• 10-mark questions = detailed (full explanation)
• 12-mark (6 marks each) = moderate detail
• 18-mark (6 marks each) = moderate detail
• 10-mark Q4/Q8 (2 marks each) = 2-3 sentences only

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SMT NHL MUNICIPAL COLLEGE - PEDIATRICS INTERNAL EXAM

SECTION 1

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QUESTION 1 (10 marks) - Write ANY ONE in detail

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Option 1: Respiratory Distress in Newborn + RDS in Preterm

• Pulmonary: RDS (Hyaline Membrane Disease), Transient Tachypnea of Newborn (TTN), Meconium Aspiration Syndrome (MAS), Pneumonia, Pneumothorax, Congenital lung malformations
• Cardiac: Cyanotic CHD, cardiac failure
• Others: Metabolic acidosis, hypothermia, polycythemia, CNS depression, diaphragmatic hernia

• Deficiency of surfactant (produced by Type II pneumocytes after 34 weeks)
• More common in <34 weeks gestation, LBW, maternal diabetes, male sex, C-section without labor, perinatal asphyxia

• Surfactant deficiency → increased alveolar surface tension → alveolar collapse (atelectasis) → V/Q mismatch → hypoxia + hypercapnia → acidosis → pulmonary vasoconstriction → protein-rich fluid leaks into alveoli forming hyaline membranes → worsening hypoxia (vicious cycle)

• Onset within 4-6 hours of birth
• Tachypnea (>60/min), grunting, nasal flaring, subcostal/intercostal retractions, cyanosis
• Chest X-ray: Ground-glass appearance, air bronchograms, reduced lung volume, "white-out" in severe cases

• Antenatal: Betamethasone/Dexamethasone to mother (34 weeks), accelerates surfactant production
• Oxygen: Warmed humidified O2; target SpO2 91-95%
• CPAP: First-line respiratory support (nasal CPAP 5-7 cm H2O)
• Surfactant therapy: Natural surfactant (Poractant alfa/Beractant) via ET tube - within 2 hours of birth (INSURE technique: Intubate-Surfactant-Extubate to CPAP)
• Mechanical ventilation: If CPAP fails
• Supportive: Thermoregulation, IV fluids, antibiotics (Ampicillin + Gentamicin), correct acidosis, maintain glucose

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Option 2: Neonatal Jaundice (10 marks)

• Increased production: Hemolytic disease (Rh/ABO incompatibility), G6PD deficiency, hereditary spherocytosis, polycythemia
• Decreased conjugation: Crigler-Najjar syndrome, Gilbert syndrome, hypothyroidism
• Increased enterohepatic circulation: Pyloric stenosis, intestinal obstruction
• Infection: Sepsis, TORCH infections
• Cholestasis: Biliary atresia, neonatal hepatitis (conjugated hyperbilirubinemia)
• Breast milk jaundice (prolonged, after day 5)

1. Neonates have higher RBC mass with shorter RBC lifespan (70-90 days vs 120 days) → more bilirubin produced
2. Immature liver with low UDP-glucuronosyltransferase activity → poor conjugation
3. Increased enterohepatic circulation (beta-glucuronidase in gut deconjugates bilirubin)
4. Low albumin binding capacity
5. Result: Unconjugated (indirect) hyperbilirubinemia - peaks then resolves as enzyme activity matures

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QUESTION 2 (12 marks) - Write ANY TWO short notes (6 marks each)

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Q2.1: 3-year-old with bow legs and wrist widening - Rickets

• Widening, fraying, cupping, and splaying of metaphysis (especially distal radius/ulna and distal femur/proximal tibia)
• Indistinct zone of provisional calcification
• Widened epiphyseal growth plate
• Osteoporosis / reduced bone density
• Looser zones (pseudofractures) in severe cases
• Bow legs (genu varum) in toddlers

• Nutritional Rickets (Vit D deficiency - most common):
  • Vitamin D: 1,000-5,000 IU/day orally for 3 months OR single stoss therapy (600,000 IU once)
  • Calcium: 500-1000 mg/day (milk, calcium supplements)
  • Sun exposure: 30 min/day
  • Maintenance: 400 IU/day thereafter
• Dietary advice: Dairy products, eggs, fortified foods
• Orthopedic: Bracing for severe deformity; surgery (corrective osteotomy) only after metabolic correction

