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AIIMS BHUBANESWAR PEDIATRICS PYQ - COMPLETE ANSWERS

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TOPIC 01 - NORMAL GROWTH

Q1. Laws / Principles of Growth (REPEATED 2x - 10 marks)

1. Growth is continuous but not uniform - spurts at infancy and puberty
2. Different tissues grow at different rates - Scammon's 4 tissue curves:
   • General type (body, organs): S-shaped with 2 spurts
   • Neural type (brain, head): rapid early, 90% by age 6
   • Lymphoid type (thymus, tonsils): peaks at puberty (~200% adult), then involutes
   • Genital type (gonads, uterus): dormant till puberty, then rapid
3. Growth is directional:
   • Cephalocaudal (head → foot)
   • Proximodistal (trunk → limbs)
   • General to specific
4. Rate of growth decreases with age - fastest in fetal life and infancy
5. Growth is influenced by genetic potential (canalization) - returns to genetic track after illness
6. Critical/sensitive periods - insult at these times causes permanent deficit (brain: 0-2 yrs)
7. Growth is measurable - anthropometric indices used

• Genetic: height potential, sex (males taller after puberty)
• Hormonal: GH (most important post-natally), thyroid hormone, sex steroids, insulin
• Nutritional: most important modifiable factor
• Socioeconomic, psychological, infection, prematurity

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Q2. Growth Monitoring Methods

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TOPIC 02 - NORMAL DEVELOPMENT

Q3. Developmental Milestones at 15 months

Q4. Milestones at 2 years

Q5. Milestones at 3 years

Q6. Principles of Development

1. Development is continuous but not uniform (spurts)
2. Sequence is fixed but rate varies
3. Cephalocaudal and proximodistal direction
4. General to specific (mass to differentiated)
5. Interrelated domains (motor, language, social)
6. Reflects CNS maturation
7. Critical periods exist (language: 0-5 yrs)
8. Both maturation and learning are necessary

Q7. Drawing Skills and Developmental Quotient

• 12 months: Scribbles spontaneously
• 15 months: Imitates scribble
• 18 months: Scribbles after demonstration
• 2 years: Copies vertical line; circular scribble
• 3 years: Copies circle; draws person with head + 1 part
• 3.5 years: Copies cross (+)
• 4 years: Copies square; person with 3 parts
• 4.5 years: Copies oblique cross (X)
• 5 years: Copies triangle; person with 6 parts
• 6 years: Copies diamond

• DQ 70-90: Slow learner
• DQ <70: Intellectual disability
• DQ >130: Superior

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TOPIC 03 - IMMUNIZATION

Q8. National Immunization Schedule (India - UIP 2024)

Q9. Measles/MR Vaccine (REPEATED 3x)

• Type: Live attenuated
• Dose: 0.5 mL SC, reconstituted with diluent
• Schedule: MR-1 at 9-12 months; MR-2 at 16-24 months
• Site: Right upper arm (anterolateral thigh in infants)
• Storage: 2-8°C or -20°C; protect from light
• Adverse events:
  • Fever (day 5-12), rash (mild)
  • ADEM (rare, 1 in 1 million)
  • Febrile seizures
  • ITP (rare)
  • Anaphylaxis (very rare)
• Contraindications: Immunodeficiency, pregnancy, recent Ig/blood products, allergy to neomycin

Q10. Japanese Encephalitis (JE) Vaccine (REPEATED 3x)

• Type: SA 14-14-2 (live attenuated) - used in India (JENVAC)
• Schedule: 2 doses - 9 months and 16-24 months (in endemic areas)
• Dose: 0.5 mL SC
• Coverage: All 297+ endemic districts in India
• Endemic states: UP, Bihar, West Bengal, Assam, Tamil Nadu, Karnataka, Goa, Kerala
• Adverse events: Mild fever, local reactions; encephalitis (extremely rare)

Q11. Cold Chain Management (REPEATED 3x)

• ILR: stores vaccines at 2-8°C
• Deep Freezer: stores OPV and for making ice packs
• Cold box: transport 12-24 hrs
• Vaccine carrier: transport for outreach (4-8 hrs with 4 ice packs)
• Hub cutter/needle destroyer

• 2-8°C: BCG, DPT, DT, Td, Hep-B, Hib, MR, PCV, Rota, IPV, JE
• -15 to -25°C: OPV
• Note: MR/BCG once reconstituted - discard after 4 hours or end of session

• Heat-sensitive square inside circle on vaccine vial
• If square is lighter than circle = USABLE
• If square same color or darker = DISCARD
• Enables open vial policy; reduces wastage

Q12. OPV vs IPV

Q13. Catch-up Immunization (1-year-old unimmunized)

Q14. Rotavirus Vaccine

• Type: Rotarix (G1P8, live attenuated, monovalent) - used in India UIP
• Doses: 3 doses at 6, 10, 14 weeks (with pentavalent)
• Route: Oral, 1.5 mL
• Maximum age for 1st dose: 15 weeks; for last dose: 32 weeks
• Efficacy: ~55% against all rotavirus diarrhea; ~70% against severe disease
• Adverse events: Mild gastroenteritis, fever; intussusception risk VERY low (not proven)

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TOPIC 04 - NEWBORNS

Q15. Kangaroo Mother Care (REPEATED 6x - highest frequency question)

1. Skin-to-skin contact - baby placed prone on mother's chest between breasts (kangaroo position), 24 hrs/day
2. Exclusive breastfeeding - expressed breast milk via NG/cup if unable to suck
3. Discharge support - early discharge with close follow-up

• Weight 1000-2000g and clinically stable
• Breathing spontaneously (may be on CPAP)
• Mother willing and trained

• Thermal regulation (reduces hypothermia)
• Promotes breastfeeding and milk production
• Reduces nosocomial infections
• Reduces apnea and bradycardia
• Better neurodevelopmental outcomes
• Reduced length of hospital stay
• Bonding and reduced maternal anxiety
• Reduces neonatal mortality by 36-51% (WHO meta-analysis)
• Cost-effective (WHO 2023 guidelines recommend immediate KMC even in unstable neonates)

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Q16. Neonatal Hypothermia

• Normal: 36.5-37.5°C (axillary)
• Cold stress: 36.0-36.4°C
• Moderate hypothermia: 32.0-35.9°C
• Severe hypothermia: <32°C

1. Large surface area to body weight ratio (more heat loss)
2. Thin subcutaneous fat, no insulation
3. Inability to shiver (shivering mechanism immature)
4. Brown fat non-shivering thermogenesis (limited reserve, especially in preterm)
5. Wet at birth + cold environment = evaporative losses
6. Thin skin with poor keratinization
7. Limited glycogen stores (fuel for thermogenesis)
8. Cannot dress/undress or seek warmth behaviorally

1. Evaporation - wet baby (most important at birth)
2. Radiation - to cold surrounding walls/surfaces
3. Conduction - direct contact with cold surface
4. Convection - to cool air currents

1. Warm delivery room (>25°C)
2. Warm resuscitation table
3. Immediate drying (remove wet cloth within 30 sec)
4. Skin-to-skin contact / KMC
5. Breastfeeding
6. Postpone bathing (>6 hrs after birth; ideally 24 hrs)
7. Appropriate clothing (hat, socks, mittens, multiple layers)
8. Mother and baby together (rooming-in)
9. Warm transportation
10. Training caregivers

• Mild (36-36.5°C): Skin-to-skin, warm room, extra clothing
• Moderate (32-36°C): Warm incubator/radiant warmer; IV dextrose; monitor vitals
• Severe (<32°C): Radiant warmer; warm IV fluids; rule out sepsis; oxygen; glucose monitoring

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Q17. Neonatal Sepsis

• Early Onset Sepsis (EOS): within 72 hours; maternal source; Group B Strep, E. coli, Listeria
• Late Onset Sepsis (LOS): >72 hours; nosocomial or community; Staph aureus, Klebsiella, Pseudomonas, CoNS

• Not feeding well / poor suck
• Lethargy, hypotonia
• Temperature instability (fever or hypothermia)
• Respiratory distress, apnea
• Jaundice (prolonged or early)
• Abdominal distension, vomiting
• Seizures, bulging fontanelle
• Sclerema, petechiae, bleeding

