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SECTION A - Long Essay Questions

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Q1. A 4-Year-Old Child with Fever for 5 Days

a) Approach to a Child with Fever

• Duration, onset, pattern (continuous/remittent/intermittent)
• Associated symptoms: cough, rash, redness of eyes, sore throat, ear pain, urinary symptoms, seizures, neck stiffness
• Travel history, contact with sick persons, immunization status
• Prior antibiotic use

• Vital signs: temperature, HR, RR, BP, SpO2
• General: toxic appearance, pallor, jaundice, lymphadenopathy, rash
• HEENT: pharyngeal injection, ear discharge, conjunctivitis
• Respiratory: tachypnea, retractions, auscultation
• Abdomen: hepatosplenomegaly
• Neurological: meningeal signs (Kernig's, Brudzinski's), sensorium
• Skin: petechiae, purpura (suggest meningococcemia - emergency!)

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b) Classification of Fever by Pattern

• Acute fever: <7 days - usually infectious (viral URTI, malaria, dengue)
• Prolonged fever: 7-14 days
• Fever of Unknown Origin (FUO): >38.3°C on more than 3 occasions over >3 weeks with no diagnosis after 1 week of evaluation (Petersdorf criteria)

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c) Investigations

• CBC with differential (WBC, neutrophilia = bacterial; lymphocytosis = viral; eosinophilia = parasitic)
• ESR, CRP (inflammatory markers)
• Blood culture and sensitivity (before antibiotics)
• Urine routine + microscopy + culture
• Peripheral blood smear for malaria (thick and thin smear)
• Dengue NS1 antigen, IgM/IgG (if dengue endemic area/season)
• Chest X-ray

• Widal test (typhoid - after 1 week of illness) / Typhidot IgM
• LFT (hepatitis, typhoid)
• Mantoux test / Chest X-ray (TB)
• Blood culture (sepsis)
• CSF analysis (meningitis - if neck stiffness/altered sensorium)
• Serology: EBV, CMV, scrub typhus, leptospira
• Echocardiography (Kawasaki disease, endocarditis)
• ANA (SLE)
• Bone marrow aspiration (leishmania, malignancy)
• Procalcitonin (bacterial vs viral differentiation)

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d) Management

• Antipyretics: Paracetamol 10-15 mg/kg/dose q6-8h (first line) OR Ibuprofen 5-10 mg/kg/dose q8h (>6 months, if no dehydration)
• Avoid aspirin in children (Reye syndrome risk)
• Tepid sponging with lukewarm water (not cold/alcohol)
• Adequate hydration (oral fluids encouraged)
• Light clothing; rest

• Altered consciousness / meningeal signs
• Petechiae/purpura
• Respiratory distress
• Shock (hypotension, poor perfusion)
• Temperature >40°C

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Q2. Severe Acute Malnutrition (SAM)

a) Definition

1. Weight-for-Height (WHZ) < -3 SD (below -3 z-score) on WHO growth standards
2. Mid-Upper Arm Circumference (MUAC) < 115 mm (in children 6-59 months)
3. Presence of bilateral pitting edema (nutritional edema - kwashiorkor)

• Marasmus: Severe wasting, no edema, "old man face," monkey facies, baggy pants, visible ribs
• Kwashiorkor: Edema (bilateral), skin peeling, hair changes (flag sign, depigmented), "flaky paint" dermatosis, fatty liver, miserable child
• Marasmic-Kwashiorkor: Features of both

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b) Clinical Features

• Severe muscle wasting and loss of subcutaneous fat
• Weight <60% of expected for age
• Wrinkled, loose skin ("baggy pants") - gluteal skin folds
• "Old man" facies - prominent eyes, sunken cheeks
• Apathetic but alert, hungry
• No edema
• Hair thin, sparse but not easily pluckable

• Bilateral pitting edema (starts feet, may ascend)
• Weight 60-80% expected (edema masks wasting)
• Miserable, anorexic, withdrawn
• Skin: hypo/hyperpigmentation, flaky paint dermatosis, ulcerations
• Hair: thin, reddish-brown, sparse, easily pluckable, "flag sign"
• Hepatomegaly (fatty liver)
• Pot-belly abdomen

• Hypothermia (impaired thermoregulation)
• Hypoglycemia (common, dangerous)
• Bradycardia
• Pallor (anemia)
• Infection signs (masked by poor immune response)

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c) Complications (Life-threatening - "The Deadly 6")