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Q2.2: 10-year-old with fever, vomiting, jaundice for 5 days

• Confirmatory: Anti-HAV IgM antibody (positive in acute infection)
• LFT: Elevated ALT/AST (>10x normal), elevated bilirubin (predominantly conjugated/direct)
• CBC: Leukopenia with relative lymphocytosis
• USG abdomen: Hepatomegaly, periportal edema
• PT/INR (assess severity/fulminant hepatitis)
• Urine: Bile salts and pigments positive

• No specific antiviral therapy
• Rest, adequate nutrition, high carbohydrate diet
• IV fluids if vomiting prevents oral intake
• Avoid hepatotoxic drugs (paracetamol high doses, NSAIDs)
• Monitor for fulminant hepatic failure (encephalopathy, coagulopathy)
• Isolation precautions: Enteric precautions, hand hygiene
• Indications for hospitalization: Encephalopathy, INR >1.5, severe vomiting, dehydration
• Prognosis: Excellent; self-limiting in 4-8 weeks; no chronicity

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Q2.3: Vitamin A Deficiency - WHO Staging + National Control Programme

• 9 months: Vitamin A 1 lakh IU (100,000 IU) with measles vaccine
• 16-18 months: 2 lakh IU (200,000 IU) with DPT booster
• Every 6 months thereafter up to 5 years: 2 lakh IU
• For an 11-month-old: Give 1st dose of 1 lakh IU now if not given at 9 months
• Dietary diversification: Green leafy vegetables, yellow fruits, eggs, dairy
• ICDS, ANM, ASHA-based delivery of supplements

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QUESTION 3 (18 marks) - Write ANY THREE short notes (6 marks each)

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Q3.1: Neonatal Hypoglycemia - Causes and Management

• Inadequate substrate: LBW/SGA/prematurity, poor feeding, delayed feeding
• Hyperinsulinism: IDM (Infant of Diabetic Mother), Rh hemolytic disease, Beckwith-Wiedemann syndrome, nesidioblastosis
• Increased utilization: Perinatal asphyxia, hypothermia, sepsis, polycythemia, respiratory distress
• Endocrine: Congenital hypopituitarism, cortisol deficiency, growth hormone deficiency
• Inborn errors of metabolism: Galactosemia, MSUD, fatty acid oxidation defects

• Blood glucose 25-45 mg/dL: Oral/NGT feeds; recheck in 1 hour
• If not responding: IV Dextrose 10% at 5-8 mg/kg/min GIR (Glucose Infusion Rate)

• IV Dextrose 10% bolus: 2 mL/kg over 5-10 minutes
• Followed by continuous infusion at 6-8 mg/kg/min
• Recheck every 30-60 min; titrate infusion

• Hydrocortisone 5 mg/kg/day (decreases glucose utilization)
• Glucagon 0.3 mg/kg IM (useful in IDM)
• Diazoxide (persistent hyperinsulinism)

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Q3.2: Breastfeeding Counselling - Antenatal and Post-Natal

• Explain benefits of breastfeeding: Best nutrition, immune protection (IgA), reduces infections (diarrhea, ARI), bonding, reduces SIDS, maternal benefits (uterine involution, ovulation suppression, reduced breast cancer risk)
• Initiation within 30-60 minutes of birth (early initiation)
• Reassure about milk sufficiency; address myths
• Breast examination - inverted nipples: Can be corrected by Hoffman technique or nipple shield
• Importance of colostrum (first milk - yellow, thick, rich in antibodies and Vitamin A)
• Counsel about exclusive breastfeeding for 6 months

• Positioning and attachment: Cradle hold; baby's mouth covers most of areola, not just nipple; chin touching breast
• Feed on demand - 8-12 times/day; both breasts each feed
• Signs of adequate feeding: 6-8 wet diapers/day, satisfactory weight gain (25-30 g/day)
• Exclusive breastfeeding for 6 months, then continue with complementary foods up to 2 years
• Manage common problems: Engorgement (frequent feeding, warm compress), sore nipples (correct latch, leave breast milk on nipple to dry), mastitis (continue feeding, antibiotics)
• Working mothers: Expression and storage of breast milk (refrigerator 72 hrs, freezer 3 months)

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Q3.3: Adolescence - Definition and Health Problems

