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Sri Aurobindo Institute - 2nd Sessional Pediatrics Exam (July 2026)

Full Model Answers

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Q1. A 1.5-year-old child with high grade fever x3 days, generalized tonic-clonic seizure, altered sensorium x1 day; febrile, drowsy, bulging anterior fontanelle, brisk DTRs, positive Kernig sign.

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(a) Likely Diagnosis (2 marks)

• Fever + altered sensorium (encephalopathy)
• Seizures
• Meningeal signs: bulging fontanelle + positive Kernig sign

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(b) Age-wise Etiological Agents (6 marks)

• S. pneumoniae: Gram-positive lancet-shaped diplococcus; associated with otitis media, sinusitis as predisposing factors
• N. meningitidis: Gram-negative diplococci; associated with petechial/purpuric rash
• H. influenzae type b: Gram-negative coccobacillus; now rare due to Hib vaccination

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(c) Detailed Management (6 marks)

1. Immediate Stabilization (ABC)

• Secure airway, give O2, IV access
• Monitor vitals, SpO2, GCS continuously

2. Investigations

• Lumbar Puncture (LP) - cornerstone of diagnosis (do after ruling out raised ICP/mass lesion)
  • CSF in bacterial meningitis: turbid/purulent, pressure >180 mm H2O, WBC 1000-10,000 (predominantly neutrophils >80%), glucose <45 mg/dL (CSF:serum ratio <0.4), protein elevated (100-500 mg/dL), Gram stain positive in 60-90%
• Blood culture (before antibiotics if possible)
• CBC, CRP, serum electrolytes, blood glucose
• CT head before LP if: papilledema, focal neurological deficit, new-onset seizure, immunocompromised, altered consciousness

3. Antibiotics (Empiric)

• Vancomycin (60 mg/kg/day in 4 divided doses) PLUS
• Ceftriaxone (100 mg/kg/day IV, max 4g/day) or Cefotaxime (200 mg/kg/day in 3-4 doses)
• Add Ampicillin if Listeria is suspected

4. Adjunctive Dexamethasone

• Dexamethasone 0.15 mg/kg IV every 6 hours for 2-4 days
• Give 10-20 minutes BEFORE (or concomitantly with) first antibiotic dose
• Reduces meningeal inflammation, decreases risk of hearing loss (especially for H. influenzae meningitis)
• Do NOT give if antibiotics already started

5. Supportive Care

• Raised ICP management: Head elevation 30°, restrict fluids to 2/3 maintenance initially, mannitol (0.25-1 g/kg IV) if cerebral herniation imminent
• Seizure control: IV lorazepam (0.1 mg/kg) or diazepam; phenobarbitone for maintenance
• Fever: Paracetamol
• Fluid management: Correct dehydration carefully; avoid SIADH (monitor urine output, serum sodium)
• Nutrition: NG feeds if GCS low

6. Chemoprophylaxis for Contacts

• Rifampicin for household contacts of N. meningitidis or H. influenzae meningitis

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(d) Complications of Bacterial Meningitis (6 marks)

Acute/Early Complications:

Late/Long-term Complications:

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Q2. 3-day-old exclusively breastfed baby, yellow discolouration extending to legs; birth weight 2.9 kg; Mother O-negative, Baby O-positive

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(a) Cause of Jaundice in this Baby (2 marks)

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(b) Differences between Physiological and Pathological Jaundice (5 marks)

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(c) 5 Causes of Pathological Jaundice (5 marks)

1. Hemolytic causes:
   • ABO incompatibility (most common in day 1-3 jaundice)
   • Rh incompatibility (erythroblastosis fetalis)
   • G6PD deficiency
   • Hereditary spherocytosis
2. Infection/Sepsis: Neonatal sepsis causes both unconjugated and conjugated hyperbilirubinemia
3. Metabolic causes:
   • Hypothyroidism (prolonged jaundice)
   • Galactosemia
4. Cholestatic/conjugated causes:
   • Biliary atresia (pale stools, dark urine, conjugated bilirubin)
   • Neonatal hepatitis (TORCH infections)
5. Other:
   • Polycythemia (excess RBC breakdown)
   • Cephalohematoma / bruising (resorption of blood)
   • Breast milk jaundice (prolonged, unconjugated, otherwise well baby)
   • Prematurity

