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AMC RECALL PAPERS: PEDIATRICS

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Photograph 9: A young child with a patch of hair loss on the scalp. Some small f
lakes of
skin are present. What is your diagnosis?
a) Tinea
b) Psoriasis
c) Alopecia areata
d) Trichotillomania
e) SLE
Ans: A.
(JM: Common Skin Problems)
* A 15 months old child was found with ambiguous genitalia, while in karyotype a
nalysis
46xy was diagnosed. WOF is the next appropriate IX?
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a) X- ray
b) 17 hydroxy progesterone---increased in Congenital Adrenal Hyperplasia
c) CT Scan
d) US of pelvic region
e) Testosterone level
Ans: B.
The term congenital adrenal hyperplasia encompasses a group of autosomal recessi
ve
disorders, each of which involves a deficiency of an enzyme involved in the synt
hesis of
cortisol,
aldosterone, or both.
Classic congenital adrenal hyperplasia is generally recognized at birth or in e
arly
childhood because of ambiguous genitalia, salt wasting, or early
virilization. Nonclassic adrenal hyperplasia is generally recognized at or after
puberty
because of oligomenorrhea or virilizing signs in females.

Ambigious Genitalia: Female; Male.


Deficiencies of enzyme activity involved in cortisol synthesis result in elevat
ions in
concentrations of corticotropic hormone (previously adrenocorticotropic hormone
[ACTH]) that often cause hyperpigmentation. This hyperpigmentation may be subtle
and is best observed in the genitalia and areolae.
Hyponatremia, hyperkalemia, and/or hypoglycemia suggests the possibility of
adrenal insufficiency.
Hypoglycemia and hypotension may, in part, be due to associated epinephrine
synthesis in the adrenal medulla due to cortisol deficiency.
Children with simple virilizing 21-hydroxylase deficiency or 11-hydroxylase def
iciency
have early pubic hair, phallic enlargement, and accelerated linear growth and
advanced skeletal maturation.
Patients with aldosterone deficiency of any etiology may present with dehydrati
on,
hyponatremia, and hyperkalemia, especially with the stress of illness.
Male or female patients with 11-hydroxylase deficiency may present in the secon
d or
third week of life with a salt-losing crisis. However, these patients develop
hypertension, hypokalemic alkalosis, or both later in life. Upon maturation,
mineralocorticoid responsiveness increases, and the elevated concentrations of
deoxycorticosterone are sufficient to cause sodium retention, potassium excretio
n,
and hypertension.
(http://emedicine.medscape.com/article/919218-overview )
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An 8-year-old boy presents with photophobia, irritability & neck stiffness. Lumb
ar
puncture findings show 50 neutrophils, 100 lymphocytes, proteins normal, glucose
normal. Which is the most likely diagnosis?
a)
b)
c)
d)
e)

Tuberculosis meningitis
H. influenza
Echo virus
E. Coli
HSV encephalitis

Ans: E.
*A 5 month old baby unwell for a week is noticed by his parents to have episodes
of
leaning forward and shaking his arms. His parents are concerned, because he is n
ot
responding as he used to. What is the likely cause?
a) Infantile spasm
b) Febrile seizures
c) Breath holding spells
d) Infantile myoclonic seizures
e) Petit mal epilepsy
Ans: D.

Infantile Spasms (Hypsarrhythmia) (JM: Faints, fits and funny turns)


These are generalised tonic seizures with sudden flexion of the arms, forward fl
exion of the
trunk and extension of the legs, lasting only a few seconds, with usual age onse
t between 3
and 7 months. They are usually restricted to the first 3 years of life and are r
eplaced by
other forms of attacks. Prognosis for cognitive development is also unfavourable
. The most
effective therapy is corticotrophin (ACTH) IM injection. Otherwise, oral prednis
olone or
valproate can be used.
A 2 month old child has strawberry naevus on its back between the scapulae, 2 cm
in size.
What is the most appropriate management?
a) Cryotherapy
b) Laser therapy
c) Observation
d) Injection of a sclerosing agent
e) Simple excision
ANS: Observation
Salmon patch also regresses automatically but port wine doesnt regress automatica
lly.
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(Kaplan Pediatrics p.2)
A child with perorbital oedema and anararca, BP is normal. All of the following
are true,
except?
a) Steroids are useful in treatment
b) Focal glomerulonephrits is the commonest cause
c) Proteinuria more than 3 grams/day is usual
d) This is commonest between 1 and 4 years of age
e) ?
Ans: C.
Nephrotic Syndrome is the diagnosis.
A fully breast feed baby, from a mother on a healthy, balanced diet, can have de
ficiency of
which vitamin?
a) Vitamin A
b) Vitamin B complex
c) Vitamin C
d) Vitamin D
e) Vitamin K
Ans: Vitamin K.
Vitamin k excess cause hemolysis, k deficiency cause bleeding, vitamin E deficie
ncy causes
hemolysis.
(Kaplan p.23)

You can see an infant with subdural haematoma, bruising and multiple subperioste
al
sclerosing zones on x-ray of the limbs. What do you first think of?
a)
b)
c)
d)
e)

Rickets
Vitamin C deficiency
Pagets disease
Non accidental injury
Haemophilia

Ans: Abuse
Rickets: wrist x ray (wrist)
Scurvy: Knee joint x ray.
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What is true about phenylketonuria inheritance?
a) Only boys are affected
b) Only girls are affected
c) 1 in 2 chance of any sex being affected
d) 1 in 4 chance of any sex being affected
e) Sporadic
Ans: AR (Kaplan Pedia)
An 8-week-old baby presents with unilateral sticky eye. Similar episode before w
as
treated with antibiotics for 3 days and resolved. What is the most likely diagno
sis?
a) Gonococcal conjunctivitis
b) Allergic conjunctivitis
c) Inadequate antibiotic treatment
d) Decreased Ig A in the tears
e) Blocked naso-lacrimal duct
Ans: E.
A neonate was born at full term with a birth weight of 1500 grams, was jittery o
n handling
noticed to have cyanosis on the hands & feet. The infant had normal temparature;
respiratory rate 40/min and lung & heart were normal on examination. The neonate
has
been given oxygen. Which of following is your step in management?
a) Reassure the infants mother and check the infant later
b) Check blood calcium
c) Give high concentration oxygen via mask
d) Take blood sample for blood sugar test
e) Take blood for full blood examination
Ans: D.
A child was recently vaccinated for polio, now presents with 1-week history of f
ever,
flaccid paralysis of both lower limbs with no reflexes. The most likely diagnosi
s is?