1. Nutritional problems: Iron deficiency anemia (especially girls - menstruation), obesity, eating disorders (anorexia nervosa, bulimia), undernutrition
2. Reproductive health: Menstrual disorders (dysmenorrhea, irregular cycles), early pregnancy, STIs, PCOD
3. Mental health: Depression, anxiety, stress, suicidal ideation, body image issues, eating disorders
4. Substance abuse: Tobacco, alcohol, drugs (gateway: peer pressure)
5. Injuries and violence: Road traffic accidents (highest cause of death in adolescents globally), physical/sexual abuse
6. Skin problems: Acne vulgaris (androgen-driven, sebaceous gland hypertrophy)
7. Musculoskeletal: Osgood-Schlatter disease, scoliosis
8. Behavioral issues: Risk-taking behavior, school dropout, delinquency
9. PCOD, thyroid disorders, type 2 diabetes (rising due to obesity)

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Q3.4: Tanner Staging in Females

• Entire process: 2-5 years
• Adrenarche (axillary hair, body odor) occurs around PH2-PH3

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QUESTION 4 (10 marks) - ANY FIVE in 2-3 sentences each (2 marks each)

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Q4.1: Microcephaly and its Causes

• Primary (genetic): Autosomal recessive microcephaly (MCPH genes), chromosomal abnormalities (Down syndrome, trisomy 13/18), Angelman syndrome
• Secondary (acquired): TORCH infections (CMV most common, Zika virus, rubella, toxoplasmosis), perinatal hypoxia-ischemia, meningitis/encephalitis, metabolic (PKU, untreated hypothyroidism), craniosynostosis (secondary), fetal alcohol syndrome, radiation exposure

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Q4.2: Components of Moro's Reflex

1. Abduction and extension of arms with opening of hands (spreading of fingers)
2. Adduction of arms (embracing movement, arms come together)
3. Cry (may or may not be present)

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Q4.3: 4 Red Flag Signs in Child Development

1. No social smile by 3 months
2. No babbling / monosyllables by 12 months (or loss of language at any age)
3. Not walking independently by 18 months
4. Not using 2-word meaningful phrases by 24 months

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Q4.4: Rotavirus Vaccine

• Rotavac (116E strain): Indigenous Indian vaccine; 3 doses at 6, 10, 14 weeks (oral); included in UIP India
• Rotarix (RV1): 2 doses at 6 and 14 weeks; RotaTeq (RV5): 3 doses at 2, 4, 6 months

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Q4.5: Age-Independent Anthropometric Parameters

• MUAC (Mid-Upper Arm Circumference): <11.5 cm = SAM; 11.5-12.5 cm = MAM; >12.5 cm = normal (for children 6 months - 5 years)
• Triceps Skinfold Thickness
• Subscapular Skinfold Thickness
• Weight-for-Height (WHZ score)

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Q4.6: 4 Causes of High Anion Gap Metabolic Acidosis

1. M - Methanol poisoning
2. U - Uremia (renal failure)
3. D - Diabetic ketoacidosis (DKA)
4. P - Paracetamol / Propylene glycol
5. L - Lactic acidosis (sepsis, tissue hypoxia)
6. I - Isoniazid / Iron poisoning
7. S - Salicylate poisoning

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SECTION 2

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QUESTION 5 (10 marks) - Write ANY ONE in detail

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Option 1: Principles of Development and Milestones up to 2 years

1. Development is continuous but not uniform (spurts occur)
2. Proceeds in a cephalocaudal direction (head → foot)
3. Proceeds in a proximodistal direction (trunk → periphery)
4. From general to specific movements
5. Sequential and predictable order
6. Differentiation before integration
7. Each child follows the same sequence but at their own pace
8. Earlier development influences later development
9. Critical/sensitive periods exist for certain functions (language, vision)
10. Genetic, environmental (nutrition, stimulation, SES) and biological factors interact

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Option 2: SAM/PEM - Definition, Classification, Management, Prevention

• WHZ (Weight-for-Height Z-score) < -3 SD (WHO standards)
• MUAC < 11.5 cm (6 months - 5 years)
• Bilateral pitting pedal edema (nutritional = Kwashiorkor)
• WFA (Weight-for-Age) < -3 SD (used in field settings)

• Moderate Acute Malnutrition (MAM): WHZ -3 to -2 SD or MUAC 11.5-12.5 cm
• SAM: WHZ <-3 SD or MUAC <11.5 cm or edema

