
• Dating scan, gestational age
• Fetal movement and growth concerns
• Prematurity and birth weight
• NICU admission, HIE, neonatal seizures, jaundice, meningitis, hypoglycemia

Ask briefly if time permits

• Duration of married life
• Exact pre-pregnancy weight
• Exact total weight gain
• Exact date of UPT
• Exact immunization dates
• Exact folic acid duration

Best concise antenatal presentation

“The child was born to non-consanguineous parents. This was the ___ order pregnancy, with no previous adverse pregnancy outcome or similarly affected sibling. The pregnancy was booked and regularly supervised. There was no history of maternal fever with rash, significant infection, hypertension, diabetes, thyroid disorder, seizures, trauma, teratogenic drug or radiation exposure. Dating scan established gestation as ___. There was/no history of multiple gestation, reduced fetal movements, or fetal growth concern.”

Examples

• Ionizing: X-rays, CT scans, fluoroscopy, nuclear-medicine scans, radiotherapy
• Non-ionizing: Ultrasound and MRI (routine MRI, without contrast)

Units to know

• mGy (milligray): absorbed radiation dose. This is usually used when discussing the fetal dose.
• mSv (millisievert): effective dose, mainly used to compare overall radiation exposure to a person.

Approximate fetal radiation doses

The number to remember for exam

Fetal exposures below 50 mGy have not been associated with fetal anomalies, growth restriction, miscarriage, or intellectual disability.

Timing matters

• Preimplantation, about 0-2 weeks: very high exposure may have an “all-or-none” effect, but routine diagnostic studies are far below such doses.
• Organogenesis, about 2-8 weeks: theoretical concern for malformations at high doses.
• 8-15 weeks: developing CNS is particularly radiosensitive at high doses.
• ACOG notes suggested thresholds for CNS effects are roughly 60-310 mGy, while the lowest documented dose associated with severe intellectual disability was 610 mGy. These are far above ordinary single diagnostic examinations.

How to say it in your CP long case

1. What test exactly? X-ray, CT, fluoroscopy, radiotherapy?
2. Which body part? Chest/limb versus abdomen/pelvis.
3. Which trimester and gestational week?
4. How many times? Single exposure versus repeated/multiple-phase study.
5. Why was it done? Trauma, serious maternal illness, suspected TB, etc.
6. Was it diagnostic imaging or radiotherapy? This distinction is essential.

Interpretation for viva

“Routine ultrasound is non-ionizing and is not a radiation concern. A single maternal chest X-ray or limb X-ray exposes the fetus to a negligible dose. CT involving the abdomen or pelvis delivers a higher fetal dose, commonly still below 50 mGy for a single study. I would document the modality, body region, timing, and number of exposures. Radiotherapy or repeated high-dose fluoroscopic/interventional procedures need specialist fetal-dose estimation by a medical physicist.”

Important distinction