a) Infection with wild poliomyelitis


b) Complication of the polio vaccine
c) Gullian Barre syndrome
d) UMN lesion
e) Acute polyneuropathy
Ans: GB
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Which of the following is the least likely cause of iron deficiency anaemia in c
hildren?
a) Cows milk
b) Thalassemia
c) Prematurity
d) Coeliac disease
e) Multiple pregnancy (e.g. Twins)
Ans: C.
*A baby delivered by normal vaginal delivery, is well after birth. On the 4th da
y, the baby
is found collapsed in the cot, breathless and floppy. On examination there are n
o
murmurs. Possible cause could be -- ***
a) TOF
b) PDA
c) TGA with VSD
d) Pulmonary stenosis
e) L. Ventricular Hypertrophy
f) Hypoplastic left heart syndrome.
Ans: ..
A 9-day-old baby with projective vomiting and dehydration with K 7.1, Na 125, Cl
80, &
HCO3 20. What is your diagnosis:
a) Pyloric stenosis
b) Dlactosemia
c) Sepsis
d) Hypoglycaemia
e) Congenital adrenal hypertrophy
Ans: E
A child with profuse diarrhoea for 5 days develops convulsions. Which of the fol
lowing
blood test results would most likely cause this convulsion?
a) K 2.2
b) K 6.5
c) Na 132
d) Na 156
e) Cl 100
Ans: D.

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A 37-year-old female gives birth to her 2nd child. At the 10th day the child bec
omes
jaundiced. His mother tells the doctor that her first child had jaundice after b
irth and then
developed bilateral cataract after the jaundice. What is the diagnosis?
a) Congenital rubella
b) Neonatal hepatitis
c) Diabetes Mellitus
d) Syphilis
e) Galactosaemia
Ans: E (Kaplan Pedia: Newborn)
A child has trouble seeing the black board at school, but no problems when using
the
computer. His vision is improved with pinhole test. What is your diagnosis?
a) Myopia
b) Hypermetropia
c) Cataract
d) Glaucoma
e) ?
Ans: A.

A child with headache and morning vomiting, ataxia and nystagmus for 6 weeks. Hi
s
school had a Chicken Pox 2 weeks ago. He has a family history migraine. What is
the most
probable diagnosis?
a) Migraine
b) Varicella cerebellitis
c) Infratentorial Tumour
d) Friedrichs ataxia
e) ?
Ans: C.
In child dizziness, headache, vomiting indicates posterior fossa tumor until pro
ved
otherwise. (JM: Headache)
Chicken pox: The incubation period is typically 10-14 days, although it may exte
nd to 21
days.
Chickenpox encephalitis classically presents with ataxia 3 to 4 days after onset
of the rash,
but may sometimes present after 8 days.
The cerebellum is most commonly affected, but in some cases the cerebrum is invo
lved, in
which case the prognosis is worse.
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80% make a full recovery, although there is a significant mortality and some are
left with
morbidity such as mental retardation and seizures. Cerebellar ataxia specificall
y seen during

the recovery period. Most common clinical features tremor ataxia and nystagmus.

In Downs syndrome, aside from the cardiac complications, all of the following are
associated with Downs syndrome, excepta) Acute leukaemia
b) Myopia
c) Hypothyroidism
d) Vesicoureteric reflux***
e) Deafness
f) Alzheirmers disease
Ans: D.
http://emedicine.medscape.com/article/943216-overview
A 15-month-old child is brought to you by his parents. He was born at 36 weeks b
y normal
vaginal delivery. At 8 months a mother child health centre test for hearing was
done,
which was normal. The parents say that he babbles, but does not speak 2-3 word p
hrases
yet. On physical examination, the child appears normal. What will you do?***
a)
b)
c)
d)
e)

Reassure the parents that this is a normal variant


Reassess at 18 months
Repeat mother child test for hearing
Arrange for audiometry testing
Rt. Orchidopexy

Ans: Reassure.
A mother notices a lump in the right groin of her 2-year-old son, which disappea
red after a
few hours. Despite a thorough examination you are unable to discover anything. T
he most
appropriate management would be?
a) reassurance & send home
b) Admission into hospital for surgery
c) Request the mother to bring the child to you immediately when the lump reappe
ars again
d) Review after 1 week
e) ?
Ans: Surgical consultation***
(JM p.1089)
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An 8-year-old boy was stung by a bee. He had difficulty breathing and facial oed
ema.
What is the best treatment?
a) Adrenalin 1:1000 IM/SC
b) Adrenaline I/V
c) Antihistamine iv
d) Hydrocortisone iv
e) Intravenous fluids
Ans: A. (JM p.1343)

A child has tenderness & pain at upper tibia of the left leg and swelling of the
knee which
is warm. He is febrile (39 degrees Celsius) and gets pain at 30 degrees flexion.
What is your
diagnosis?
a)
b)
c)
d)
e)
f)

Osteomyelitis
Osteosarcoma
Septic arthritis
Fracture tibia
Irritable hip (Transient synovitis)
Thrombophlebitis/Cellulitis

Ans: Osteomyelitis.
Septic arthritis can be difficult to diagnose in the early stages of progression
. Once
purulence has developed and a bulging effusion is noted, diagnosis is made easil
y. Typically,
the patient presents with fever and a joint that is hot, red, painful, distended
, and has a
markedly decreased range of motion. Restriction of movement occurs to active and
passive
attempts.

A 2-year-old child presents with a clean superficial laceration on the forehead.


The child
has never been immunized. What is the most appropriate management?
a) Give antibiotics
b) Tetanus Toxoid***
c) Tetanus Immunoglobin
d) DTP vaccination***
e) Reassure & send home
Ans: D.
Immunization schedule: JM p78
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Contraindications:
1. Febrile illness >38.5C.
2. Previous anaphylactic
reaction.
3. Encephalopathy within 7
days of DTP vaccination.
4. For live vaccines
OPV, MMR, Vericella, BCG
5. Immunocompromised
eg. Chemotherapy or
corticosteroids more
than 2mg/kg/day.

