— สหพันธ์นิสิตนักศึกษาแพทย์แห่งประเทศไทย ในพระอุปถัมภ์ฯ (สพท.
) —
— PEDIATRICS —
1. A 5-year-old girl presented with vaginal
bleeding and pain on urination 1 day.
Mother said she is inappropriate sexual
with toy the girl seeming insecure. What
is the initial management ?
A. Police notification
B. Vaginal examination
C. Make the girl feel safe first
D. History taking from mother
individually
E. History taking from neighbour
2. A 20-day-old infant presented with
regurgitation after feeding 3-4 times. He
currently has cow milk base formula 3 oz
x 10 feeds per day. Birth weight 3,200
gram. Physical examination — BW 4,500
gram, Abdomen — soft, not tender,
normoactive bowel sound. What is the
most appropriate management ?
A. Reassure
B. Feeding in upright position
C. Anti-emetic drug
D. Decrease amount of milk per day
E. Change to protein hydrolysed
milk
3. เด็กอายุ 1 เดือน มาด้วยมีก้อนที่หัวโตขึ้นเรื่อย ๆ
มา 1 สัปดาห์ PE — solitary mass at scalp.
What is the proper management ?
A. Reassure
B. Intra-lesion steroid
C. Laser excision
D. Surgical excision
E. Propanolol
NLE Step II 2019_Apr
4. Late preterm infant was delivered by
elective C/S. The maternal history was
uncomplicated. The infant has respiratory
distress immediately after labor. CXR —
hyperaeration, perihilar infiltrate with
interlobar fissure. What is most
appropriate management ?
A. Oxygen therapy
B. Diuretic drugs
C. Antibiotic drugs
D. Dexamethasone
E. Surfactant
5. Female 12 years old presented with fever
and fatigue for 5 days, splenomegaly 1
cm Hct 20 %, WBC normal,platelet
normal, DAT 2+, PBS — spherocyte 2+,
reticulocyte 10 %, polychromasia. What is
the most appropriate management ?
A. Splenectomy
B. Folic acid
C. Prednisolone
D. PRC transfusion
E. IV immunoglobulin
6. A term newborn with cyanosis. Her
mother has rupture membrane for 12
hours before delivery. PE — BT 37 °C, RR
45 /min, SpO2 85 % (room air), active,
central cyanosis, no dyspnea and normal
breath sound. CBC and CXR show
normal. What is most appropriated
management ?
A. Echocardiogram
B. Oxygen box 5 LMP
C. Hypoxia hyperventilation test
D. Hemoculture
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 — สหพันธ์นิสิตนักศึกษาแพทย์แห่งประเทศไทย ในพระอุปถัมภ์ฯ (สพท.) —

7. A 2-year-old girl presented with high- 10. เด็กอายุ 14 วัน คลอด preterm มา 30 weeks
grade fever for 2 days. PE — BT 39 °C, BP มี billous vomiting, abdominal distension
90/60 mmHg, RR 30 /min, PR 100 bpm, มีไข้ ได้ antibiotics เป็น PGS and cefotaxime
irritable, stiff neck positive, CSF profile — แล้วอาการไม่ดีขึ้น มี distension ทั่ว ๆ มี
WBC 500 cell/mm3 (N 90 % L10%), guarding CXR include abdomen as figure
protein 200 mg/dL, glucose 30 mg/dL, below.
(plasma glucose 80 mg/dL), CSF gram
stain — numerous gram positive
diplococci. What is the most appropriate
management ?
A. Cefotaxime
B. Ceftriazone
C. Penicillin G
D. Vancomycin + Rifampicin
E. Vancomycin + Cefotaxime
8. เด็กหญิง 8 เดือน ไข้ไอน้ำมูกมา 2 วัน PE — BT
38.5 °C, RR 26 /min, PR 100 bpm,
bilateral conjunctivitis with cervical
lymph node enlargement, cluster of
white lesion on buccal mucosa, injected
pharynx and tonsil. What is the most What is the most appropriate
proper treatment ? management ?
A. Cefdinir A. Follow-up film
B. Vitamin A B. Add Vancomycin
C. Oseltamivir C. Change drugs to ………..
D. Amoxicillin D. Consult pediatric surgery
E. Co-amoxiclav 11. เด็กอายุ 2 เดือนเป็นผื่นที่แก้มลักษณะ
9. เด็กหญิงอายุ 13 ปี มาด้วย Small multiple excoriative at both cheek มี crust จงให้การ
color papule ขึ้นตาม forehead, back with วินิจฉัย ?
facial inflammatory papule. What is the A. Atopic dermatitis
proper management ? B. Impetigo
A. Topical clindamycin C. Contact dermatitis
B. Oral isotretinoin
C. Oral contraceptive pills (OCP)
D. Topical tretinoin
E. Topical vitamin A