• CBC, CRP, blood culture (before antibiotics), CSF culture (if meningitis suspected), urine culture
• Blood glucose, serum electrolytes, bilirubin

1. Supportive: IV fluids, thermoregulation, O2/CPAP if needed, glucose correction
2. Antibiotics:
   • EOS empirical: Ampicillin + Gentamicin
   • LOS empirical: Cloxacillin + Gentamicin (or Piperacillin-Tazobactam for nosocomial)
   • Adjust as per culture sensitivity
   • Duration: Uncomplicated 7-10 days; meningitis 14-21 days

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Q18. Neonatal Jaundice

• Appears day 2-3, peaks day 3-5, resolves by day 10-14
• Serum bilirubin <12 mg/dL (term), <15 mg/dL (preterm)
• Indirect bilirubin predominant
• Rate of rise <5 mg/dL/day

• Appears <24 hrs: Hemolytic (Rh, ABO incompatibility, G6PD)
• Day 2-3: Physiological, bruising, polycythemia, sepsis
• >Day 3: Sepsis, hemolysis, metabolic
• Prolonged (>14 days term/>21 days preterm): Breast milk jaundice, hypothyroidism, biliary atresia, neonatal hepatitis

• Mother Rh-negative, baby Rh-positive
• Jaundice within 24 hours, rapid rise
• Hemolytic anemia, hepatosplenomegaly, hydrops fetalis
• DCT (Coombs) positive
• Management: Phototherapy, IV IgG, exchange transfusion if needed
• Prevention: Anti-D Ig to mother at 28 weeks and within 72 hrs of delivery

• Mechanism: Photo-isomerization (lumirubin) and photo-oxidation
• Converts unconjugated bilirubin to water-soluble isomers excreted in bile and urine
• Indications: As per NNF/AAP threshold charts based on age (hours), gestation, and risk factors
• Complications: Bronze baby syndrome, loose stools, rash, hyperthermia, dehydration, retinal damage (eye cover mandatory)

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Q19. Neonatal Hypoglycemia (REPEATED 3x)

• Increased glucose utilization: Hyperinsulinism (IDM, Beckwith-Wiedemann, nesidioblastosis), asphyxia, sepsis
• Decreased glucose production: Prematurity/LBW (poor glycogen stores), SGA, glycogen storage disorders, inborn errors
• Hormonal: Hypothyroidism, panhypopituitarism, GH deficiency

• Jitteriness, tremors, seizures
• Apnea, cyanosis
• Poor feeding, lethargy, hypotonia
• High-pitched cry
• Hypothermia

• Asymptomatic, glucose 25-45 mg/dL: Feed (EBM/formula); recheck glucose 30 min later
• Symptomatic or glucose <25 mg/dL: IV Dextrose 10% @ 2 mL/kg bolus (200 mg/kg) over 5 min → maintenance GIR 6-8 mg/kg/min
• Persistent: Increase GIR; hydrocortisone 5 mg/kg/day if >12 mg/kg/min; investigate for hyperinsulinism
• Maintain glucose >45 mg/dL; target 50-100 mg/dL
• Monitor 30 min post-bolus, hourly × 4 hrs, then every 3-6 hrs

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Q20. APGAR Score

• Assessed at 1 minute and 5 minutes
• Score 7-10: Normal; 4-6: Moderate depression; 0-3: Severe depression (needs resuscitation)
• 1-min score: predicts need for resuscitation
• 5-min score: prognostic for neonatal outcome
• NOT used to decide resuscitation - resuscitation begins in the first 60 seconds based on: breathing/crying? Good tone? Born at term?

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Q21. Warm Chain (REPEATED 3x) - See Q16 above (10 steps)

Q22. Janani Shishu Suraksha Karyakram (JSSK) (REPEATED 2x)

• Free delivery (normal and caesarean)
• Free drugs and consumables
• Free diagnostics
• Free diet during stay (3 days for normal, 7 days for C-section)
• Free blood transfusion
• Free transport to facility and back home
• Exemption from all user charges

• Free treatment (including NICU care)
• Free drugs, consumables, diagnostics
• Free diet to mother
• Free blood
• Free transport
• Exemption from user charges

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TOPIC 05 & 06 - INFANT FEEDING & BREASTFEEDING

Q23. Complementary Feeding Guidelines (REPEATED 4x)

• A - Age: Start at 6 months
• B - Breastfeeding: Continue along with CF up to 2 years
• C - Content: Nutrient-dense, soft, family foods; energy density >1 kcal/mL
• D - Density: Start thin, gradually increase thickness; avoid watery foods
• E - Energy: Increase amount progressively

• Cereals, pulses (khichdi, dal-rice, porridge)
• Mashed fruits and vegetables
• Egg, fish, chicken, meat (animal source protein)
• Dairy (after 1 year as drink; can use in food from 6 months)
• Avoid: honey (before 1 year), whole nuts, salt-added foods, sugar-sweetened beverages, cow's milk as main drink before 1 year

Q24. Breast Milk Composition vs Cow Milk

• Species-specific immunoglobulins (sIgA, IgM, IgG)
• LCPUFA (DHA, ARA) for brain/retinal development
• Lactoferrin, lysozyme, bifidus factor (promotes Lactobacillus)
• Leptin, adiponectin, insulin, EGF (growth factors)
• No allergens; low renal solute load
• Always right temperature, sterile, free

Q25. Signs of Correct Breastfeeding Positioning and Attachment

• Chest to chest (baby's chest touches mother's)
• Head free to tilt back slightly
• In line (baby's ear, shoulder, hip in straight line)
• Nose to nipple initially
• Supported back of baby

1. Wide open mouth (100-140° gape)
2. Lower lip everted (flanged outward)
3. Chin touching breast
4. More areola visible above baby's top lip than below
5. Cheeks rounded (not sunken)
6. Jaw movement visible (deep rhythmic jaw movements)
7. Baby calm and relaxed
8. Mother feels no pain

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TOPIC 07 - SHORT STATURE

Q26. Evaluation of Short Stature / Mid-Parental Height (REPEATED 3x)

• Boys: (Father's height + Mother's height + 13 cm) / 2
• Girls: (Father's height + Mother's height - 13 cm) / 2
• Target height range: MPH ± 8.5 cm

• Height, weight, BMI, arm span, upper:lower segment ratio
• Sitting height
• Body proportions (disproportionate vs proportionate)
• Pubertal staging
• Dysmorphic features, goiter, signs of chronic disease

• Tier 1: X-ray wrist (bone age), CBC, ESR, TFT, urine routine, blood sugar, stool exam
• Tier 2: IGF-1, IGFBP-3, karyotype (girls), celiac serology, renal function
• Tier 3: GH stimulation test, pituitary MRI

Q27. Sexual Maturity Rating (SMR) - Tanner Staging (REPEATED 4x)

• First sign of puberty in boys: testicular enlargement (>4 mL) - SMR 2 (average age 11.5 yrs)
• Growth spurt in boys: SMR 3-4 (Tanner 3)
• Voice change, facial hair: SMR 4

• First sign of puberty in girls: breast bud (thelarche) - SMR 2 (average age 10.5-11 yrs)
• Menarche: SMR 4 (usually 2-3 years after thelarche)

• Timing of vaccinations (HPV at SMR 2-3)
• Assessment of pubertal disorders (precocious/delayed puberty)
• Adolescent growth counseling
• Sports eligibility
• Predicting adult height

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TOPIC 09 - VITAMIN DEFICIENCY

Q28. Vitamin D Deficiency Rickets (REPEATED 3x)

• Skeletal: Craniotabes (earliest), frontal bossing, rachitic rosary, Harrison's groove, pigeon chest, bowlegs (genu varum) or knock knees (genu valgum), wrist widening (double malleoli sign), delayed closure of fontanelles
• Dental: Delayed dentition, enamel hypoplasia
• Muscular: Hypotonia, pot belly, delayed walking
• Signs of hypocalcemia: Tetany, seizures, laryngospasm, Trousseau's sign, Chvostek's sign

• Cupping, fraying, splaying of metaphysis (most characteristic)
• Widening of growth plate
• "Looser zones" (pseudofractures) in advanced disease
• Osteopenia, decreased bone density