6. OPV household
contacts
immunocompromised
7. MMR/Vericella: within
3 months of giving
blood products.
8. MMR/ Vericella can be
given same day or 4
months apart.
Not contraindication:
1. Simple febrile convulsion in
the past or pre existing
neurological disease is not
a contraindication for
pertusis
2. Egg allergy is not a
contraindication for MMR
vaccine.
All adult should receive an ADT every 10 years.
All women in their childbearing age should have their
MMR antibody status reviewed.
Influenza vaccine annual basis: Chronic cardiac,
pulmonary, kidney, metabolic diseases, persons over
65years and
Aboriginal over 50.
Pneumococcal vaccine same as influenza.
Hepatitis to high risk group.
Q fever vaccine for abattoir worker.
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JM: Guide to Tetanus Prophylaxis
The commonest cause of hip pain in a 3-yearold child?
a)
c)
d)
e)

Transient synovitis b) Perthes disease


Slipped upper femoral epiphysis
Arthritis
Tuberculosis

Ans: A.
Transient synovitis or irritable hip is the most common cause of hip pain and li
mp in
childhood. (JM p.697)
A 2-week-old baby gained 200 grams/week since birth. The mother complaints that
the
child vomits milk soon after feeding, otherwise okey. What will you do?***
a) Reduce the time between feeds
b) Shorten the duration of feeding
c) Give water before feeding with milk
d) Endoscopy
e) Urine microscopy
Ans: A. Small regular feeds and if necessary thicken it.
Weight gain 250 gm/15 days.
(GORD JM p.515)

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A child was born premature(30 weeks gestation), via vaginal delivery. APGAR 5 at
1 min. &
8 at 5 min. At 18 months, the child is brought by the mother with moderate menta
l
retardation. Which family history would be likely cause of the mental retardatio
n?
a) Uncle has mental retardation***
b) Sister has febrile convulsions
c) Mother has 2 caf au lait spots
d) Father is an alcoholic
e) Paternal grandmother has hypothyroidism ***
Ans: A.
5 min APGAR score is more important than 1 min APGAR score.
A 4-year-old child presents with sudden onset of cough, unilateral wheeze and de
creased
respiratory movement on one side. There is no family history of atopy. What is t
he most
appropriate management?
a) Chest X ray
b) Full blood examination
c) CT of chest
d) Ultrasound
e) Inspiratory & expiratory chest X ray
Ans: Inspiratory & expiratory chest X ray (Kaplan p.135)
An obese 8 yrs. Old boy came to you. O/E his weight was 48 kg, which is more tha
n 98th
percentile and the height was 140 cm, which is more than 90th percentile, otherw
ise
normal. WOF is correct in relation to this boy--a) Advanced bone age
b) Increased blood sugar level
c) Thyrotoxicosis
d) Hypothyroidism
e) Primary hyperaldesteronism
Ans: A. Advanced bone age.
Diabetes in this age group is IDDM and usually associated polyuria, polydipsia a
nd weight
loss.
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(Kaplan Pedia)
Some relevant questions from Pre-test about Bone age and Chronological age: (fre
quently
asked topics)
430. A 13-year-old boy is below the third percentile for height (fiftiethperc
entile for age

9). Which of the following would give him the best prognosis for normal adult he
ight?
(Pediatrics Pre-test: p.294)
a) A bone age of 9 years
b) A bone age of 13 years
c) A bone age of 15 years
d) Being at the fiftieth percentile for weight
e) Being at the third percentile for weight
430. The answer is a. (Behrman, 16/e, pp 56, 5960. McMillan, 3/e, pp
17761780, 17901791. Rudolph, 21/e, p 20152017, 2094.) The determination of bone age
by the radiographic examination of ossification centers provides a measure o
f a childs
level of growth that is independent of his or her chronologic age. Height age is
the age that
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corresponds to the fiftieth percentile for a childs height. When bone age and hei
ght age are
equally retarded several years behind chronologic age, a child is described as h
aving
constitutional short stature. Such a child is usually shorter than peers in adol
escence
because of the delayed growth spurt, but the prognosis for normal adult height
is
excellent because there is still the potential for growth. Detailed quest
ioning will usually
identify other family members with a history of delayed growth and sexual matur
ation but
with ultimately normal stature. Children with genetic or familial short stature
grow at an
adequate rate, but remain small throughout life; their ultimate height is
consistent with
predictions based on parental heights. Bone age is within the limits of normal f
or
chronologic age, and puberty occurs at the normal time. In all cases, a thorough
history and
physical examination are necessary to identify any other cause of growth delay.
434. Bone age will be advanced in short stature caused by which of the following
?
(Pediatrics Pre-test: Page: 295)
a) Environmental deprivation syndrome
b) Hypopituitarism
c) Hypothyroidism
d) Congenital adrenal hyperplasia
e) Chronic administration of glucocorticoids in high doses
434. The answer is d. (Behrman, 16/e, pp 5960, 16751680, 16981704, 17291736, 1738.
McMillan, 3/e, pp 17761780. Rudolph, 21/e, pp 79, 466, 20172021, 20382042, 2045.)
The appearance and union of the various centers
of ossification fol
low
a
fairly
definite
pattern and time schedule from birth through adolescence. This process provid
es, through
x-ray studies, a valuable criterion for estimating normal and abnormal growth. T
he skeletal
maturity of any person is known as the bone age. Bone maturation is particularly
influenced
by the androgenic and estrogenic hormones. In congenital adrenal hyperplasia, a
deficiency

of enzyme (21-hydroxylase in 80% of cases) causes an interruption in


the pathway for
production of cortisol; the end result is hypersecretion of androgenic precursor
s and clinical
manifestations of virilism and protein anabolism. In both males and female
s, muscles are
well developed and there is rapid growth in stature, with marked acce
leration of osseous
maturation. The result is early closure of epiphyses and failure to a
chieve full growth.
Thyroid hormone appears to act as a primary stimulant to skeletal maturation. De
ficiency of
thyroxine results in marked retardation of bone age. Failure to thrive
as a consequence of
profound environmental
deprivation
is
characterized
by
very low
levels of circulating
pituitary hormones and is associated with a delay in skeletal maturati
on. Removal of
the
child
from
the abnormal environment results in dramatic catch-up gr
owth and a rapid
return of hormone levels to normal. Glucocorticoid excess, either endog
enous or
exogenous, is usually associated with a decrease in the rate of growt
h and a delay in the
onset of puberty, the exception being a case of glucocorticoid excess resulting
in significant
virilization and rapid closure of growth plates. The effects of glucocorticoid e
xcess appear to
be mediated at end-organ sites as part of the catabolic effects of these steroid
s.
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A baby is born a normal full term delivery. On examination of the newborn, which
of the
following may normally be seen?
a)
b)
c)
d)
e)