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(d) Treatment of Hyperbilirubinemia (6 marks)

1. Phototherapy

• First-line treatment for unconjugated hyperbilirubinemia
• Blue-green light (wavelength 460-490 nm) converts unconjugated bilirubin in skin to water-soluble photoisomers (lumirubin) excreted without conjugation
• Indications based on AAP nomogram (bilirubin level + age in hours + risk factors)
• Cover eyes during phototherapy; continue breastfeeding; monitor temperature
• Intensive phototherapy: multiple banks of lights, bili blanket

2. Exchange Transfusion (Double Volume)

• For severe hyperbilirubinemia not responding to phototherapy, or signs of acute bilirubin encephalopathy
• Double-volume exchange (160-200 mL/kg) removes sensitized RBCs, bilirubin, and maternal antibodies
• Replaces with O-negative packed RBCs + FFP (or whole blood)
• Complications: metabolic (hypocalcemia, hypoglycemia), infection, thromboembolism, electrolyte disturbances

3. IV Immunoglobulin (IVIG)

• For hemolytic jaundice (ABO/Rh incompatibility)
• IVIG 0.5-1 g/kg IV over 2 hours - blocks Fc receptors on macrophages, reduces hemolysis
• Reduces need for exchange transfusion

4. Pharmacological

• Phenobarbitone: Induces hepatic glucuronosyltransferase (rarely used now)
• Tin-mesoporphyrin: Inhibits heme oxygenase (investigational)

5. Treat underlying cause

• Antibiotics for sepsis
• Thyroid hormone for hypothyroidism

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(e) 2 Complications of Hyperbilirubinemia (2 marks)

1. Acute Bilirubin Encephalopathy (ABE) / Kernicterus:
   • Unconjugated bilirubin crosses blood-brain barrier (>20-25 mg/dL) and deposits in basal ganglia (globus pallidus), hippocampus, cerebellum
   • Acute: poor feeding, lethargy, high-pitched cry, opisthotonus, seizures
   • Chronic (kernicterus): choreoathetoid cerebral palsy, sensorineural hearing loss, dental enamel dysplasia, upward gaze palsy (permanent)
2. Kernicterus (chronic bilirubin encephalopathy):
   • Permanent brain damage manifesting as athetoid/dyskinetic cerebral palsy, cognitive impairment, sensorineural deafness, and dental dysplasia

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Q3. Immunization

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(a) National Immunization Schedule (NIS) - Birth to 5 Years (10 marks)

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(b) Adverse Events Following Immunization (AEFI) (5 marks)

Classification of AEFI:

• Due to inherent properties of the vaccine
• Examples: Local BCG ulcer/lymphadenitis; febrile seizures with DPT; measles vaccine-related rash/fever; OPV-related VAPP (Vaccine-Associated Paralytic Poliomyelitis)

• Due to manufacturing defect (e.g., improper attenuation)

• Most common and preventable
• Wrong vaccine, wrong dose, wrong route, wrong site, reconstitution errors, use of non-sterile equipment
• Example: BCG given SC instead of ID → large abscess; wrong diluent used → severe reaction

• Vasovagal syncope, hyperventilation in older children and adolescents

• Unrelated to vaccine; temporal association only (e.g., fever due to concurrent illness)

Common Specific AEFIs:

• DPT: Fever, local pain/swelling, febrile seizures (1:1750), hypotonic-hyporesponsive episode (HHE - rare), anaphylaxis (1:50,000)
• BCG: Local ulcer, regional (axillary) lymphadenopathy, BCG osteitis, disseminated BCG (in immunocompromised)
• Measles vaccine: Fever day 5-12, rash, febrile convulsions
• OPV: VAPP (1:1.4 million first doses)
• MMR: Parotitis, mild thrombocytopenia
• Hepatitis B: Anaphylaxis (rare)

Serious AEFIs requiring immediate action:

• Anaphylaxis (within 30 min): epinephrine 0.01 mg/kg IM thigh
• All AEFIs must be reported on the AEFI reporting form to the District Immunization Officer

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(c) 2 Differences between Live Vaccine and Killed Vaccine, with 2 Examples each (5 marks)

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