• Serum Ca (low/normal), P (low), ALP (markedly elevated)
• Serum 25-OH Vitamin D (gold standard) - <20 ng/mL = deficient
• PTH (elevated)
• Urine Ca (low), phosphate (high)
• X-ray wrist

• Vitamin D 60,000 IU/week for 6-12 weeks (Stoss for poor compliance)
• OR 2000-4000 IU/day for 3 months
• Calcium supplementation: 500-1000 mg/day elemental calcium
• After healing: maintenance 400-600 IU/day

• Single large dose regimen: 3,00,000-6,00,000 IU of Vitamin D orally or IM (Vit D3)
• Used when compliance is poor
• Advantage: Single dose; avoid daily compliance issues
• Disadvantage: Risk of toxicity (hypercalcemia), must give calcium supplements concomitantly
• Contraindication: Granulomatous diseases, primary hyperparathyroidism

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Q29. Vitamin A Deficiency / Xerophthalmia (WHO Classification)

1. Vit A as per VASP: 200,000 IU immediately (oral or IM)
2. Repeat at 24 hrs; repeat at 2-4 weeks
3. For infants <1 yr: 100,000 IU
4. Topical: antibiotic eye drops/ointment; artificial tears; eye pad
5. Nutritional rehabilitation
6. Treat measles/malnutrition/diarrhea (often concurrent)

• 1st dose: 100,000 IU at 9 months (with MR)
• 2nd dose: 200,000 IU at 16-18 months
• Subsequent doses: 200,000 IU every 6 months until 5 years

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Q30. Hypocalcemia - Clinical Features and Management (REPEATED 3x)

• Neuromuscular: Tetany (carpopedal spasm - Trousseau's sign, Chvostek's sign), muscle cramps, numbness/tingling
• Laryngospasm (stridor, crow-like sound, life-threatening)
• Seizures (focal or generalized)
• Cardiac: Prolonged QTc, reduced contractility
• Rickets signs (if nutritional cause)

• Acute symptomatic (tetany/seizures/laryngospasm):
  • IV Calcium gluconate 10% @ 1-2 mL/kg (max 10 mL) slow IV over 5-10 minutes with cardiac monitoring
  • Followed by IV calcium infusion 2-4 mg/kg/hr of elemental Ca
• Maintenance:
  • Oral calcium: 50-75 mg/kg/day elemental Ca in 4 divided doses
  • Vitamin D: Calcitriol 0.025-0.05 mcg/kg/day (if hypoparathyroidism)
  • Or Cholecalciferol for nutritional deficiency

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Q31. Hyperkalemia - Causes and Management (REPEATED 3x)

• Renal: AKI, CKD, adrenal insufficiency (aldosterone deficiency), RTA type IV
• Transcellular shift: Acidosis, rhabdomyolysis, tumor lysis syndrome, hemolysis, succinylcholine, digoxin toxicity
• Increased intake: Excessive IV potassium, potassium-containing medications
• Pseudohyperkalemia: Hemolysis during blood collection

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TOPIC 11 - PEM / SAM

Q32. SAM Definition, Kwashiorkor vs Marasmus, Management (REPEATED multiple times)

• WHZ < -3 SD, OR
• MUAC < 11.5 cm (6-59 months), OR
• Presence of bilateral pitting edema of nutritional origin

• F-75: 75 kcal/100 mL; 0.9g protein/100mL; used in stabilization phase (1st week) - 100-130 mL/kg/day
• F-100: 100 kcal/100 mL; 2.9g protein/100mL; used in rehabilitation phase - 150-220 mL/kg/day

• Energy-dense (500 kcal/92g sachet); 12-15% protein
• Based on peanut paste, milk powder, sugar, vegetable oil, vitamins, minerals
• Equivalent to F-100 but ready to eat, no preparation needed
• Can be given at home (CMAM - Community-based Management)
• Long shelf life; microbiologically safe (no water)
• WHO recommends RUTF for SAM without complications (for outpatient treatment)
• Dose: 200 kcal/kg/day (15-20 g/kg/day peanut paste)

• Refeeding syndrome (hypokalemia, hypophosphatemia, hypomagnesemia)
• Vitamin A deficiency-related complications
• Cardiac failure (from rapid feeding)
• Iron deficiency anemia (post-stabilization)
• Worm infestation exacerbation

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TOPIC 12 - DIPHTHERIA AND PERTUSSIS

Q33. Stridor in 2-year-old - Causes and Management of Croup (REPEATED 2x)

• Croup (Laryngotracheobronchitis) - MC cause
• Epiglottitis (Hib, child typically 2-6 years, toxic, tripod position)
• Foreign body aspiration
• Bacterial tracheitis
• Retropharyngeal abscess
• Diphtheria (membranous laryngitis)
• Anaphylaxis/angioedema

• Laryngomalacia, subglottic stenosis, vascular ring, laryngeal web

1. Dexamethasone 0.15-0.6 mg/kg IM/oral single dose (most important - reduces severity, duration; works in 6 hrs; lasts 12-24 hrs)
2. Nebulized Epinephrine (adrenaline 1:1000 - 0.5 mL/kg, max 5 mL) - for moderate-severe; onset 30 min; repeat 20 min if needed; observe 2-4 hrs for rebound
3. Cool mist/humidified oxygen (controversial)
4. Avoid agitation; keep child calm with parent
5. Heliox (helium-oxygen mixture) in refractory cases
6. DO NOT examine throat if epiglottitis suspected (risk of total obstruction)

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TOPIC 14 - CARDIOLOGY

Q34. Management of Cyanotic Spell (TOF) (REPEATED 4x - MOST REPEATED CARDIOLOGY Q)

• Caused by sudden decrease in pulmonary blood flow (infundibular spasm + drop in SVR)
• Precipitants: crying, defecation, feeding, dehydration, anemia, fever
• Features: Increasing cyanosis, hyperpnea, weakness, limpness → LOC → seizures → death

1. Knee-chest position (squatting equivalent) - increases SVR, decreases R-to-L shunt
2. Calm the child - stop crying if possible; sedation with morphine 0.1-0.2 mg/kg IV/SC/IM
3. Oxygen - 100% via mask (though limited effect, as problem is decreased flow not decreased saturation)
4. Propranolol 0.01-0.1 mg/kg IV slow (reduces infundibular spasm; first-line drug)
5. IV fluids - Normal saline 10-20 mL/kg bolus (increases preload → augments pulmonary flow)
6. Sodium bicarbonate 1-2 mEq/kg IV (for metabolic acidosis which worsens spasm)
7. Phenylephrine 0.02 mg/kg IV (increases SVR, reduces R-L shunt) - if above fails
8. Ketamine 1-2 mg/kg IV (if procedural sedation needed, also increases SVR)
9. Intubation and ventilation in refractory cases

• Oral propranolol 1-4 mg/kg/day prophylaxis
• Surgical correction: Total correction of TOF (TOFR) vs palliative (B-T shunt) depending on anatomy/age
• Correct anemia; iron supplementation

Q35. Ventricular Septal Defect (VSD) (REPEATED 2x)

• Perimembranous (most common, 80%) - near aortic valve
• Muscular (5-20%)
• Outlet (supracristal/doubly committed)
• Inlet (AV canal type)

• L-to-R shunt → increased pulmonary blood flow → pulmonary HTN → Eisenmenger's (if large, untreated)
• Roger's disease: small restrictive VSD, murmur but no hemodynamic significance

• Small VSD: Loud pansystolic murmur at LLSB (loud because high pressure difference), thrill, no other findings
• Large VSD: Heart failure, failure to thrive, recurrent LRTIs, cardiomegaly, hyperdynamic precordium

• ECG: LVH (small), biventricular hypertrophy (large)
• CXR: Cardiomegaly, increased pulmonary vascular markings, plethora
• Echo (2D + Doppler): Definitive - size, site, shunt direction, Qp:Qs

• Medical: Anti-failure (diuretics: furosemide 1-2 mg/kg/day; digoxin; captopril); nutritional support; treat infections
• Surgical: Patch closure; timing:
  • Large VSD with failure: before 6 months
  • Moderate VSD: by 1-2 years
  • Small VSD with no failure: observe (50% close spontaneously by age 5)
• Catheter-based closure: Muscular and perimembranous (Amplatzer device)