Breast enlargement in male infants


Enlarged clitoris in female infants
Fusion of labia
Enlarge liver more than 5 cm and palpable
Cleft palate

Ans: Breast enlargement (Kaplan p.4 DH p.44)


A mother brings her baby who is babbling and squeaking, is able to hold his head
, move
from prone to supine position, is able to sit up unsupported, can reach for obje
cts and
when supported, can stand and bounce. What is the possible age of this child?
a) 5 weeks
b) 2 weeks
c) 7 months
d) 10 months
e) 12 months
Ans: 12 months. (Kaplan p.43)

During 12 weeks of pregnancy Ultrasound shows nuchal thickness of the fetus. Ker
iotype
also done. Now your advice should be--a) Terminate the pregnancy at 12 week
b) Repeat Keriotype test
c) Serum fetoprotein test at second trimester
d) Full blood test
Ans: A.
Nuchal scan is performed between the 11th and 13th week of gestation, because th
e
accuracy is best in this period
After a difficult forceps delivery, it is noticed that the baby hangs his arm to
the side, and
cannot move it. What is the likely cause?
a) Fracture humerus
b) Erbs palsy
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Ans: C 5,6,
C 8, T1 Klampke.
Six week old child initially was normal but after 3 wks she was not sucking milk
. She
appeared as a floppy child, which was progressively getting worse. WOF is your d
iagnosis-a) Botulism
b) Werdnig-hoffman disease(spinal muscular atrophy)
c) Cerebral pulsy
d) Myasthenia gravis
e)
Ans: A.
A 6 week old infant vomiting intermittently since birth. She looks thin, not gai
ning weight.
No abnormality on physical examination. What is your Dx : ***
a) cystic fibrosis
b) pyloric stenosis
c) subdural haematoma
d) phenyl ketonuria
e) regurgitation
f) UTI
Ans: E

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Photo: A child with rash on the buttocks and legs .Both ankles swollen and tende
r, also
abdominal pain, but no fever. No neck stiffness.WOF is most common major complic
ation(Dx:HS purpura ;AMC-286)
a. Nephritis
Photo: X-ray chest of a 8 months old infant with opacity in Rt lower zone and
pneumatoceles (Staph. Pneumonia).Rx- (AMC: Fig-119)
I/V Flucloxacillin
Photo: X-ray chest of a 9 months old infant as shown in AMC book (page-119). Wha
t is the
Dx? Staph. Pneumonia (But most common in this age group is Streptococcus pneumon
ia)
A baby has jaundice just after delivery. Mother is Rh ve, baby also Rh ve. Coombs T
est
is ve. What may be the Dx?
a. Autoimmune condition
b. ABO incompatibility
c. Rh incompatibility
Ans: Coombs test is positive in Rh incompatibility, and weekly positive in ABO
incompatibility.
Jaundice 1
st
day is pathological. Day 2 to day 7: may be pathological and the Br doesnt go
beyond 12.5 to 15. Beyond 1 week it can be breast milk jaundice.
See page 11 Kaplan USMLE.
What a 3 yrs. Old can do?
a. Draw a man with 6 parts: 48 m
b. Hop on one foot: 48 m
c. Climb stairs: 24 m
d. Name four colours:??
Ans: See page 44 Kaplan USMLE.
AOF are used in BISHOP Score, Excepta. Cervical length
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b. Cervical dilatation
c. Position relation to ischial spine
d. Moulding of the head
e. Cervical effacement
CPEDS: Consistency, Position, Effacement, Dilation, Station
WOF is X linked Recessive?
Haemophilia.
Notes:
Child with her mother in a Supermarket picked a packet of Balloon. His mum snatc
hed it &

kept in place. The child started crying and at one stage he became unconscious b
ut regain
consciousness within 45 seconds.WOF may be the causea. Petitmal epilepsy
b. infantile spasm
c. Breath holding attack
d. Complex partial seizure
e. Grand mal seizure
Ans: C.
Six month old infant was brought by his parents. He had funny turns, sudden flex
ion of
upper and lower limbs for one week. Previously he had coryzal illness. Now child
is not
responding like previously. DxInfantile spasm: age- 4 to 8 months occurs during sleep or initial arousal. Pres
entation: Brief
symmetrical contraction of neck, trunk and extremities. Types: flexors, extensor
s or mixed.
EEG shows: Hypsarrhythmia. Treatment: ACTH and Prednisolone.
Ans: Meningitis
Mother came with her 3 month old baby, she told you that her baby cries a lot at
evening
time. Mother wants to know does the baby cry when he becomes hungry or any other
cause and what she needs to do when her baby cries.
Reassure the mother
Colic or unexplained crying: self limited and benign condition and etiology is u
nexplained.
Gentle rocking movement, vibration, riding in a car can be helpful. See page 25
Kaplan
USMLE.
RHP p.149
A 3 yrs old child came with her mother. The child has been suffering an attack u
sually once
in a month. The attack lasts for 2-3 minutes and during the attack she is seen i
n spinning.
She does not loose conscious during that, but feels frightened & runs to her mot
hers lap
for comfort.WOF is your Dx:
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a. Minor form of epilepsy
b. benign positional vertigo
c. partial complex seizure
Ans: simple partial seizures. There is always loss of consciousness in complex p
artial seizures
along with automatism (Verbal or Motor). Benign positional vertigo is due to sud
den change
in the head position causing vertigo.
Complex partial seizures: http://emedicine.medscape.com/article/1183962-overview
Simple partial seizures: http://emedicine.medscape.com/article/1184384-overview
An 11 yr old boy has difficulty climbing stairs and walking & running. O/E there
is
weakness of both legs and loss of reflexes. All other examinations are normal.WO
F

investigations will confirm the Dx?