NLE Step II 2019_Apr Page 28

 — สหพันธ์นิสิตนักศึกษาแพทย์แห่งประเทศไทย ในพระอุปถัมภ์ฯ (สพท.) —

12. A 2-month-old infant relapse rash at both 15. เด็กอายุ 8 เดือน มารดาพาไปเข้า program ให้
cheek บรรยาย lesion เป็น plaque with มารดาอ่านหนังสือให้ฟังก่อนนอน 15 นาที ท่าน
scale and yellow crust ประวัติเพิ่มเติมแม่ คิดว่า program นี้ช่วยเรื่องอะไร ?
เป็น allergic rhinitis จงให้การวินิจฉัย ? A. Improve intellectual
A. Tinea versicolor B. Increase motor child relationship
B. Impetigo C. Decrease risk of intellectual
C. Atopic dermatitis disability
D. Seborrheic dermatitis 16. Neonate with scaphoid abdomen, and
13. A 3-month-old infant presents with decreased breath sound left lung. What
dyspnea and tachypnea for 2 days. He is proper management ?
has received breastfeeding and chewed A. Orogastric intubation
sticky rice. His mother has consumed 17. A boy, with history of partial gastrectomy
only sticky rice and some fishes after due to corrosive ingestion, came with
giving birth. PE — BT 37.0 °C, PR 140 anemia. Peripheral blood smear was
bpm, RR 50 /min, fine crepitation both done as shown below.
lungs, no cardiac murmur, liver 4 cm
below RCM, CXR shows cardiomegaly
with pulmonary congestion. What is the
most likely diagnosis ?
A. Myocarditis
B. Cardiac beriberi
C. Cardiomyopathy
D. Pericardial effusion
E. Glycogen storage disease
14. A 4-year-old boy presents with poor
attention in the classroom and cannot What is the etiology ?
wait in the line. He often loses his toys A. Folic deficiency
and cannot play quietly with others. He B. B12 deficiency
doesn’t stay seated while doctor takes C. Iron deficiency
physical examination. What is the most D. Copper deficiency
appropriate management ? E. Zinc deficiency
A. Reassurance
B. Behavioural modification
C. Family therapy
D. Risperidone administration
E. Methylphenidate administration

NLE Step II 2019_Apr Page 29

 — สหพันธ์นิสิตนักศึกษาแพทย์แห่งประเทศไทย ในพระอุปถัมภ์ฯ (สพท.) —

18. เด็กอายุ 9 ปี underlying disease as asthma 20. A 4-year-old girl presented with fever and
มีอาการ cough dyspnea for 2 hours ได้ cough for 1 week. PE — BT 39 °C, RR 40 /
ทำการพ่น Salbutamol MDI 1 hour ago PE min, PR 120 bpm, BP 100/60 mmHg,
— BP 110/70 mmHg, PR 120 bpm, SpO2 SpO2 94 %, decreased breath sound and
92 %, distress expiratory wheezing dullness on percussion RLL, CXR as
retraction. What is the initial shown.
management ?
A. Salbutamol nebulizer
B. IV Dexamethasone
C. Ipratropium
D. O2 mask with bag
E. Theophylline subcutaneous
19. A 4 years old boy present with fever for 2
days. Last night his mother detects he
passed dark urine. Today he develops
dyspnea. PE — BT 37.5 °C, PR 140 bpm,
RR 40 /min, BP 100/60 mmHg, moderate What is the initial management ?
pallor, others are unremarkable. A. CT chest
Complete blood count — Hb 5.0 g/dL, B. Immediate antibiotic
WBC 7,000 cells/mm3 (N 80 %, L 20 %), C. High flow oxygen
platelet 390,000 /mm3, UA — dark D. Thoracocentesis
brown, urine blood 3+, urobilinogen E. Tube thoracostomy
positive. What is the most appropriate 21. A 3-day-old newborn with copious yellow
management ? discharge both eyes PE: normal cornea,
A. Force diuresis mildly injected conjunctivae. What is the
B. Dexamethasone most appropriate management ?
C. Urine alkalinization A. Lacrimal sac massage
D. Pack red cell infusion B. Terramycin ointment
E. IV immunoglobulin C. Dex-oph eye drop
D. Oral dicloxacillin
E. IV Ceftriaxone