1. Hypoglycemia - blood glucose <3 mmol/L (<54 mg/dL)
2. Hypothermia - axillary temp <35°C
3. Dehydration - difficult to assess (use history: diarrhea/vomiting)
4. Electrolyte imbalances - especially hypokalemia, hypomagnesemia
5. Infections - sepsis, pneumonia, meningitis (signs masked - no fever, no leukocytosis)
6. Severe anemia - Hb <4 g/dL

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d) Management Protocol (WHO 10-Step Protocol)

• <6 months: 50,000 IU
• 6-12 months: 100,000 IU

• 1 year: 200,000 IU

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e) Discharge Criteria (WHO)

1. No edema for 2 weeks
2. MUAC ≥ 125 mm OR WHZ ≥ -2 SD
3. Good appetite (eating well)
4. No acute illness / medical complications
5. Caregiver counseled on home feeding and follow-up
6. Immunizations up-to-date
7. Receives a 4-week supply of ready-to-use therapeutic food (RUTF) for home

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SECTION B - Short Essay Questions

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Q3. Diarrhea with Dehydration

Classification of Diarrhea

• Acute: <14 days (most common)
• Persistent: 14-29 days
• Chronic: >30 days

• Secretory: Watery, large volume (cholera, ETEC)
• Osmotic: Watery, stops with fasting (viral - rotavirus)
• Inflammatory/Dysentery: Blood + mucus, tenesmus (Shigella, Entamoeba)

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Assessment of Dehydration (WHO/IMNCI Scale)

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Management Plans

• Give extra fluids at home (ORS, rice water, dal water, butter milk)
• ORS: 50-100 mL after each loose stool
• Continue breastfeeding and normal feeding
• Zinc supplementation: <6 months: 10 mg/day; >6 months: 20 mg/day for 10-14 days
• Return signs: blood in stool, not improving in 3 days, sunken eyes, unable to drink

• ORS 75 mL/kg over 4 hours (reassess after 4 hours)
• Give ORS sip by sip (5 mL every 1-2 minutes)
• If child vomits, wait 10 min then restart slowly
• Continue breastfeeding between ORS
• After 4 hours: reassess and assign new plan

• IV Ringer's Lactate (or Normal Saline if RL unavailable):
  • < 12 months: 30 mL/kg over 1 hour, then 70 mL/kg over 5 hours
  • ≥ 12 months (or >5 years): 30 mL/kg over 30 minutes, then 70 mL/kg over 2.5 hours
• Reassess every 15-30 minutes
• Start ORS (5 mL/kg/hr) as soon as child can drink
• If no IV access in infant: intraosseous route

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Q4. Approach to Child with Anemia

Definition

• Neonate: Hb <14 g/dL
• 6 months - 6 years: Hb <11 g/dL
• 6-14 years: Hb <12 g/dL

Types of Anemia

1. Decreased production: Iron deficiency, B12/folate deficiency, aplastic anemia, chronic disease
2. Increased destruction (Hemolysis): Hereditary spherocytosis, G6PD deficiency, thalassemia, sickle cell disease
3. Blood loss: Acute (trauma) or chronic (hookworm, Meckel's diverticulum)

Clinical Evaluation

• Age (neonatal vs infant vs older child)
• Diet history (iron, B12, folate intake)
• Blood in stool (hookworm, cow milk protein allergy)
• Jaundice (hemolysis)
• Pica (iron deficiency)
• Family history (thalassemia, sickle cell)
• Medications (chloramphenicol - aplastic)

• Pallor (conjunctiva, palm, nail beds)
• Jaundice (hemolysis)
• Splenomegaly (thalassemia, hemolytic anemia)
• Frontal bossing, prominent malar eminences (thalassemia)
• Angular stomatitis, glossitis, koilonychia (iron deficiency)
• Petechiae (aplastic anemia / leukemia)
• Lymphadenopathy (malignancy)

Laboratory Investigations

• CBC: Hb, MCV, MCH, MCHC, RDW
• Peripheral blood smear (essential - shows morphology)
• Reticulocyte count (high = hemolysis/blood loss; low = marrow failure)

• Serum iron, TIBC, serum ferritin (iron deficiency: low Fe, high TIBC, low ferritin)
• Serum B12, folate
• HPLC/Hb electrophoresis (thalassemia, sickle cell)
• Osmotic fragility test (hereditary spherocytosis)
• G6PD assay
• Coombs test (autoimmune hemolysis)
• Bone marrow aspiration (aplastic anemia, leukemia)
• Stool for ova/parasites (hookworm)