a. CSF analysis
b. Forced vital capacity
c. MRI
d. Nerve conduction study
e. X-ray
Ans: Diagnosis is Gullianbarre syndrome also known as acute post infectious neur
opathy
causing demyelination of motor and sensory nerves. Rubbery legs and areflexia ar
e the
initial symtoms.
Infectious etiology: Campylobacter Jejuni, Mycoplasma Pneumoni, usually occurs 1
0 days
after viral infection.
Diagnosis: CSF- Albimino-cytogenic dissociation, marked elevation of CSF protein
s and
decrease in cell count.
Treatment: Glucocorticoids, IVIG and plasmapheresis. See page: 228 Kaplan USMLE.
An infant presents with a typical crowing noise on inspiration. The noise is mor
e
noticeable on crying. There is no cough.WOF is the Dxa.Croup
b. Laryngomalacia
c. Bronchiolitis (Forrest-596 OHCS-558)
Ans: Croup is usually associated with typical inspiratory stridors and seal like
coughing,
occurs in 3months to 5 years age group due to viral infection. Bronchiolitis is
not associated
with stridor.
Laryngomalacia is a congenital abnormality of the laryngeal cartilage. It is tho
ught to
represent a delay of maturation of the supporting structures of the larynx. Lary
ngomalacia is
the most common cause of congenital stridor and is the most common congenital le
sion of
the larynx. But cry is usually normal in laryngomalacia.
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Laryngomalacia: http://emedicine.medscape.com/article/1002527-overview
(Kaplan p.136)
A 5 yr old boy brought by his parents, who is suffering from delayed development
of
speech after a period of normal development. O/E he avoids eye contact. Parents
give h/o
his unusual love for a toy Turtle.WOF is most probable Dxa. Autism
b. ADHD
c. Deafness
Autism: see page 47 Kaplan Medicine.
Parents of a 6 yr old boy complain that their son is overactive, not cooperative
enough
with other children at kindergarten, also of destructive behaviour. But when kep
t alone,
was found to be playing happily with toys and other children.WOF is correct- ***

a. It is a normal variant
b. ADHD
c. Autism
d. Poor parenting
Ans: ..
WOF is true about ADHDa. Children has reading disability
b. The child responds to cognitive therapy
c. They respond very well to behavioural therapy
d. commonly seen in pre-school age (5-7 yrs)
Ans: 5 to 7 yrs.
Behavioural therapy
http://www.emedicinehealth.com/attention_deficit_hyperactivity_disorder/page8_em
.htm
A mother complains of her 10 months old baby who wakes up during night many time
s.
The baby is otherwise healthy and gaining weight properly. The mother is worried
about
this. What is the Mx- ***
a. Urine culture
b. Give sedative to the baby
c. Tell the mother to cuddle the baby when he cries
Ans: c.
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A 12 yr old boy presented with painless lump in the scrotum for the last 6 month
s. He is
otherwise healthy grown up. What is the most likely Dx?
a. Hernia
b. Seminoma
c. Encysted hydrocele of the cord
d. Varicocele
e. Haematocele
Ans: Hernia
Seminoma: As noted above, germ cell tumors are the most common solid tumors in m
en aged 15-35
years. Seminoma (the most common germ cell tumor) occurs most commonly in the fo
urth decade
of life. Children represent only 2-5% of all patients with testicular cancer. Se
minoma is considered a
postpubertal tumor, although it has been reported in a patient as young as 8 yea
rs.
A mother of a 4 yr old child noticed that there is a solid mass in the Rt. Loin
area of her
child which she noticed for the first time with occasional blood in urine.WOF is
your initial
Dx: OHCS-220
a.Neuroblastoma Wilms tumour: Commonest intra abdominal tumour of
b. Wilms tumour childhood. Haematuria not common, but fever, flank pain c
c.Hydronephrosis abdominal mass found. US-pelvicdisortion, hydronephrosis
d.Plycystic kidney disease .
Two months old childs mother noticed a firm lump in her baby in the left side of
upper

abdomen while bathing.Child has bilateral periorbital ecchymosis.what is the mos


t likely
cause?
a.Neuroblastoma May-2000
b.Wilms tumour
Ans: A.
Blue berry muffin face.
Mother of a 3 year old child noticed a mass in the abdomen on the left side.AOF
could be
the cause,excepta.Hydronephrosis October96
b.Neuroblastoma
c.Nephroblastoma(Wilms tumour)
d.Poly cystic kidneys
e.Chr. constipation
Ans: E.
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A baby with Downs syndrome is born to a couple who definitely refuse to take the
child
home after failure to convince them. The most appropriate course of action:
Arrange temporary foster care
An 8 yr old girl presents with abdominal protusion,anaemia and tenderness.O/E th
ere is a
big irregular and mobile mass crossing the midline.DxNeuroblastoma
Sixty-five percent of primary neuroblastomas occur in the abdomen, with most of
these
occurring in the adrenal gland. As a result, most children present with abdomina
l symptoms,
such as fullness or distension.
Symptoms are usually related to either an abdominal mass or bone pain secondary
to
metastatic neuroblastoma. Reports of fatigue, bone pain, and changes in bowel or
bladder
habits may contribute to an accurate diagnosis. Physical findings might include
hepatomegaly; blanching subcutaneous nodules; or a large, irregular, firm abdomi
nal mass.
Derived from sympathetic neuroblasts,most common solid tumour in children<5yr.Li
kely to
present with abdominal swelling and urinary catecholamines (vanillylmandelic&
homovanillic acids) raised in 92% cases.
Neuroblastoma has been called the great mimicker because of its myriad clinical
presentations related to the site of the primary tumor, metastatic disease, and
its metabolic
tumor by-products. Sixty-five percent of primary neuroblastomas occur in the abd
omen,
with most of these occurring in the adrenal gland. As a result, most children pr
esent with
abdominal symptoms, such as fullness or distension.
Obtaining a complete history and physical examination are paramount to an accura
te
diagnosis and subsequent management of neuroblastoma. Eliciting a history of the