Q36. Acute Rheumatic Fever - Jones Criteria (REPEATED 2x)

1. Carditis (clinical or subclinical/echocardiographic)
2. Polyarthritis (migratory)
3. Chorea (Sydenham's)
4. Erythema marginatum
5. Subcutaneous nodules

1. Fever (>38.5°C)
2. Elevated ESR (>60 mm/hr) or CRP (>3 mg/dL)
3. Prolonged PR interval (not if carditis is major criterion)
4. Polyarthralgia (only if arthritis not used as major)

• Positive throat culture or rapid antigen test
• Elevated or rising ASO or anti-DNAse B titers

1. Bed rest: Until inflammatory markers normalize
2. Penicillin: Benzathine penicillin 1.2 million units IM single dose (to eradicate strep)
   • Or oral penicillin V 10 days
3. Arthritis: Aspirin 80-100 mg/kg/day in 4 doses × 2 weeks, then taper; or Naproxen
4. Carditis without CHF: Aspirin alone
5. Carditis with CHF: Prednisolone 2 mg/kg/day (max 60 mg) × 2-4 weeks, then taper
6. Chorea: Carbamazepine or haloperidol; valproate

• No carditis: 5 years or until age 21 (whichever is longer)
• Carditis without residual: 10 years or until age 21
• Carditis with residual: 10 years or until age 40 (lifelong if severe)

Q37. Congestive Cardiac Failure (CCF) in 5-year-old (REPEATED 2x)

• Congenital heart disease (large VSD, AVSD, PDA)
• Rheumatic heart disease
• Cardiomyopathy (dilated, hypertrophic)
• Myocarditis (viral)
• Severe anemia
• Sepsis
• Hypertensive crisis

1. Oxygen and semi-recumbent position
2. Furosemide 1-2 mg/kg/dose IV or oral - mainstay diuretic
3. Digoxin 8-10 mcg/kg/day in 2 doses oral (maintenance); loading dose in acute setting
4. ACE inhibitor (captopril 0.1-0.5 mg/kg/dose TDS; enalapril 0.1-0.5 mg/kg/day) - reduces afterload
5. Spironolactone 1-3 mg/kg/day (K+ sparing diuretic, additive effect)
6. Carvedilol (for chronic dilated cardiomyopathy)
7. Treat underlying cause
8. Nutritional support (high caloric density feeds; continuous NG feeds if needed)
9. Salt restriction (mild); fluid restriction in severe

Q38. Breath Holding Spells (REPEATED 2x)

1. Cyanotic (most common, 75%): Precipitated by crying/frustration; cry → holds breath in expiration → cyanosis → LOC → limp (not tonic-clonic) → recovery
2. Pallid (25%): Precipitated by sudden fright/pain; vagally-mediated; pallor → LOC → bradycardia

• Reassurance (self-limiting, stops by age 5-6)
• Parents: lay child flat; do NOT put in knee-chest; avoid reinforcing behavior
• Check hemoglobin (treat iron deficiency anemia - reduces frequency)
• EEG/cardiac evaluation if doubt about seizure/cardiac arrhythmia
• Atropine for pallid type if severe
• Piracetam (some evidence for reducing frequency of cyanotic type)

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TOPIC 15 - GASTROENTEROLOGY

Q39. Dehydration Classification and Management

• ORS 10 mL/kg after every loose stool (or 50-100 mL per stool)
• Continue feeding/breastfeeding
• Zinc 20 mg/day for 14 days (10 mg/day for <6 months)
• Return immediately if: worse, not drinking, blood in stool, sunken eyes, fever

• ORS 75 mL/kg over 4 hours (calculated as ml = 75 x wt in kg)
• 10 mL/kg after every loose stool
• Reassess every hour
• If vomiting, give slowly (spoon-feeding); continue breastfeeding
• If no improvement in 4 hrs → escalate to Plan C
• After correction → switch to Plan A

• Ringer's Lactate (preferred) or Normal Saline
• Age <12 months: 30 mL/kg in 1 hr, then 70 mL/kg in 5 hrs
• Age >12 months: 30 mL/kg in 30 min, then 70 mL/kg in 2.5 hrs
• Reassess every 15-30 min; repeat bolus if still severe
• Start ORS as soon as patient can drink
• WHO ORS composition (per liter): Na 75 mEq, Cl 65 mEq, Glucose 75 mmol, K 20 mEq, Citrate 10 mEq; Osmolarity 245 mOsm/L

Q40. Persistent Diarrhea (REPEATED 2x)

• Post-enteritis syndrome (secondary lactose intolerance)
• Giardia lamblia, Cryptosporidium, E. histolytica (protozoal)
• Small intestinal bacterial overgrowth (SIBO)
• Malnutrition (vicious cycle)
• Cow's milk protein allergy
• Celiac disease (in older children)
• HIV/immune compromise

• Stool exam: microscopy (cysts, trophozoites, pus cells, fat globules), culture
• CBC, serum electrolytes, albumin, LFT
• Hydrogen breath test (lactose intolerance)
• Stool reducing substances
• HIV testing if at risk
• Jejunal biopsy (celiac, SIBO) - in selected

1. Avoid lactose: Use lactose-free formula or acidified milk (curd/yogurt), cereal-based feeds
2. Cereal-legume mix: Rice + dal/lentils (khichdi); well-cooked easily digestible foods
3. Energy-dense, low-fiber small frequent feeds
4. Chicken/egg/fish as tolerated (protein source)
5. Micronutrient supplementation: Zinc, folate, multivitamins
6. Continue breastfeeding if breastfed
7. Treat specific cause: Metronidazole for Giardia/amoeba; co-trimoxazole for SIBO; gluten-free diet for celiac

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TOPIC 16 - INFECTIOUS DISEASES

Q41. Severe Malaria - Criteria and Management (REPEATED 2x)

1. Cerebral malaria (unarousable coma - Blantyre scale ≤2)
2. Severe anemia (Hb <7 g/dL in children)
3. Respiratory distress (acidotic breathing)
4. Hypoglycemia (<2.2 mmol/L or <40 mg/dL)
5. Circulatory collapse/shock (algid malaria) - SBP <70 mmHg in children
6. Abnormal bleeding (DIC, petechiae)
7. Jaundice (bilirubin >3 mg/dL with other complications)
8. Hemoglobinuria (blackwater fever)
9. Hyperparasitemia (>5% parasitized RBCs or >250,000/µL)
10. Impaired consciousness (not coma)
11. Prostration/extreme weakness
12. Convulsions (>2 episodes/24 hrs)
13. Pulmonary edema (ARDS)
14. Acute kidney injury (creatinine >3 mg/dL)

1. Artesunate IV 2.4 mg/kg at 0, 12, 24 hrs, then daily × 7 days (drug of choice - WHO 2023; superior to quinine)
   • If unavailable: Artemether IM 3.2 mg/kg loading → 1.6 mg/kg/day
   • Or Quinine IV (10 mg/kg TDS in 4% dextrose, slow infusion over 4 hrs)
2. Dextrose 25% @ 1-2 mL/kg for hypoglycemia; then maintain with 5-10% dextrose
3. Blood transfusion if Hb <7 g/dL (packed RBCs 10-15 mL/kg)
4. Fluid management cautiously (risk of pulmonary edema and raised ICP); crystalloids
5. Antipyretics: Paracetamol (avoid aspirin in children)
6. Anticonvulsants: Diazepam or lorazepam for seizures; phenobarbitone prophylaxis in cerebral malaria
7. IV broad-spectrum antibiotics if sepsis coexists
8. Dialysis for AKI
9. Dexamethasone CONTRAINDICATED in cerebral malaria (increases coma duration/infections)
10. After parenteral course, complete with oral artemisinin combination therapy (ACT)

Q42. Scrub Typhus (REPEATED 3x)

• Etiological agent: Orientia tsutsugamushi (obligate intracellular organism; earlier Rickettsia tsutsugamushi)
• Vector: Trombiculid mites (Leptotrombidium species - larval form "chigger"); vector AND reservoir
• Distribution: Asia-Pacific region; "Tsutsugamushi triangle"; endemic in India (hilly areas, Himalayas, Northeast, Odisha, Tamil Nadu)