Management Principles

• Iron deficiency: Elemental iron 3-6 mg/kg/day in 2-3 divided doses x 3 months; treat cause; dietary advice
• Thalassemia major: Regular transfusions + chelation (Desferrioxamine)
• B12/Folate deficiency: IM cyanocobalamin / oral folic acid
• Hemolytic: Treat underlying cause; folate supplement; transfusion if severe
• Aplastic anemia: Bone marrow transplant (curative); immunosuppression (ATG + cyclosporine); supportive transfusions

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Q5. Vitamin D Deficiency

Etiology

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Signs and Symptoms

• Craniotabes (ping-pong ball feel of skull)
• Delayed closure of fontanelles
• Frontal bossing (box-shaped skull)
• Rachitic rosary (beading of costochondral junctions)
• Harrison's sulcus (horizontal groove at lower chest due to diaphragm pull)
• Hypotonia (floppy baby)
• Hypocalcemic tetany: carpopedal spasm, Trousseau's sign, Chvostek's sign
• Seizures (hypocalcemia)
• Stridor (laryngospasm)

• Bow legs (genu varum) - most common
• Knock knees (genu valgum)
• Coxa vara - waddling gait
• Widened wrists and ankles (epiphyseal enlargement)
• Rachitic rosary
• Scoliosis, kyphosis
• Dental: delayed eruption, enamel hypoplasia, caries
• Short stature, muscle weakness

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Investigations

• Widened, frayed, cup-shaped metaphysis (most characteristic)
• Osteopenia (reduced bone density)
• Delayed bone age
• "Milkman fractures" / Looser zones in severe cases

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Treatment and Prevention

• Stoss therapy (high-dose): Vitamin D3 600,000 IU single oral or IM dose (children >1 year; one dose, may repeat after 3 months)
• Daily therapy: 1,000-2,000 IU/day for 3 months
• Alternative: 50,000 IU/week for 6-8 weeks
• Calcium supplementation: 500-1000 mg/day elemental calcium x 3 months
• Monitor: ALP, Ca, P, 25-OH D3 at 3 months

• Vitamin D supplementation: 400 IU/day starting from first few days of life for all breastfed infants (AAP/IAP recommendation)
• Formula-fed infants: adequately fortified formula
• Safe sunlight exposure (15-30 min/day face and forearms)
• Dietary fortification of foods (milk, cereal)
• Pregnant women: 600-2000 IU/day Vitamin D
• At-risk groups (preterm, dark skin, malabsorption): 800-1000 IU/day

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Q6. Status Epilepticus

Definition

• Clinical: Seizure lasting >30 minutes OR two or more seizures without regaining consciousness between them
• Operational (for treatment): Seizure lasting >5 minutes (because seizures >5 min rarely stop spontaneously - this is when you treat)
• Refractory Status Epilepticus: Seizures continuing despite 2 appropriate first-line agents

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Investigations

1. Blood glucose (Dextrostix) - hypoglycemia is common and treatable cause
2. SpO2, ECG monitoring
3. Electrolytes: Na, K, Ca, Mg (hyponatremia, hypocalcemia can cause seizures)

• CBC (infection, leukemia)
• Blood culture (meningitis/encephalitis)
• LFT, RFT (metabolic causes)
• Blood gas (acidosis from prolonged seizure)
• Serum anticonvulsant levels (if on medication)
• Urine/serum toxicology screen
• Serum ammonia (urea cycle disorder)

• CT head (non-contrast first) - after stabilization: hemorrhage, mass, SOL
• MRI brain - definitive (structural causes, ADEM, herpes encephalitis)
• CSF analysis: LP after raised ICP ruled out - meningitis, encephalitis (herpes PCR, culture, cell count)
• EEG - after stabilization; non-convulsive status epilepticus, diagnosis

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Detailed Management Protocol

• ABC: Airway (position, suction), Breathing (O2 by mask, bag-mask if needed), Circulation (IV access x2)
• Place in recovery position (lateral decubitus)
• Cardiac/SpO2 monitoring
• Check blood glucose - if <60 mg/dL: 2 mL/kg 25% Dextrose IV, then 10% dextrose infusion

• Lorazepam 0.1 mg/kg IV (max 4 mg) - preferred; acts in 2-3 min, lasts 12-24 hours
• If no IV access: Midazolam 0.2 mg/kg IM/buccal/intranasal OR Diazepam 0.5 mg/kg rectal (max 10 mg)
• Can repeat benzodiazepine once after 5 min if seizure persists