• Marasmus: Severe wasting, skin over bones appearance, "old man face," loss of buccal fat pad (Bichat's fat pad), irritable, alert, no edema, ravenous appetite
• Kwashiorkor: Edema (starts feet → legs → face), moon face, sparse reddish discoloured hair (flag sign), "flaky paint" dermatosis, hepatomegaly (fatty liver), apathetic, no appetite

1. Treat/prevent HYPOGLYCEMIA (10% glucose NGT or D10% IV if unconscious)
2. Treat/prevent HYPOTHERMIA (warm environment, skin-to-skin, warm feeds)
3. Treat/prevent DEHYDRATION (ReSoMal solution - not standard ORS)
4. Correct ELECTROLYTE imbalance (K, Mg supplementation; avoid Na)
5. Treat/prevent INFECTION (Amoxicillin for all SAM children; add Gentamicin if severely ill)
6. Correct MICRONUTRIENT deficiencies (Vit A, Zinc, Folic acid, multivitamins; IRON only in rehabilitation phase)
7. Start CAUTIOUS FEEDING (F-75 formula: 75 kcal/100 mL; 130 mL/kg/day)
8. Achieve CATCH-UP GROWTH
9. Provide SENSORY STIMULATION (play, activities)
10. Prepare for FOLLOW-UP

• Transition from F-75 to F-100 (100 kcal/100 mL)
• Increase gradually to 150-220 kcal/kg/day
• RUTF (Ready-to-Use Therapeutic Food = Plumpy'Nut): 500 kcal/day
• Iron supplementation started here
• Sensory stimulation, play therapy, mother education

• Promote exclusive breastfeeding for 6 months + timely complementary feeding
• ICDS (Integrated Child Development Services): Supplementary nutrition, growth monitoring
• Vitamin A supplementation program
• Immunization (prevents infections leading to malnutrition)
• POSHAN Abhiyan (National Nutrition Mission)
• Growth monitoring with Road-to-Health chart (weight faltering detection)
• MAM management with RUTF in community (CMAM - Community-based Management)
• Sanitation, safe water (WASH programs)
• Mother literacy and education

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QUESTION 6 (12 marks) - Write ANY TWO short notes (6 marks each)

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Q6.1: Dehydration Classification + Fluid Management (WHO)

• If can drink: ORS 20 mL/kg/hr orally/NGT for 4-6 hours
• IV fluids preferred: Ringer's Lactate (or normal saline):
  • <12 months: 30 mL/kg IV over 1 hour, then 70 mL/kg over 5 hours
  • >12 months: 30 mL/kg IV over 30 min, then 70 mL/kg over 2.5 hours
• Reassess every 15-30 min
• Once alert/can drink: Start ORS
• Continue feeding (breastfeeding throughout)
• Zinc supplementation: 10 mg/day (<6 months) or 20 mg/day (>6 months) for 14 days

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Q6.2: Malaria - Differential Diagnosis, Investigations, Treatment

1. Malaria (most likely)
2. Typhoid fever (enteric fever)
3. Viral hepatitis
4. Infective endocarditis
5. Kala-azar (visceral leishmaniasis - prolonged fever, massive splenomegaly)
6. Hemolytic anemia (sickle cell, thalassemia)
7. Lymphoma / leukemia
8. Brucellosis

• Peripheral blood smear (thick and thin film): Gold standard; identifies species and parasite density
• Rapid Diagnostic Test (RDT): HRP-2 antigen (P. falciparum), pLDH antigen (P. vivax) - quick bedside test
• CBC: Anemia, thrombocytopenia, leukopenia
• LFT, RFT (assess organ involvement)
• Blood sugar (hypoglycemia in P. falciparum)
• Blood culture (rule out typhoid/bacteremia)

• Uncomplicated P. vivax:
  • Chloroquine 25 mg/kg over 3 days (10 + 10 + 5 mg/kg) + Primaquine 0.25 mg/kg/day × 14 days (after G6PD test)
• Uncomplicated P. falciparum (per NVBDCP India):
  • Artemisinin-based Combination Therapy (ACT): Artesunate + Lumefantrine OR Arterakine (AS + SP) × 3 days
  • Primaquine single dose (0.75 mg/kg) to clear gametocytes
• Severe/Complicated Malaria (P. falciparum):
  • IV Artesunate 2.4 mg/kg at 0, 12, 24 hrs, then daily
  • If not available: IV Quinine (loading dose 20 mg/kg in dextrose saline over 4 hrs, then 10 mg/kg 8-hourly)
  • Treat complications: IV dextrose (hypoglycemia), transfusion (severe anemia Hb <5), anticonvulsants (cerebral malaria), dialysis (renal failure)