• Fever (high grade, continuous, >7 days)
• Eschar (pathognomonic - painless black ulcer with central black crust at bite site; found in 50-80%)
• Rash (maculopapular, trunk → limbs, appears day 4-5)
• Lymphadenopathy (regional draining eschar)
• Hepatosplenomegaly
• Myalgia, headache
• Severe: Meningoencephalitis, ARDS, myocarditis, AKI

• Weil-Felix test (OX-K agglutination): Titer ≥1:80 or 4-fold rise (low sensitivity/specificity; available at peripheral level)
• Gold standard: IgM/IgG ELISA (Orientia-specific)
• PCR: Most sensitive; not routinely available
• Immunofluorescence assay (IFA): Reference standard
• CBC: Thrombocytopenia, elevated LFT, low sodium

• Drug of choice: Doxycycline 2.2 mg/kg/dose BD (max 100 mg/dose) × 7-14 days (even in children <8 years given severity)
• Alternative: Azithromycin 10 mg/kg/day × 5 days (preferred in young children and pregnancy)
• Chloramphenicol (alternative; reserved for resistant areas)
• Response: Dramatic defervescence within 24-48 hours (therapeutic diagnosis)

Q43. Pulmonary TB Diagnosis and NTEP Guidelines

• Presumptive TB: Any child with persistent cough >2 weeks, fever >2 weeks, weight loss/failure to thrive, contact with sputum-positive TB case

1. Tuberculin Skin Test (Mantoux): 2 TU PPD intradermal; read at 48-72 hrs
   • Positive: ≥10 mm (immunocompetent); ≥5 mm (HIV/malnourished/recent contact)
2. Chest X-ray: Hilar adenopathy, consolidation, miliary pattern, pleural effusion, cavitation (rare in children)
3. Bacteriological confirmation (CBNAAT/Xpert MTB/RIF): Sputum, gastric aspirate (3 early morning samples), BAL, lymph node aspirate, stool
4. Clinical scoring system (IAP modified): Used when bacteriology not possible
5. IGRA (Interferon-Gamma Release Assay): T-SPOT.TB or QuantiFERON-Gold (not available routinely)

• New cases (Pulmonary, EP): 2HRZE + 4HR (2 months intensive: Isoniazid + Rifampicin + Pyrazinamide + Ethambutol; 4 months continuation: H + R)

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TOPIC 17 - NEPHROLOGY

Q44. Nephrotic Syndrome - Management (REPEATED multiple times)

1. Confirm diagnosis: 24-hour urine protein (>40 mg/m²/hr or >1000 mg/m²/day), urine albumin:creatinine ratio, serum albumin, cholesterol, LFT, RFT, complement (C3)
2. Prednisolone 2 mg/kg/day (max 60 mg/day) × 4 weeks, then 1.5 mg/kg alternate day × 4 weeks → taper over 8 weeks Total: ~12-16 weeks (ISKDC protocol); IAP recommends extended 12-16 week initial course
3. Salt restriction + fluid restriction (severe edema)
4. Furosemide for symptomatic edema
5. Albumin infusion 1 g/kg if severe edema/anasarca followed by furosemide
6. Antibiotics if infection (spontaneous bacterial peritonitis, cellulitis - Pneumococcal is most common)
7. Immunizations: Pneumococcal vaccine (before steroids); varicella; influenza
8. Monitor: BP, urine albumin (remission = trace/nil × 3 consecutive days), growth, steroid side effects

• Remission: Urine albumin nil or trace for 3 consecutive days
• Relapse: Urine albumin 3+ or 4+ for 3 consecutive days after remission
• Frequent relapse: ≥2 relapses in 6 months, or ≥4 relapses in any 12 months
• Steroid dependence: 2 consecutive relapses during steroid therapy or within 14 days of stopping steroids
• Steroid resistance: No remission after 8 weeks of prednisolone

1. Cyclophosphamide (alkylating agent): 2-3 mg/kg/day × 8-12 weeks; induces long-term remission; avoid in pre-pubertal children (gonadotoxic)
2. Levamisole 2.5 mg/kg alternate days × 12-24 months (immunomodulator; cheap; good option for frequent relapsers)
3. Calcineurin inhibitors: Cyclosporine 4-6 mg/kg/day or Tacrolimus 0.1-0.2 mg/kg/day (for steroid-dependent/resistant); monitor drug levels
4. Mycophenolate mofetil (MMF) 600 mg/m²/dose BD
5. Rituximab (anti-CD20 B-cell depletion): 375 mg/m² IV × 1-4 doses; for difficult steroid-dependent cases

Q45. Steroid-Resistant Nephrotic Syndrome

1. Renal biopsy (to determine histology: FSGS most common, MCD, MPGN, membranous)
2. Cyclosporine + prednisolone (first choice)
3. Tacrolimus + prednisolone
4. Rituximab (for genetic SRNS: often does not respond)
5. Genetic testing (for mutations: NPHS1, NPHS2, WT1, TRPC6) - genetic SRNS unlikely to respond to immunosuppression
6. Supportive: ACE inhibitor (antiproteinuric), treat edema, hypertension, nutrition

Q46. VUR - Vesicoureteric Reflux (REPEATED 2x)

• Grade I: Into ureter only
• Grade II: Into pelvis without dilatation
• Grade III: Mild calyceal dilatation
• Grade IV: Moderate dilatation, blunted fornices
• Grade V: Severe dilatation, tortuous ureter, effaced calyces

1. Urine culture and sensitivity
2. IV/oral antibiotics (culture-directed): co-trimoxazole, nitrofurantoin, cephalexin
3. Treat fever, adequate hydration

• Antibiotic prophylaxis: Trimethoprim 2 mg/kg or nitrofurantoin 1 mg/kg once daily at night
  • Duration: Until spontaneous resolution confirmed or surgical correction
  • Indication: Grade I-III (lower grades; children <2 years; recurrent UTIs)
• Surgical/Endoscopic correction:
  • Endoscopic subureteric injection (STING procedure - dextranomer/hyaluronic acid) - for Grade II-III
  • Ureteric reimplantation - for Grade IV-V or breakthrough UTIs despite prophylaxis
• Follow-up: VCUG (voiding cystourethrogram) or radionuclide cystogram every 1-2 years; DMSA scan for renal scarring
• NICE/AUA guidelines: Continuous antibiotic prophylaxis recommended for children <2 years with any VUR grade and for Grade III-V regardless of age

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TOPIC 18 - HEMATOLOGY

Q47. Approach to Anemia with Hepatosplenomegaly in 2-year-old (REPEATED 2x)

• Thalassemia major (most likely)
• Sickle cell disease (with splenomegaly if young)
• Hemolytic anemia (hereditary spherocytosis, G6PD)
• Storage disorders (Gaucher's, Niemann-Pick)
• Leukemia
• Malaria (if endemic area)

1. History: Age of onset, ethnicity, family history, blood transfusions, jaundice episodes, splenectomy
2. CBC: Hb, MCV, MCH, MCHC, reticulocyte count, peripheral smear
3. Peripheral smear: Key investigation - hypochromia, microcytosis, target cells, nucleated RBCs in thalassemia; sickle cells; spherocytes; tear-drop cells
4. Serum bilirubin (indirect elevated in hemolysis)
5. Serum iron, TIBC, ferritin
6. Hb electrophoresis / HPLC (High Performance Liquid Chromatography) - confirmatory for thalassemia, sickle cell disease

1. Blood transfusion: Every 2-4 weeks; maintain pre-transfusion Hb >9-10 g/dL; target >12 g/dL
2. Iron chelation (REPEATED 2x):
   • Start when serum ferritin >1000 ng/mL or after 10-20 transfusions
   • Deferasirox (Exjade): 20-40 mg/kg/day oral; once daily; monitor kidney/liver function
   • Deferoxamine (Desferal): 40-50 mg/kg/day SC infusion over 8-12 hrs × 5 days/week (subcutaneous pump); IM 30 mg/kg/day
   • Deferiprone (L1): 75-100 mg/kg/day oral in 3 doses; monitor neutrophil count (agranulocytosis risk)
3. Splenectomy: When transfusion requirement increases by 50%; after age 5; vaccinate before (Pneumococcal, Hib, MenC); penicillin prophylaxis after
4. Folic acid supplementation (1-5 mg/day)
5. Bone marrow transplantation (curative)
6. Gene therapy (thalassemia: betibeglogene - FDA approved 2022)
7. Endocrinopathy monitoring: Hypothyroidism, hypoparathyroidism, diabetes, delayed puberty (iron overload in endocrine glands)