• Phenytoin/Fosphenytoin: 20 mg/kg IV over 20 min (max 1 g); monitor ECG (bradycardia, hypotension)
• OR Phenobarbitone: 20 mg/kg IV over 20 min (if <2 years or no phenytoin)
• OR Sodium valproate: 30-40 mg/kg IV over 5 min (avoid in liver disease, metabolic disorder)
• OR Levetiracetam: 60 mg/kg IV (increasingly preferred, fewer side effects)

• Intubation + ICU admission
• Midazolam infusion: 0.05-0.4 mg/kg/hr IV (titrate to EEG burst suppression)
• OR Thiopental/Pentobarbital infusion (anesthetic dose)
• OR Propofol (not <16 years - propofol infusion syndrome risk)
• OR Ketamine infusion

• Treat fever (paracetamol IV/rectal)
• Treat hypocalcemia if found (10% calcium gluconate 1 mL/kg IV slowly)
• Treat hyponatremia if found (3% NaCl 2-3 mL/kg over 10-20 min)
• If meningitis/encephalitis suspected: Ceftriaxone + Acyclovir empirically
• Thiamine before glucose if malnutrition suspected

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Q7. Nephrotic Syndrome

Definition

1. Massive proteinuria >40 mg/m²/hr (or >3.5 g/day in adults; >1 g/m²/day in children) - First-line criterion
2. Hypoalbuminemia <2.5 g/dL (serum albumin)
3. Generalized edema (anasarca - periorbital, pedal, ascites, pleural effusion)
4. Hyperlipidemia (hypercholesterolemia >200 mg/dL) with lipiduria (Maltese cross - oval fat bodies on urine microscopy)

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Clinical Features

• First noticed as periorbital puffiness (morning, periorbital swelling - often mistaken for allergy)
• Progresses to dependent edema, ascites, scrotal/labial edema, pleural effusion, pericardial effusion
• Pitting in nature

• Frothy urine (proteinuria)
• Pallor (dilutional anemia, protein loss)
• Malnutrition (protein loss)
• Diarrhea (bowel wall edema)
• Respiratory distress (pleural effusion/ascites)
• Blood pressure: normal in MCD; elevated in secondary nephrotic syndrome

• Infections: Spontaneous bacterial peritonitis (Pneumococcus, E. coli - most common and dangerous), cellulitis, urinary tract infection
• Thrombosis: DVT, pulmonary embolism (loss of antithrombin III, protein C/S in urine)
• Hypocalcemia: Loss of Vitamin D-binding protein
• Hypovolemia: Despite edema (watch for shock if treated with diuretics without albumin)
• Steroid toxicity (in treatment)

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Investigations

• Urine protein: 3+ or 4+ on dipstick; spot urine protein:creatinine ratio >2 mg/mg (or >200 mg/mmol)
• 24-hour urine protein: >40 mg/m²/hr
• Urine microscopy: lipid droplets (Maltese cross fat bodies), hyaline/granular casts
• No significant RBC casts (unlike nephritis)

• Serum albumin: low (<2.5 g/dL)
• Serum cholesterol: high (>200 mg/dL); LDL elevated; triglycerides elevated
• Serum creatinine, BUN: usually normal in MCD
• CBC: hemoconcentration possible
• Serum electrolytes (hyponatremia common - dilutional)
• Serum C3, C4 (low in membranoproliferative GN, lupus nephritis)
• ANA, anti-dsDNA (lupus)
• HBsAg, anti-HCV (secondary causes)
• Serum IgG (low - explains susceptibility to infection)
• Serum T3, T4 (thyroid binding globulin lost)

• Age <1 year or >16 years
• Steroid resistant (no response after 8 weeks of full dose steroids)
• Steroid-dependent or frequent relapsing
• Hematuria, hypertension, reduced GFR, low C3 (atypical features)
• Family history of nephropathy

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Management

• Normal diet: Normal sodium, normal protein (1.5-2 g/kg/day), restrict fluids only if severe edema
• No added salt during active disease
• Penicillin prophylaxis (250 mg BD oral amoxicillin) while edematous
• Pneumococcal vaccine (before steroids if possible)

• Prednisolone: 2 mg/kg/day (max 60 mg/day) for 4 weeks (single daily dose or alternate day)
• Then 1.5 mg/kg/alternate day for 4 weeks
• Then taper over next 2-3 months
• Total initial therapy: 12 weeks

• Furosemide 1-2 mg/kg/day with spironolactone 2-3 mg/kg/day
• IV albumin (1 g/kg over 4 hours) + furosemide if severe edema with hypovolemia