child s
general appearance, recent trauma, changes in appetite and weight, and recurrent
abdominal pain is important. Symptoms are usually related to either an abdominal
mass or
bone pain secondary to metastatic neuroblastoma. Reports of fatigue, bone pain,
and
changes in bowel or bladder habits may contribute to an accurate diagnosis. Phys
ical
findings might include hepatomegaly; blanching subcutaneous nodules; or a large,
irregular,
firm abdominal mass.
Typically, children with localized disease are asymptomatic, whereas children wi
th
disseminated neuroblastoma are generally sick and may have systemic manifestatio
ns,
including unexplained fevers, weight loss, anorexia, failure to thrive, general
malaise,
irritability, and bone pain. The most common finding upon physical examination i
s a
nontender, firm, irregular abdominal mass that crosses the midline. In contrast,
children
who present with Wilms tumor have a smooth mobile flank mass that typically does
not
cross the midline.
At diagnosis, the site of neuroblastoma is predictably age-dependent. Infants of
ten present
with compression of the sympathetic ganglia in the thoracic region, which might
result, for
23 | P E D S
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example, in Horner syndrome (myosis, anhydrosis, and ptosis) or superior vena ca
va
syndrome. Older children typically present with abdominal symptoms because, as s
tated
above, more than 40% of neuroblastomas are adrenal in origin. Children who are p
reschool
aged should have working differential diagnoses for an abdominal mass, including
lymphoma,hepatoblastoma, rhabdomyosarcoma, renal cell carcinoma, and neuroblasto
ma.
More than 50% of patients who present with neuroblastoma have metastatic disease
. The
fact that many other syndromes related to metastatic neuroblastoma are also comm
on in
these patients is not surprising.
For example, Pepper syndrome occurs in infants with overwhelming metastatic
neuroblastoma of the liver that results in respiratory compromise. Described by
William
Pepper in 1901, Pepper syndrome was identified as a localized primary tumor and
metastatic disease limited to the skin, liver, and bone marrow in infants. Peppe
r syndrome
has since been associated with stage 4S neuroblastoma, a unique entity that occu
rs only in
infants younger than 1 year. Pepper syndrome generally confers a better prognosi
s, as it is
associated with spontaneous regression. Some infants with stage 4S neuroblastoma
,
however, die of massive hepatomegaly, respiratory failure, and overwhelming seps

is.
"Blueberry muffin" babies are infants in whom neuroblastoma has
random
subcutaneous sites. When provoked, the nodules become intensely
ntly
blanch for several minutes thereafter. The response is probably
release of
vasoconstrictive metabolic tumor by-products. These nodules can

metastasized to
red and subseque
secondary to the
be diagnostic of

neuroblastoma, but leukemic infiltrates that metastasize to the skin should be c


onsidered in
the differential diagnoses when these children are evaluated.
Widespread metastasis of neuroblastoma to the bone may result in Hutchinson synd
rome,
which results in bone pain with consequent limping and pathologic fractures.
Neuroblastomas that arise in the paraspinal ganglia may invade through the neura
l
foramina, compress the spinal cord, and subsequently cause paralysis.
Infrequently, neuroblastoma can become metastatic to the retrobulbar region, lea
ding to
rapidly progressive, unilateral, painless proptosis; periorbital edema; and ecch
ymosis of the
upper lid. This lesion often can be confused with trauma or child abuse.
Most neuroblastomas produce catecholamines as metabolic by-products, which resul
t in
some of the most interesting presentations observed in children with neuroblasto
ma. For
example, Kerner-Morrison syndrome causes intractable secretory diarrhea, resulti
ng in
hypovolemia, hypokalemia, and prostration. This syndrome is caused by vasoactive
intestinal peptide (VIP) tumor secretion and is more commonly associated with
ganglioneuroblastoma or ganglioneuroma. Kerner-Morrison syndrome typically resol
ves
following the complete removal of the tumor.
A wide variety of neoplastic and nonneoplastic lesions might be confused with
neuroblastoma. Wilms tumor and lymphoma are 2 malignant lesions that might be mi
staken
for neuroblastoma. The nonneoplastic lesions are particularly confusing, especia
lly in the 511% of neuroblastomas that do not produce catecholamine metabolic by-products.
Nonmalignant lesions that might be confused with neuroblastoma include ganglione
uroma
and congenital mesoblastic nephroma.
24 | P E D S
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Hypospadias: incidence of 1:350 male birth.


All are autosomal recessive , Excepta.Neurofibroblastoma
b.Phenylketonuria
c.Galactossemia
d.Cystic fibrosis
e.Sickle cell anaemia
Ans: A.

After his baby sister was born, a 6 yr old boy began suck his thumb and wetting
his bed,
behaviour he had grown out of long before. This is an instance ofa. Regression
A child has swollen joints and cries whenever the napkin is changed, irritable,
ecchymoses
and hyperplastic gums. WOF is Dx ?
a.Rickets
b.Scurvy
Ans:
Survy: Physical Features:
The infant is apprehensive, anxious, and progressively irritable. Upon handling
and
changing of diapers, severe tenderness over the thighs is present. The excruciat
ing
pain results in pseudoparalysis. The infant assumes the frog leg posture (ie, ke
eping
hips and knees slightly flexed and externally rotated) for comfort.
Hemorrhages of the gums usually involve the tissue around the upper incisors. T
he
gums have a bluish-purple hue and feel spongy. Gum hemorrhage occurs only if
teeth have erupted.
Subperiosteal hemorrhage is a typical finding of infantile scurvy. The lower en
ds of
the femur and tibia are the most frequently involved sites. The subperiosteal
hemorrhage is often palpable and tender in the acute phase.
Petechial hemorrhage of the skin and mucous membranes can occur. Rarely,
hematuria, hematochezia, and melena are noted.
Proptosis of the eyeball secondary to orbital hemorrhage is a sign of scurvy.
Costochondral beading or scorbutic rosary is a common finding. The scorbutic ro
sary
is distinguished from rickety rosary (which is knobby and nodular) by being more
angular and having a step-off at the costochondral junction. The sternum is typi
cally
depressed.
Low-grade fever, anemia, and poor wound healing are signs of scurvy.
25 | P E D S
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Hyperkeratosis, corkscrew hair, and sicca syndrome are typically observed in ad
ult
scurvy but rarely occur in infantile scurvy.