Q48. Sickle Cell Disease - Crises and Management

1. Vaso-occlusive (painful) crisis: Most common; dactylitis (hand-foot syndrome) in young children; bone pain; abdominal crisis; pulmonary
2. Sequestration crisis: Sudden trapping of blood in spleen (acute splenomegaly, anemia, shock)
3. Aplastic crisis: Parvovirus B19 infection → bone marrow suppression → profound anemia
4. Hemolytic crisis: Sudden drop in Hb from accelerated hemolysis
5. Acute chest syndrome: Fever + pulmonary infiltrates + O2 desaturation (vaso-occlusion + infection + fat embolism)
6. Stroke / CVA (ischemic; hemorrhagic): 11% lifetime risk; prophylactic transfusions if TCD >200 cm/sec

1. Hydration: IV fluids 1.5 times maintenance; or oral
2. Analgesia: Paracetamol → NSAIDs → oral morphine → IV morphine (PCA)
3. Oxygen (only if hypoxic)
4. Treat infection (pneumococcal/other - these children are functionally asplenic)
5. Folic acid 5 mg/day

• Hydroxyurea 20-35 mg/kg/day (increases HbF, reduces sickling, reduces crisis frequency by 50%)
• Pneumococcal + Hib + Meningococcal + Influenza vaccines
• Penicillin prophylaxis (125 mg BD < 3 years; 250 mg BD ≥ 3 years) - life-long or until age 5
• Avoid cold, dehydration, hypoxia, infection
• Regular transfusions if TCD elevated (stroke prevention)

Q49. ITP - Pathogenesis, Clinical Features, Management (REPEATED 3x)

• Immune-mediated platelet destruction
• Antibodies (IgG anti-GPIIb/IIIa or anti-GPIb/IX) coat platelets → destruction by splenic macrophages (Fc receptor-mediated)
• Often follows viral infection (2-4 weeks prior)
• Megakaryocytes normal or increased in marrow

• Sudden onset petechiae/purpura, bruising in an otherwise healthy child
• Bleeding from mucous membranes (epistaxis, gum bleeding)
• No lymphadenopathy, no hepatosplenomegaly (these suggest another diagnosis)
• Platelet count <100,000/µL (usually <20,000 in acute ITP)

• CBC: isolated thrombocytopenia; Hb and WBC normal
• Peripheral smear: decreased platelets; confirm no blast cells
• BMP only if unusual features (to rule out other causes)
• Bone marrow biopsy NOT routinely needed in typical acute ITP

• Observation only if platelet >20,000 and minimal bleeding (wet purpura absent)
• IVIG 1 g/kg/day × 1-2 days - fastest increase; use if severe bleeding or surgery needed
• IV anti-D immunoglobulin 75 µg/kg - if Rh positive (blocks Fc receptors)
• Prednisolone 1-2 mg/kg/day × 2-4 weeks - standard first-line oral
• Emergency: IV methylprednisolone 30 mg/kg/day × 3 days; platelet transfusion only if life-threatening bleeding
• Chronic ITP (>12 months): Rituximab, eltrombopag/romiplostim (TPO agonists), splenectomy (last resort)
• Most children (80%): spontaneous remission within 6 months

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TOPIC 19 - NEUROLOGY

Q50. Status Epilepticus - Management (REPEATED 3x)

• ABC, position (left lateral), oxygen, IV access, blood glucose, IV fluids
• Do not restrain; protect airway

• Lorazepam 0.1 mg/kg IV (max 4 mg) - preferred; OR
• Diazepam 0.3-0.5 mg/kg IV (max 10 mg), or rectal diazepam 0.5 mg/kg; OR
• Midazolam 0.2 mg/kg IM/buccal (excellent for pre-hospital/no IV access)
• Glucose: 25% Dextrose 2-4 mL/kg IV bolus if hypoglycemic

• Phenytoin/Fosphenytoin 20 mg PE/kg IV (rate <1 mg/kg/min; ECG monitoring) - classic 2nd line; OR
• Valproate sodium 20-40 mg/kg IV over 5-10 min; OR
• Levetiracetam 20-60 mg/kg IV over 15 min (fewer drug interactions; now preferred 2nd line per 2023 guidelines)
• Phenobarbitone 15-20 mg/kg IV (alternative 2nd line, especially in neonates)

• RSI + Intubation
• Midazolam infusion 0.05-2 mg/kg/hr
• Propofol (adults/older children)
• Thiopental/pentobarbital infusion (if above fails - induced coma)
• EEG monitoring (burst suppression target)
• ICU admission

Q51. Febrile Seizures (Simple vs Complex)

1. ABC, lateral position, O2
2. Temperature: paracetamol 15 mg/kg oral/rectal
3. If still seizing at 5 min: diazepam 0.3-0.5 mg/kg IV or 0.5 mg/kg rectal
4. Monitor SpO2, glucose
5. IV fluids if dehydrated
6. Identify and treat source of fever (if meningitis suspected - LP)

• Blood: CBC, glucose, electrolytes, Ca, Mg
• Cultures if clinically indicated
• LP (if <18 months, first febrile seizure, signs of meningism, or complex)
• EEG (not routinely needed for simple febrile seizure)
• CT/MRI (only if focal, prolonged, or neurological deficit)

Q52. Acute Bacterial Meningitis - Presentation and Management

• Classic triad: Fever, headache/bulging fontanelle, neck stiffness
• Meningeal signs: Kernig's sign (resistance to knee extension with hip flexed), Brudzinski's sign (involuntary knee flexion on neck flexion), nuchal rigidity
• IICP: Headache, vomiting, papilledema, sunset sign in infants, bulging fontanelle
• Infants: irritability, poor feeding, high-pitched cry, seizures, fever/hypothermia
• Petechial/purpuric rash: Meningococcal septicemia (N. meningitidis - do NOT delay treatment)

1. Do not delay antibiotics while waiting for CT scan (get blood cultures first)
2. Dexamethasone 0.15 mg/kg/dose QDS × 4 days; give 15-20 min BEFORE first antibiotic dose (reduces hearing loss in Hib meningitis; benefit in pneumococcal)
3. Antibiotics:
   • <3 months: Ampicillin + Cefotaxime (covers Listeria and GBS)

   • 3 months: Ceftriaxone 100 mg/kg/day in 2 divided doses × 10-14 days

   • Dexamethasone + Ceftriaxone (standard protocol)
4. Supportive:
   • Fluid restriction (SIADH can occur)
   • Treat seizures (lorazepam/diazepam → phenytoin)
   • Maintain normal BP and glucose
   • Treat IICP: head elevation 30°, mannitol, hyperventilation
5. Complications: Subdural empyema, hydrocephalus, brain abscess, deafness, seizures, cognitive impairment, DIC
6. Monitoring: Repeat LP if not improving at 48 hrs

Q53. AFP (Acute Flaccid Paralysis) - Polio Endgame Strategy (REPEATED 2x)

• Polio: Asymmetric, fever at onset, no sensory loss, CSF shows pleocytosis
• GBS: Symmetric, ascending, sensory symptoms, albuminocytological dissociation in CSF

• Non-polio AFP rate target: ≥2 per 100,000 children <15 years
• Stool sample: 2 samples collected 24 hrs apart within 14 days of onset of paralysis
• Adequate sample: >8 grams; collected within 14 days; delivered on ice to accredited lab

1. Switch from tOPV to bOPV (bivalent - types 1 and 3 only; type 2 component removed as wild type 2 eradicated)
2. Introduce at least 1 dose of IPV in routine immunization (reduces VAPP risk)
3. India: IPV dose added at 14 weeks in UIP
4. Maintain high routine immunization coverage
5. Pulse immunization during National Immunization Days (NID) and Sub-NIDs
6. Environmental surveillance (sewage sampling)
7. Outbreak response immunization (mOPV1 or mOPV3)