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Q6.3: Catch-up Immunization for 9-month-old + AEFI

• DTwP/IPV/Hib/PCV: Minimum interval = 4 weeks between doses
• At 9 months: Give DTwP1 + IPV1 + Hib1 + PCV1 + Rotavirus1 NOW
• 4 weeks later (10 months): DTwP2 + IPV2 + Hib2 + PCV2 + Rotavirus2
• 4 weeks later (11 months): DTwP3 + IPV3 + Hib3 + PCV3
• At 9 months: Also give MR/MMR (scheduled dose), Vitamin A 1 lakh IU, JE 1 (if endemic area)
• Never restart a series; count valid prior doses and continue from where left off

• Vaccine reaction: Programmatic error (abscess, injection site infection), vaccine-induced (fever, anaphylaxis, febrile seizures post-DTP, intussusception post-Rotavirus - rare)
• Coincidental: Would have occurred regardless of vaccine
• Injection reaction: Fainting, pain at site

• Fever, local redness/swelling (most common - within 48 hrs, self-limiting)
• BCG: Local ulcer → scar (expected); abscess (programmatic error)
• DTwP: Persistent screaming, hypotonic-hyporesponsive episode (HHE)
• MMR: Rash, fever at day 5-12 (vaccine-strain viremia)
• Anaphylaxis: Rare but most serious; treat with Adrenaline 0.01 mg/kg IM

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QUESTION 7 (18 marks) - Write ANY THREE short notes (6 marks each)

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Q7.1: Measles - Clinical Features and Complications

• High fever (39-40°C), cough, coryza (3 C's), conjunctivitis
• Koplik's spots: Pathognomonic - bluish-white spots on red base on buccal mucosa (opposite lower molars); appear 1-2 days before rash

• Maculopapular rash appears day 3-4 of fever
• Starts behind ears/hairline → spreads downward: Face → neck → trunk → extremities (cephalocaudal spread)
• Rash lasts 4-6 days, then fades in order of appearance (leaving brownish discolouration = desquamation)
• Fever highest when rash appears on face

• Rash fades with branny desquamation
• "Koplik's + cough + conjunctivitis + cephalocaudal rash" = clinical diagnosis

• Vit A: 2 lakh IU at diagnosis and next day (reduces mortality)
• Supportive: antipyretics, fluids, nutrition
• Antibiotics for bacterial superinfection

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Q7.2: Dengue - Clinical Phases, Warning Signs, Severe Dengue, Management of DSS

• Sudden high fever (39-40°C), "breakbone fever" (severe myalgia, arthralgia, retroorbital pain)
• Flushed face, headache, nausea, vomiting
• Early rash (macular), thrombocytopenia begins
• Positive tourniquet test

• Fever may defervese (misleading improvement)
• Plasma leakage → pleural effusion, ascites, hemoconcentration (HCT rises >20%)
• Thrombocytopenia <100,000 → platelet <20,000 in severe
• Bleeding manifestations: petechiae, epistaxis, gum bleeding, melena
• WARNING SIGNS occur here

• Reabsorption of leaked plasma → fluid overload risk
• Bradycardia, dilutional thrombocytopenia
• "Convalescent rash" - isles of white in sea of red

• Abdominal pain or tenderness
• Persistent vomiting
• Clinical fluid accumulation (ascites, pleural effusion)
• Mucosal bleeding
• Lethargy/restlessness
• Liver enlargement >2 cm
• Rapid rise in HCT with rapid fall in platelet

• Severe plasma leakage → Dengue Shock Syndrome (DSS) or fluid accumulation with respiratory distress
• Severe bleeding (clinically significant)
• Severe organ involvement: liver (AST/ALT >1000), CNS (encephalitis), heart (myocarditis), renal failure