NLE Step II 2019_Apr Page 30

 — สหพันธ์นิสิตนักศึกษาแพทย์แห่งประเทศไทย ในพระอุปถัมภ์ฯ (สพท.) —
22. A 10 years old boy presented with high
grade fever, headache, poor appetite,
myalgia, and nausea for 3 day. PE — BT
39.0 °C, PR 100 bpm, BP 100/60 mmHg,
RR 20 /min, liver palpated 2 cm below
right costal margin, liver span 10 cm with
tenderness. Complete blood count
shown Hct 40 %, WBC 25,000 cells/mm3
(neutrophil 35 %, lymphocyte 60 %,
atypical lymphocyte 5 %). What is the
most appropriate management ?
A. NS1 antigen
B. Nasal swab for influenza
C. Hemoculture
D. Immunofluorescence (IFA) for
scrub typhus
E. Liver function test
23. On January 7, 2019, a high school girl
presented with fever, cough, and sore
throat and is diagnosed with acute
tonsillitis. She informed that she had this
symptom since January 3, 2019 and went
to the clinic on January 5, 2019 and
reviewed antibiotic which slightly
improved her symptoms. She claims that
her purpose of visiting is to get a grant for
school leaving. What should you do ?
A. 1. No school leave granted.
B. 2. Grant for school leaving from
Jan 3-5, 2019
C. 3. Grant for school leaving from
Jan 5-7, 2019
D. 4. Grant for school leaving from
Jan 5-9, 2019
E. 5. Grant for school leaving from
Jan 7-8, 2019
NLE Step II 2019_Apr
24. A 1-year-old boy presented with rash for
1 day. He had history of high grade fever
3 days ago and received amoxicillin.
Yesterday, fever subsided and rash
developed. PE — BT 37 °C, PR 100 bpm,
RR 30 /min, alert, generalized
maculopapular rash at face and body.
What is the most proper management ?
A. Reassure
B. Co-amoxiclav
C. Chlorpheniramine (CPM)
D. Azithromycin
E. 0.02% TA cream
25. A 7-month-old boy came with low grade
fever and runny nose for 3 days, dyspnea
for 1 day. PE — BT 37.8 °C, RR 60 /min,
PR 130 bpm, BP 80/50 mmHg, SpO2 92
%, subcostal retraction, expiratory
wheezing both lungs. CXR —
hyperaeration with perihilar infiltration.
After first dose of nebulized salbutamol,
he still has expiratory wheezing both
lungs. What is the most appropriate next
step of management ?
A. Repeated nebulized salbutamol
B. Nebulized adrenaline
C. Nebulized normal saline
D. Nebulized ipratropium bromide
E. Endotracheal intubation
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26. A 21-day male newborn with birth weight
of 3000 gram exclusively breastfed
presented with jaundice for 7 days. PE —
active, vigorously cry, BW 3900 gram, Lab
— Total bilirubin 15.0 mg/dL, direct
bilirubin 0.4 mg/dL, Hct 45 %,
Reticulocyte 3%, DAPT negative, Blood
group — Newborn A Rh+, Mother O Rh+.
What is the diagnosis ?
A. Alpha Thalassemia
B. Biliary Atresia
C. Breastfeeding Jaundice
D. Breastmilk Jaundice
E. Neonatal Hepatitis
27. A 5-month-old baby presented with
generalized tonic-clonic seizure for 2
minutes. He had fever and rhinorrhea for
6 hours prior to the seizure. PE — BT 39
°C, sleepy, Brudzinski’s sign negative,
anterior fontanelle 2x2 cm, no bulging,
otherwise normal. What is the
appropriate investigation ?
A. Blood chemistry
B. Ultrasound brain
C. CT brain
D. Electroencephalogram (EEG)
E. Lumbar puncture
28. A 6-year-old boy fever with sore throat 2
days. PE — BT 39 °C, muffle voice, lean
forward sitting, drooling. Film lateral neck
showed thumb sign. What is the most
appropriate antibiotic drugs ?
A. Imipenem
B. Ceftriaxone
C. Ceftazidime
D. Clindamycin