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TOPIC 20 - TOXICOLOGY & ENDOCRINOLOGY

Q54. Snake Bite with Ptosis (REPEATED 3x)

• Krait: presynaptic neurotoxin (irreversible, very serious)
• Cobra: postsynaptic (reversible with neostigmine)

1. Ptosis (drooping eyelids)
2. Ophthalmoplegia (external, then internal)
3. Bulbar palsy (dysphagia, dysarthria, nasal voice)
4. Facial palsy
5. Neck muscle weakness (unable to lift head)
6. Limb weakness
7. Respiratory failure (most feared, cause of death)

1. General first aid:
   • Immobilize limb (splint), below heart level
   • Pressure immobilization bandage (for neurotoxic bites - Australian technique)
   • No incision, no tourniquet, no suction
   • Transport urgently to hospital
2. Assessment at hospital:
   • 20-Minute Whole Blood Clotting Test (20WBCT): Place 2 mL blood in plain glass tube; if clotted in 20 min = no coagulopathy
   • Signs: Ptosis, cranial nerve palsies, local swelling, bleeding
3. Polyvalent Anti-Snake Venom (ASV):
   • Only definitive treatment
   • Indications: Neurotoxicity signs (ptosis, ophthalmoplegia), coagulopathy (20WBCT positive), hemolysis, AKI
   • Initial dose: 10 vials (neurological) - 8-10 vials IV infused in NS over 30-60 min
   • If no improvement in 1-2 hours: Repeat 10 vials
   • No ceiling dose; give until reversal of coagulopathy/improvement in neurotoxicity
   • Pre-medication: Adrenaline 0.25 mL SC (NOT recommended routinely by WHO 2024) OR Promethazine + Hydrocortisone (traditional practice in India)
4. Neostigmine test (Cobra bite):
   • Neostigmine 0.04 mg/kg IM + Atropine 0.02 mg/kg IV
   • If ptosis improves in 30 min → postsynaptic (cobra) → continue neostigmine 0.5-2.5 mg every 30-60 min
   • Krait does NOT respond to neostigmine
5. Respiratory support:
   • Monitor: Respiratory rate, SpO2, ability to lift head
   • Intubation and mechanical ventilation if respiratory failure
6. Other: IV fluids, treat AKI (dialysis), blood products for coagulopathy (FFP, cryoprecipitate)

Q55. Congenital Hypothyroidism (REPEATED 3x)

• Thyroid dysgenesis (agenesis, ectopia, hypoplasia) - 85%
• Dyshormonogenesis (enzyme defects) - 10-15%
• Transient (maternal anti-thyroid drugs, iodine deficiency, maternal TSHr-blocking antibodies)
• Central hypothyroidism (TSH deficiency) - rare

• Newborn: Often asymptomatic; large fontanelle, prolonged jaundice, constipation, feeding difficulties, hypothermia, umbilical hernia, hoarse cry
• Infantile: Classic features: Coarse facies, macroglossia, protruding tongue, depressed nasal bridge, hoarse cry, pot belly, umbilical hernia, dry skin, cold extremities, bradycardia
• Late: Mental retardation (cretinism), short stature, deafness, delayed dentition, if untreated

• Neonatal TSH screening at 48-72 hours of life (heel-prick blood spot)
• TSH >20 µIU/mL on screen → confirm with serum TSH + free T4
• Cut-off for treatment: TSH >10 µIU/mL with low/normal T4

1. Levothyroxine (L-T4): Start as early as possible (within 2 weeks of birth)
   • Starting dose: 10-15 µg/kg/day oral (crush and give with small amount breast milk or formula)
   • Target TSH: 0.5-2.0 µIU/mL; T4 at upper half of normal range
2. Follow-up schedule:
   • Every 2 weeks until euthyroid
   • Monthly until 12 months
   • Every 3-6 months thereafter
3. Monitor: TSH + fT4 at each visit; growth (height, weight); developmental milestones; bone age
4. Duration: Lifelong in permanent hypothyroidism; trial off therapy at 3 years if transient hypothyroidism suspected (repeat TFT 4 weeks after stopping)
5. Prognosis: If treated within 2 weeks → normal IQ; delay → irreversible intellectual disability

Q56. Diabetic Ketoacidosis - Fluid Management (REPEATED 2x)

• Mild: pH 7.2-7.3
• Moderate: pH 7.1-7.2
• Severe: pH <7.1

1. Resuscitation (only if shock/hemodynamic compromise):
   • Normal saline 10-20 mL/kg over 30 min
   • Avoid in DKA unless hemodynamically compromised (increases risk of cerebral edema)
2. Rehydration (deficit + maintenance over 48 hours):
   • Deficit: Severe DKA = 10% dehydration = 10% × 15 kg = 1500 mL deficit
   • Maintenance: Holliday-Segar for 15 kg = 1250 mL/day = 2500 mL for 48 hrs
   • Total = 1500 + 2500 = 4000 mL over 48 hours
   • Rate = 4000/48 ≈ 83 mL/hr
   • Use NS (0.9%) for first 12 hrs, then change to 0.45% NS with added KCl and 5% dextrose (when glucose <250 mg/dL)
   • Subtract resuscitation fluids given
3. Insulin:
   • Start AFTER 1-2 hrs of fluid resuscitation
   • Regular insulin/soluble insulin: 0.05-0.1 U/kg/hr continuous IV infusion
   • DO NOT give insulin bolus in children
   • Change to subcutaneous insulin when pH >7.3, HCO3 >15, child eating
4. Potassium:
   • Add 40 mEq/L KCl (20 mEq KCl + 20 mEq KPO4) to IV fluid from the start (unless hyperkalemic or no urine output)
   • DKA always has total body K deficit even if serum K appears normal/elevated
5. Monitoring: Neuro status every hour (cerebral edema risk), glucose every hour, electrolytes every 2 hours, pH every 4-6 hrs
6. Bicarbonate: NOT recommended (may worsen cerebral edema); only if pH <6.9 with cardiovascular compromise
7. Cerebral edema (dreaded complication): Headache, confusion, bradycardia, Cushing's triad → Mannitol 0.5-1 g/kg or 3% saline 2-5 mL/kg; reduce IV fluid rate

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TOPIC 22 - GENERAL PEDIATRICS

Q57. Down Syndrome - Complications on Follow-up (REPEATED 3x)

1. Cardiac (40-50%): AV septal defect, VSD, ASD, PDA, TOF - echocardiogram at birth; surgery if needed
2. Thyroid: Hypothyroidism (15-20%); TSH annually from birth; autoimmune thyroiditis
3. Hearing: Conductive hearing loss (otitis media with effusion, Eustachian tube dysfunction); BERA/audiometry from birth; grommets
4. Vision: Squint (strabismus), cataracts, refractive errors, nystagmus - ophthalmology from 6 months
5. Hematological: Transient abnormal myelopoiesis (TAM) in neonates; AML/ALL (20-30x higher risk); CBC annually
6. Atlantoaxial instability (AAI): C-spine X-ray before sports/anesthesia; if atlantodental interval >5 mm → restrict contact sports
7. GI: Duodenal atresia, Hirschsprung's disease, celiac disease (prevalence ~10%)
8. Respiratory: Obstructive sleep apnea (OSA) - PSG; adenotonsillectomy; CPAP; chronic lung disease
9. Neurodevelopment/Cognitive: Mild-moderate intellectual disability; early intervention; special education
10. Autism spectrum disorder (higher prevalence in DS)
11. Dental: Delayed dentition, malocclusion; dental visits from age 1
12. Epilepsy: Infantile spasms, tonic-clonic; EEG if seizures
13. Alzheimer's disease: Virtual certainty after age 40; cognitive decline assessment from age 35
14. Orthopedic: Patellar instability, flat feet, scoliosis

Q58. ITP - See Q49 above

Q59. RBSK (Rashtriya Bal Swasthya Karyakram) (REPEATED 3x)

1. Deficiencies: Anemia, malnutrition, Vit A/D deficiency, dental caries
2. Diseases: Congenital heart disease, congenital deafness, neural tube defects, retinopathy of prematurity
3. Developmental delays: Autism, cerebral palsy, intellectual disability, learning disability
4. Disabilities: Locomotor disability, visual impairment, hearing impairment