• Calcineurin inhibitors: Cyclosporine A or Tacrolimus
• Mycophenolate mofetil (MMF)
• Rituximab (anti-CD20 B-cell depletion)
• Renal biopsy mandatory before initiating

• Cyclophosphamide (cumulative dose 168 mg/kg over 8-12 weeks)
• Levamisole (adjuvant immunomodulator)
• MMF, Rituximab

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SECTION C - Short Answer Questions

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Q8. IMNCI Classification of Pneumonia

• Stridor at rest = severe disease (refer)
• Wheeze = if first episode, treat as pneumonia; if recurrent, may be asthma

• Unable to drink/breastfeed
• Vomits everything
• Convulsions
• Lethargic or unconscious

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Q9. Revised Jones Criteria for Rheumatic Fever (2015 AHA Revision)

• 2 Major criteria OR 1 Major + 2 Minor criteria

Evidence of GAS Infection (MANDATORY):

• Elevated/rising ASO titer (most common) or other streptococcal antibodies (Anti-DNase B)
• Positive throat culture for GAS
• Positive rapid GAS antigen test
• Recent history of scarlet fever

Major Criteria (JONES - Mnemonic):

Minor Criteria:

• Fever (>38.5°C)
• Arthralgia (only if arthritis NOT counted as major criterion)

• Elevated ESR (>60 mm/hr) or CRP (>3 mg/dL)
• Prolonged PR interval on ECG (only if carditis NOT counted as major criterion)

2015 AHA Revision Notes:

• Low-risk populations: Requires 2 major OR 1 major + 2 minor (traditional)
• Moderate/high-risk populations (where ARF is endemic): Monoarthritis or polyarthralgia may count as a major criterion; echocardiographic evidence of subclinical carditis counts as a major criterion

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Q10. Formula for Normal Weight and Height in a 3-Year-Old Child

Weight Formulas:

• Birth weight: ~3 kg
• Doubles by 5 months (~6 kg)
• Triples by 1 year (~9 kg)
• Quadruples by 2 years (~12 kg)

Height (Length) Formulas:

• Birth: 50 cm
• 1 year: 75 cm
• 2 years: 87 cm (or 1 year height + 12 cm)
• 4 years: doubles birth length (~100 cm)

Head Circumference (bonus):

• Birth: 34 cm
• 3 months: 40 cm
• 6 months: 43 cm
• 1 year: 46-47 cm
• 2 years: 48 cm
• Adult: 55-57 cm

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Q11. Apgar Score - Components and Scoring

Interpretation:

• 1-minute Apgar: reflects intrapartum events
• 5-minute Apgar: reflects response to resuscitation and predicts neonatal outcome
• Apgar is NOT used to decide whether to resuscitate - resuscitation starts if baby doesn't breathe/cry at birth regardless of Apgar
• Low Apgar at 10-20 min correlates with risk of hypoxic-ischemic encephalopathy (HIE)
• Reliable even in preterm infants (though expected to be lower)

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Q12. Diagnostic Criteria of Kawasaki Disease

Incomplete/Atypical Kawasaki Disease:

• Fever ≥5 days + only 2-3 principal features
• Requires echocardiography (coronary artery aneurysm on echo = incomplete KD confirmed)
• More common in infants <1 year and older children/adults

Supportive Lab Findings (not diagnostic but support diagnosis):

• Elevated: CRP >3 mg/dL, ESR >40 mm/hr, WBC >15,000, Platelets (thrombocytosis in 2nd week >450,000 - characteristic), Neutrophilia, ALT/AST, Ferritin
• Low: Albumin <3 g/dL, Sodium <130 mEq/L, Hematocrit <30%
• Urine: sterile pyuria (urethritis)
• ECG: PR prolongation, QT changes
• Echo: coronary artery aneurysms (most serious complication, affects 25% if untreated)

Treatment (for completeness):

1. IVIG: 2 g/kg single infusion over 10-12 hours - reduces coronary aneurysm risk from 25% to <5%
2. Aspirin: 80-100 mg/kg/day (anti-inflammatory) during fever, then 3-5 mg/kg/day (antiplatelet) for 6-8 weeks (or longer if coronary aneurysms)
3. IVIG resistance: repeat IVIG or Infliximab or Corticosteroids

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Sources: Nelson Textbook of Pediatrics (21st Ed.), Ghai Essential Pediatrics (9th Ed.), IAP Textbook of Pediatrics (7th Ed.), WHO IMNCI guidelines, 2015 AHA Jones Criteria revision, WHO 10-step management protocol for SAM.