E. Co-amoxiclav
NLE Step II 2019_Apr
29. A 5-day-old neonate presented with
jaundice for 1 day, his birth weight is
3,000 gram with exclusive breastfeeding.
PE — cephalhematoma, body weight
2,600 gram, Mother — blood group A+,
Neonate — blood group O+, DAT
negative, PBS — no bite cell. What is the
most likely cause of jaundice ?
A. Cephalhematoma
B. Breastfeeding jaundice
C. G6PD deficiency
D. Minor blood group incapability
E. Thalassemia
30. A 2-day-old neonate, birthweight 2,200 g
and 34 weeks of GA, labor by cesarean
section. Her apgar score was 2 and 5 at 1
and 5 minutes respectively. She received
phototherapy at 2nd day due to
microbilirubin of 16 mg/dL. Which of the
following is the most importance to
investigate hearing test?
A. Apgar score
B. Birth weight
C. Phototherapy
D. Cesarean section
E. Level of microbilirubin
31. A term newborn, cesarean section due to
fetal distress. History of antepartum are
unremarkable. After initial neonatal
resuscitation, she still grasping, hypotonia,
HR 50 bpm. What is your appropriate
next management ?
A. PPV via mask
B. Chest compression
C. Adrenaline infusion
D. NSS infusion
E. Intubation
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32. A 4-year-old boy presented with
projectile vomiting, fever, poor appetite
for 10 days. PE — BT 38.3 °C, Kernig’s
sign positive, generalized hyperreflexia.
LP — straw color, opening pressure 22
cmH2O, WBC 550 cells/mm3 (Monocyte
90%), protein 200 mg/dL, glucose 20 mg/
dL (blood glucose 100 mg/dL), india ink
negative. What is the appropriate
management ?
A. Amphotericin B
B. Cefotaxime
C. Anti-TB drugs
D. Acyclovir
33. A 6-year-old girl comes to hospital due to
non-stop bleed after tooth extraction
yesterday. PE — bleeding at site of
extraction, ecchymosis at buttock. CBC —
Hb 12 mg/dL, WBC 6,500 (neutrophil 60
%, lymphocyte 20 %, eosinophil 15 %),
platelet 270,000 /mm3, aPTT 30 seconds,
PT 11.5 seconds. What is the most
appropriate management ?
A. Fresh frozen plasma (FFP)
B. Cryoprecipitate
C. Concentrated platelet
D. Vitamin K
E. Factor VIII
34. A 3-year-old infant, VSD with delay
development. PE — brachycephaly,
upslant palpabral fissure, bilateral single
palmar crease. What is the most
appropriate investigation?
A. Serum CPK
B. Chromosome study
C. Nerve conduction velocity
D. MRI brain
NLE Step II 2019_Apr
35. A 14-year-old boy present with
abdominal pain 2 days, he has arthralgia
and rash (as figure above) for 1 week, PE
— BP 110/70 mmHg, PR 80 bpm, RR 24 /
min, BT 37 °C, Abdomen — generalized
tenderness, no guarding. UA — protein
negative, WBC 0-5 cells/hpf, RBC 3-5
cells/hpf, stool occult blood positive.
What is the most appropriate
management ?
A. Steroid
B. Antibiotic
C. Antihistamine
36. A 4-year-old with tetralogy of Fallot
presented with fever and increase degree
of cyanosis for 1 weeks. PE — T 38.8 °C,
RR 24 /min, central cyanosis, SEM at
LUPSB grade II, discrete petechiae all
extremities, splinter hemorrhage at left
index finger. Lab — Hb 19 mg/dL, Hct 59
%, WBC 21,000 cells/mm3 (N 85, L 22),
platelet 450,000 /mm3. What is most
useful investigations for diagnosis and
management in this boy ?
A. Arterial blood gas
B. Hemoculture
C. Chest x-ray
D. Electrocardiography
E. Echocardiogram
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 — สหพันธ์นิสิตนักศึกษาแพทย์แห่งประเทศไทย ในพระอุปถัมภ์ฯ (สพท.) —
37. A 7-day-old neonate presented with