26 | P E D S
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Recently, an infant with diffuse nonscarring alopecia of the scalp and radiolog
ic
features of scurvy was reported.
4

2 0 0 7
A sudanese boy came to you after administration of Co-timoxazole with the compla
ints of
pallor and increasing darkness of colour of urine. His reticulocyte count was 8%
. His
Coomb s test was negative, no family history and on electrophoresis Type A hb wa
s
detected. What is the Dx?
Ans: G6PD deficiency
What is the most common association of childhood obesity in Australia?
A. Above average height
B. Hypercholesterolaemia
C. DM
D. Cataract
Ans: A. (JM p.850)
Parental obesity is the strongest risk factor of obesity.
Endocrine causes of obesity are rare.
A child came with pallor, drooling of saliva and stridor. What will be your init
ial
management?
A. Admit to hospital
B. Give O2
C. Give antibiotics
D. Do cricothyriodotomy
Ans: A.
Epiglottitis:
Acute epiglottitis due to Haemophilus influenzae is a life-threatening emergency
in a child. A
toxic febrile illness, with sudden onset of expiratory stridor, should alert one
to this
potentially fatal condition. A high index of suspicion of epiglottitis is always
warranted in
such presentations.
27 | P E D S
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The main alternative diagnosis is viral laryngotracheobronchitis (croup). There
are, however,

significant clinical differences. Epiglottitis is characterised by fever, a soft


voice, lack of a
harsh cough, a preference to sit quietly (rather than lie down) and especially b
y a soft
stridor with a sonorous expiratory component.
Croup is distinguished by a harsh inspiratory stridor, a hoarse voice and brassy
cough. Other
differential diagnoses include tonsillitis, infectious mononucleosis and bacteri
al tracheitis.
The clinical features of croup and epiglottitis are compared in JM.
A child came shortly after birth when there was a murmur heard at the lest stern
al border.
This was systolic in timing. 3 months later he was lying down in hospital bed wi
th URTI
and there was no murmur. What could be the murmur?
Ans: Venous hum
A child came with a systolic murmur which radiated to the back and to the axilla
. Femoral
pulse was weak. Dx?
A. CoA
B. VSD
C. AS
Ans: A.
A child came with pain and redness and swelling of one eye. He had fever and was
(probably) vomiting. i could diagnosis it as orbital cellulitis. Mn?
28 | P E D S
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A. Ceftriaxon IV
B. Ampi + Genta IV
C. Cefurixime + metro
Ans: A
A woman came G1P2 with prevoius delivery of a 4200 gm baby at 42 wks with should
er
dystocia. What do you do this time?
A. Induce at 38 wks
B. Induce prematurely
C. do x-ray pelvimetry at term
D. CS
Ans: A.
Regarding soulder dystocia, which is correct?
A.
B.
C.
D.

It is not assoc. with maternal DM


Arrest occurs at pelvic inlet
Increased possibility if epidual anaesthesia given
Most cases can be resolved by hyperflexing the fetal thighs onto the abdomen.

E Erb s palsy (C8-T1) is a complication


Ans: E.

Most often the brachial plexus is injured.


An infant was brought who was vomiting from birth. He was pale, dehydrated and n
ot
gainig weight. What is most likely to find?
A. Lump
B. Distension
C. Anuria
Ans: Distension.
A child presented with undescended testis at 6 weeks. What will you do
a.do an immediate orchidopexy
b. wait till 4 years and then do orchidopexy
c. encourage the mother to massage the inguinal region to milk down the testis and
review
after 2 months
d. review after 6 months
Ans: D. (JM p.1089)
29 | P E D S
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Undescended testis is most frequently associated with
a.neoplasm
b.inguinal hernia
c.tortion
Ans: Inguinal hernia.

A 4 year old child with lacerated wound after falling on garden bed. He has take
n dtpa at 2
and 4 months. After that no vaccination was given. What will you do
a)
b)
c)
d)
e)

Give
Give
Give
Give
dtpa

antibiotics
immunoglobulins
dtpa and Ig
dtpa
and booster after 2 months

Ans: B.
All of the following occurs in the first few days of neonatal life except.
a.increase in right ventricular pressure
b.closure of ductus venoses
c.closure of ductus arterioses
d.decreased flow through foramen ovale
Ans: A.
What is true about portwine stain
a) Will regress spontaneously
b) Will not regress spontaneously and might increase in later life
c) Treat immediately because of high potential to turn malignant
Ans: .

30 | P E D S
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2009
WOF is the most predisposing factors in developing atopic asthma?
a.) house rugs
b.) toys and lounge suit stuffed with animal ski and feathers
c.) household pets
d.) house mites
Ans: C.
infections, especially colds
allergies, e.g. to animal fur, feathers, grass pollens, mould
allergy to house dust, especially the dust mites
cigarette smoke, other smoke and fumes
sudden changes in weather or temperature
occupational irritants, e.g. wood dust, synthetic sprays, chemicals
drugs, e.g. aspirin, NSAIDs, beta-blockers (oral, parenteral or topical)
certain foods and food additives may trigger asthma
monosodium glutamate
metabisulphites/sulphite preservatives/food colouring agents
seafood
nuts
(JM: Allergy)
WOF preservatives is allergic to asthma patients?
a.)
b.)
c.)
d.)
e.)

sulphites
benzyl benzoate
lecithin
terbutaline
ephedrine

Ans: A
Previous Question
WOF is the most ill prognosis in a child who suffers from mealses in a developin
g
country?***
31 | P E D S
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a.)
b.)
c.)
d.)
e.)

lack of proper treatment


poor accessibility to measles vaccines
lack of nutrition
poor sanitation
immune deficiency

Ans: C.
A young scientist has decided to study the causes of neonatal jaundice. He selec
ts 150
babys with jaundice and 150 without, and examines there previous historiies look

ing for
factors that could have determined there jaundice. This kind of study is called?
a.)
b.)
c.)
d.)
e.)

cohort study
case study
case control study
prospective study

Ans: B.