• Mobile Health Teams (MHTs): 2 AYUSH doctors + paramedics → screen at anganwadi and school
• District Early Intervention Centre (DEIC): Referral point for confirmed cases; provides early interventions (rehabilitation, audiometry, prosthetics, surgery)
• 30 conditions screened at birth-6 weeks; 30 conditions in children 6 weeks-6 years; primary school and secondary school children

• One per district
• Provides: Audiometry, vision testing, speech therapy, occupational therapy, physiotherapy, child psychology, dental services
• Links with tertiary care for surgeries (cardiac correction, cochlear implant, club foot, etc.)
• Free of cost

Q60. UTI in 3-year-old Boy - Diagnosis and Evaluation (REPEATED 2x)

• Symptoms: Fever, dysuria, increased frequency, enuresis, foul-smelling urine; in young children - fever without focus
• Urine dipstick: Nitrites + leukocyte esterase + = presumptive UTI
• Urine microscopy: >10 WBC/HPF (pyuria); >5 WBC/HPF in centrifuged specimen
• Urine culture (gold standard): >10⁵ CFU/mL of single organism (midstream clean catch); >10⁴ in suprapubic aspirate; any growth in catheter specimen
• Suprapubic aspiration (SPA): Any growth = significant (used in infants)

• Uncomplicated UTI (afebrile, >2 years): Oral co-trimoxazole 8/40 mg/kg/day BD × 7-10 days; or nitrofurantoin × 5-7 days; or cefixime × 7 days (as per local sensitivity)
• Febrile UTI/Pyelonephritis: IV gentamicin or ceftriaxone; switch to oral when afebrile

1. Renal USG: During acute illness (for hydronephrosis, duplex kidney, abscess); repeat in 6 weeks
2. VCUG (Voiding Cystourethrogram) or MCU: To detect VUR and posterior urethral valves - do 6 weeks after infection resolves; standard in boys
3. DMSA scan: 4-6 months post-infection to detect renal scarring
4. Blood pressure, serum creatinine
5. Urine culture repeat at 1 week, 1 month, 3 months (to detect early recurrence)

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TOPIC 13 - TETANUS

Q61. Neonatal Tetanus

• Clostridium tetani (gram positive, anaerobic, spore-forming bacillus) enters via umbilical stump (unsterile cord cutting/application of cow dung)
• Produces tetanospasmin (zinc endopeptidase)
• Toxin travels retrograde via motor neurons to spinal cord
• Blocks inhibitory neurons (glycinergic interneurons - Renshaw cells) in spinal cord and GABA-ergic neurons in brainstem
• Uncontrolled motor activity → tetanic spasms

1. Fluid: IV/NG tube feeding; avoid oral feeding (aspiration risk); IV dextrose for energy
2. Fighting the infection: Metronidazole 15 mg/kg/day IV in 3 doses × 7 days (preferred over penicillin); clean umbilicus; debride any wound
3. Fixing the toxin: Human Tetanus Immunoglobulin (TIG) 500-3000 IU IM (neutralizes circulating toxin; does NOT reverse already fixed toxin); OR Equine Tetanus Antitoxin 10,000 IU IM
4. Fighting spasms:
   • Diazepam 0.1-0.3 mg/kg/dose every 3-4 hrs (drug of choice for spasm control)
   • Continuous diazepam infusion 0.1-0.3 mg/kg/hr
   • Phenobarbitone 10 mg/kg IV then 5 mg/kg/day maintenance
   • Minimize stimuli (dark quiet room); gentle handling
   • Intubation + vecuronium if severe/refractory spasms

• Antenatal: TT 2 doses to all pregnant women (TT1 at first contact; TT2 four weeks later); or TT booster if previous vaccination within 5 years
• Postnatal: Clean delivery (sterile cord cutting, clean birth surface)
• Cord care: Keep dry and clean; do NOT apply cow dung, herbs, oil
• Primary immunization: DPT series (DT component prevents neonatal tetanus via maternal vaccination)

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TOPIC 08 - AUTISM / PDD (REPEATED 2x)

Q62. Features of Autism Spectrum Disorder (ASD)

1. Deficits in social-emotional reciprocity (no back-and-forth conversation, reduced sharing of interests)
2. Deficits in nonverbal communicative behaviors (poor eye contact, limited facial expression)
3. Deficits in developing/maintaining/understanding relationships (no pretend play, no peer friendships)

1. Stereotyped or repetitive movements/speech (echolalia, hand flapping, spinning objects)
2. Insistence on sameness (rigid routines, distress at minor changes)
3. Highly restricted, fixated interests
4. Hyper or hypo-reactivity to sensory input

• No babbling by 12 months
• No gestures (pointing, waving) by 12 months
• No single words by 16 months
• No 2-word phrases by 24 months
• Any regression in language or social skills at any age

• ABA (Applied Behavior Analysis) - evidence-based behavioral therapy
• Speech-language therapy
• Occupational therapy (sensory integration)
• Social skills training
• Special education (individualized)
• Treat comorbidities: ADHD (methylphenidate), anxiety, sleep problems (melatonin)
• NO medications specifically for core ASD symptoms; risperidone/aripiprazole for severe behavioral issues

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TOPIC 10 - MICRONUTRIENT DEFICIENCY

Q63. Maintenance Fluid Calculation (Holliday-Segar Method)

• First 10 kg: 100 mL/kg/day = 1000 mL/day
• Next 2 kg: 50 mL/kg/day = 100 mL/day
• Total = 1100 mL/day = 45.8 mL/hr

• Hypotonic (dilutional): SIADH, diarrhea with hypotonic replacement, inappropriate IV fluids, liver failure, nephrotic syndrome, hypothyroidism
• Hypovolemic: GI losses, sweating, adrenal insufficiency
• Hypervolemic: Cardiac failure, nephrotic syndrome, cirrhosis

• Fluid restriction (if SIADH/euvolemic)
• Oral salt supplementation (if hypovolemic)
• Severe/symptomatic (<125 mEq/L with seizures/coma): 3% NaCl 3-5 mL/kg IV bolus over 15 min; raise Na by 5 mEq/L within first hr
• Correction rate: No more than 8-10 mEq/L per 24 hrs (risk of osmotic demyelination if corrected too rapidly)

Q64. Zinc Deficiency

• Growth retardation (most common)
• Delayed wound healing
• Acrodermatitis enteropathica (periorificial and acral dermatitis, alopecia, diarrhea - triad)
• Decreased immunity → recurrent infections
• Hypogonadism, delayed puberty
• Night blindness (zinc needed for retinol-binding protein)
• Dysgeusia, hyposmia (altered taste and smell)
• Behavioral changes, cognitive impairment

• Elemental zinc: 20 mg/day × 14 days (for acute diarrhea)
• Nutritional zinc deficiency: 1-2 mg/kg/day

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TOPIC 16 - DENGUE AND SEVERE DENGUE

Q65. Severe Dengue / Dengue Shock Syndrome

• Dengue without warning signs (Group A)
• Dengue with warning signs (Group B): Abdominal pain, persistent vomiting, fluid accumulation, mucosal bleeding, lethargy, liver enlargement >2 cm, hematocrit rise ≥20%, rapid platelet fall
• Severe dengue (Group C): Severe plasma leakage (DSS), severe bleeding, severe organ impairment

• Compensated shock: Isotonic crystalloid (NS or RL) 10-20 mL/kg over 1 hour; reassess
  • If improving: reduce to 7 mL/kg/hr → 5 → 3 → 2 → stop (stepdown every 1-2 hrs)
  • If not improving: Repeat bolus up to 3 times
• Uncompensated/Profound shock: Colloid (dextran 40 or gelatin) 10-20 mL/kg over 30 min
• Crystalloid of choice: Ringer's Lactate (preferred over NS as less acidosis)
• Hematocrit monitoring: Every 1-2 hrs; rising Hct = plasma leakage continuing
• Avoid excessive fluids (leads to pulmonary edema in recovery phase)

• Platelet transfusion: NOT recommended for platelet count alone (even if 20,000); only if active significant bleeding or pre-operative
• FFP/packed RBCs: If severe bleeding with hemodynamic compromise

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