mucous discharge both eye, eyelid
swelling, erythematosus and swelling
eyelid, PE — swelling and injected
conjunctiva and mucous discharge. What
is the most proper treatment?
A. Oral amoxicillin
B. Oral erythromycin
C. Prednisolone
D. Polymyxin eyedrop
E. Terramycin ointment
38. A 6-year-old female presented with rash
and fever for 3 days. PE — BT 38.0 °C,
generalized erythematous rash, vesicles,
papules, pustules. What is the
appropriate management ?
A. Topical mupirocin
B. Acetaminophen
C. Acyclovir
D. Co-amoxiclav
E. Cloxacillin
39. เด็กอายุ 7 ปี fever, cough, and dyspnea ได้
Augmentin มา 4 วัน อาการดีขึ้นเล็กน้อย แต่ยัง
คงมีไข้อยู่ CXR — Right pleural effusion at
RLL. Thoracentesis — straw color, Sp.
1.03, protein 3 mg/dL, sugar 49 mg/dL,
WBC 1,500 cells/mm3 (neutrophil 85 %,
lymphocyte 15 %), no organism. What is
the most appropriate management ?
A. Add Vancomycin
B. Change to Cetriaxone
C. Change to Imipenem
D. Tube thoracostomy
E. Pleurodesis
NLE Step II 2019_Apr
40. A 4-year-old boy presented with acute
respiratory distress without fever. PE —
BT 37 °C, PR 110 bpm, RR 30 /min, alert,
look dyspnea. decreased breath sound
right side. CXR shows right middle lobe
atelectasis. What is the most appropriate
management ?
A. Direct laryngoscope
B. Flexible bronchoscope
C. Rigid bronchoscope
D. Flexible esophagoscopy
E. Rigid esophagoscopy
41. An exclusive feeding 1 day-old male term
neonate presented with jaundice.
Delivery by vacuum extraction and birth
weight 3,000 gram. PE — weight 2,950
gm, weak cry, caput succedaneum at
occiput, no hepatosplenomegaly. Lab —
microbilirubin 14 mg/dL, Hct 35 %, WBC
15,000 cells/mm3, platelet 200,000 /
mm3, DAT positive. Infant blood gr. A
Rh+. Mother blood gr. O Rh+. What is the
most appropriated management ?
A. Follow-up microbilirubin and
hematocrit next 6 hours
B. Single phototherapy
C. Intensive phototherapy
D. Partial blood exchange
transfusion
E. Total blood exchange transfusion
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42. A term newborn มี sacral mass 1.5 cm
มีขน ไม่ถ่าย meconium มา 24 ชั่วโมง ตรวจ
ร่างกายพบ deep tendon reflex 3+ both
knees. What is the most appropriate
management ?
A. Consult neurosurgeon
B. Rectal irrigate
C. NPO and IV fluid
D. Barium enema
43. A term female newborn cannot pass
meconium with excessive saliva. Anus
and perineal fistula cannot be found.
What is the most appropriate
investigation ?
A. OG tube insertion and chest x-ray
B. Renal ultrasonography
44. เด็กอายุ 2 ปี สามารถพูดได้เพียง 1 คำ ขณะเด็ก
อายุ 1 ปี เด็กสามารถเดินได้เอง มีภาวะไม่ค่อย
สบตา ไม่ค่อยสนใจผู้อื่น จงให้การวินิจฉัย ?
A. Selective mutism
B. Learning disorder
C. Autism spectrum disorder
NLE Step II 2019_Apr
45. A newborn laboured from mother with
poorly controlled DM type II presents
with jitteriness 1 hour later after labor. PE
— body weight 4,500 gram. Lab — Hct
72 %, plasma glucose 45 mg/dL. What is
the proper management ?
A. Early feeding
B. 10% DW 9ml IV push
C. 10% DW 80ml/kg/day IV
D. Partial transfusion with NSS
E. Transfusion with PRC O low titer
46. A 6-year-old girl presented with dyspnea
on exertion for 1 day. She had a history
of arthralgia for 10 days. PE — BT 38.5,
multiple joints redness, tenderness, pan-
systolic murmur at apex. What is the
diagnosis ?
A. Acute rheumatic fever
B. Kawasaki disease
C. Infective endocarditis
Page 35