Studies:
A cohort study or panel study is a form of longitudinal study used in medicine,
social
science and ecology. It is one type of study design and should be compared with
a crosssectional study.
A cohort is a group of people who share a common characteristic or experience wi
thin a
defined period (e.g., are born, leave school, lose their job, are exposed to a d
rug or a
vaccine, etc.). Thus a group of people who were born on a day or in a particular
period, say
1948, form a birth cohort. The comparison group may be the general population fr
om
which the cohort is drawn, or it may be another cohort of persons thought to hav
e had
little or no exposure to the substance under investigation, but otherwise simila
r.
Alternatively, subgroups within the cohort may be compared with each other.
A prospective cohort study is a cohort study that follows over time a group of s
imilar
individuals ("cohort") who differ with respect to certain factors under study, i
n order to
determine how these factors affect rates of a certain outcome.
For example, one might follow a cohort of middle-aged truck drivers who vary in
terms of
smoking habits, in order to test the hypothesis that the 20-year incidence rate
of lung
cancer will be highest among heavy smokers, followed by moderate smokers, and th
en
non-smokers.
32 | P E D S
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The prospective study is important for research on the etiology of diseases and
disorders
in humans because for ethical reasons people cannot be deliberately exposed to
suspected risk factors in controlled experiments.
A retrospective cohort study, also called a historic cohort study, is a medical
research
study in which the medical records of groups of individuals who are alike in man
y ways but

differ by a certain characteristic (for example, female nurses who smoke and tho
se who
do not smoke) are compared for a particular outcome (such as lung cancer).
In order to differentiate Retrospective versus Prospective Cohort, following ana
logy can be
considered.
A retrospective (historic) cohort study is different from a prospective cohort s
tudy in the
manner in which it is conducted. In the case of a Retrospective Cohort Study, th
e
investigator basically collects data from past records and does not follow patie
nts up as is
the case with a prospective study. However, the starting point of this study is
the same as
for all Cohort studies. The first objective is still to establish two groups - E
xposed versus
Non-exposed; and these groups are followed up in the ensuing time period. A case
study is
one of several ways of doing research whether it is social science related or ev
en socially
related. It is an intensive study of a single group, incident, or community.
Other ways include experiments, surveys, or analysis of archival information.
Rather than using samples and following a rigid protocol to examine limited numb
er of
variables, case study methods involve an in-depth, longitudinal examination of a
single
instance or event: a case. They provide a systematic way of looking at events, c
ollecting
data, analysing information, and reporting the results. As a result the research
er may gain
a sharpened understanding of why the instance happened as it did, and what might
become important to look at more extensively in future research. Case studies le
nd
themselves to both generating and testing hypotheses.
Case-control is a type of epidemiological study design. Case-control studies are
used to
identify factors that may contribute to a medical condition by comparing subject
s who
have that condition (the cases ) with patients who do not have the condition bu
t are
otherwise similar (the controls ).
Case-control studies are a relatively inexpensive and frequently-used type of
epidemiological study that can be carried out by small teams or individual resea
rchers in
single facilities in a way that more structured experimental studies often canno
t be. They
have pointed the way to a number of important discoveries and advances, but thei
r
retrospective, non-randomized nature limits the conclusions that can be drawn fr
om
them.
(Wikipedia)

*One child with red eye, pain, fever and ophthalmoplegia presented in the emerge
ncy.
What is the best next investigation to do?
a. Eye swab
33 | P E D S
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b. CT scan
c. Blood culture
d. USG
Ans: CT scan
(JM and RHP)
A couple came to your surgery. Father is a carrier; mother is not having any eff
ect. What is
the chance of getting a cystic fibrosis baby?
a. 0
b. 25%
c. 12.5%
d. 100%
Ans: 0
A Frequently asked topic: Relevant Diagrams

34 | P E D S

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A boy was stung by bee and developed severe breathlessness and urticaria. What i
s the
management?
a. Adrenaline IM
b. Promethazine
c. Corticosteroids
Ans: Adrenaline IM (JM: Emergency)
During operation a boy who has history of atopy suddenly developed whhezing.
Anaesthetics managed the condition. What is the cause of the condition?
a. Iodine
b. Latex
c. Isoflurane
Ans: B (JM: Allergy)
A boy while having milk shake ice cream suddenly develop urticaria and wheezing.
What is
the cause?
a. Tertarazine
Ans: Tertarazine
A small child of 8 years of age was playing in the laundry and suddenly started
crying.
Far=ther saw washing powder in his mouth. What is the most serious complication?
a. Esophageal stricture
b. Respiratory failure
c. Gastric perforation
35 | P E D S
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Ans: Esophageal stricture
A one year old boy presented with fever, wheezing, retreaction of ICS. What is t
he
diagnosis?
a. Parainfluenza
b. RSV
c. RDS
Ans: RSV (Kaplan Pedia: RS)
A one year old boy presented with fever, wheezing, retreaction of ICS. What is t
he
management?
a. Nebulised sulbutamol
b. Nebulised corticosteroids
c. Nebulised adrenaline
Ans: C (Kaplan Pedia: RS)
A child presented with red tympanic membrane, no bulging and pain in the ear. Wh
at is the
management?

a. Amox
b. Cipro
c. Difluclox
Ans: amox (JM: Ear)
A child presented with deafness. He has a history of AOM and antibiotics were gi
ven at 12
months of age. He is now 19. What is the diagnosis?
a. Drug reaction
36 | P E D S
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b. Serous OM
Ans: In children OM is most of the time bilateral. Gentamycin is rarely given to
children for
AOM. (JM)
A boy from Vietnam is presenting 6 weeks after migrating to Australia with fever
and
myelgia. What is the diagnosis?
a. Malaria
b. EBV
c. HIV
Ans: Malaria (JM: Travel Medicine)
A aboriginal boy presented with myelgia, arthralgia and rash. He was also having
mild fever.
What is the diagnosis?
a. Ross river virus
b. Chicken pox
c. EBV
Ans: Ross river.(JM)
A boy presented with petechie in few places of the body. There is a history of v
iral infection
7 days before. What of following investigation will lead to diagnosis?
a. Full blood count
b. INR
c. APTT
Ans: full blood count (JM, Kaplan Pedia: Hemat)
A baby was born with jaundice. Mother is Rh positive and baby too. What is the m
ost
probable cause of jaundice (I think blood group was also given and it was compat
ible)?
a. Infection
37 | P E D S
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Ans: Infection (Kaplan Pedia: Newborn)