• Compensated shock (BP maintained): Isotonic crystalloid (NS or RL) 10 mL/kg over 1 hour; reassess; repeat if improving, reduce gradually (10→5→3 mL/kg/hr)
• Hypotensive shock: Crystalloid 20 mL/kg over 15-30 min bolus; if HCT rises = use colloid (Dextran 70 or 6% HES 10 mL/kg)
• Monitor: Vital signs every 15-30 min, urine output (target >1 mL/kg/hr), HCT, BP
• Avoid: Excessive IV fluids (cause pulmonary edema in recovery phase)
• Platelet transfusion only if <10,000 or active significant bleeding
• Blood transfusion if severe hemorrhage
• Monitor for fluid overload in recovery phase (diuretics if needed)

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Q7.3: Behavioural Problems in Toddlers + PICA

1. Temper tantrums: Most common; child throws self on floor, screams when wishes thwarted; peaks 18-36 months; management: ignore, consistent limit-setting, positive reinforcement, avoid giving in
2. Breath-holding spells: Provoked by frustration/pain; child holds breath → cyanosis/pallor → may faint; benign; management: reassure parents, no medication needed
3. Night terrors and nightmares: Night terrors (NREM, inconsolable, no memory); management: reassurance, regular sleep schedule
4. Thumb sucking: Normal up to 4 years; dental problems if persists; ignore until 4 years
5. Head banging/rocking: Self-stimulatory; often at bedtime; usually benign; padding of crib
6. Feeding problems: Food refusal, food jags (eating same food repeatedly); normal autonomy-related
7. Sleep problems: Resistance to bedtime, night waking
8. Aggression/biting: Normal toddler behavior related to autonomy development

• Definition: Persistent eating of non-nutritive, non-food substances for >1 month, inappropriate for developmental level (age > 18 months to diagnose)
• Substances: Soil/mud (geophagia - most common), paint chips (lead poisoning risk), hair (trichophagia), ice (pagophagia - suggests iron deficiency), paper, chalk, clay

• Iron deficiency anemia (most common association)
• Zinc deficiency
• Autism spectrum disorder, intellectual disability
• Neglect, psychosocial deprivation
• Cultural practices (e.g., geophagia in some communities)

• Lead poisoning (paint chips)
• Intestinal obstruction (trichobezoar from hair)
• Parasitic infections (soil eating)
• Dental injury, constipation

• Treat underlying deficiency (Iron, Zinc supplementation)
• Behavioral therapy (positive reinforcement, redirection)
• Environmental safety (remove access to substances)
• Psychosocial support
• Address autism/ID if present

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Q7.4: Childhood Tuberculosis - Clinical Features and Diagnostic Approach

• Constitutional: Fever (low-grade, persistent >2 weeks), night sweats, weight loss/failure to thrive, fatigue, loss of appetite
• Respiratory: Chronic cough >2 weeks, rarely hemoptysis in children
• Lymphadenopathy (hilar, paratracheal on CXR - most common finding)
• Primary complex: Ghon's focus + lymphangitis + hilar lymphadenopathy

• TB Lymphadenitis: Most common extrapulmonary; cervical nodes; cold abscess (non-tender, matted), "collar stud abscess"
• TB Meningitis: Fever + headache + altered sensorium + meningismus; high mortality; CSF - lymphocytic pleocytosis, high protein, low glucose, cobweb clot
• Miliary TB: Hematogenous dissemination; diffuse micronodular "millet seed" shadows on CXR; choroid tubercles on fundus examination
• Skeletal TB: Pott's spine (gibbus deformity), cold abscess
• Abdominal TB: Doughy abdomen, ascites, tabes mesenterica

1. History: Contact with adult TB case (most important in children), BCG status, previous treatment
2. Mantoux (TST): Intradermal PPD 2 TU; read at 48-72 hrs
   • ≥10 mm = positive (≥5 mm if immunocompromised/malnutritioned/HIV)
   • Negative TST does NOT rule out TB in children
3. IGRA (Interferon-Gamma Release Assay): Quantiferon TB Gold / T-SPOT; preferred in BCG-vaccinated
4. Chest X-ray: Primary complex, hilar lymphadenopathy, miliary pattern, cavities (uncommon in children), pleural effusion
5. Microbiological: Gastric lavage (young children can't expectorate) × 3 days; sputum AFB smear + culture (Lowenstein-Jensen); GeneXpert MTB/RIF (rapid, detects rifampicin resistance)
6. Scoring System (Stegen-Toledo / Indian Pediatric TB Score): Used when bacteriology unavailable - scores symptoms, contact, TST, CXR, malnutrition, response to antibiotics
7. Other: CSF analysis (TBM), tissue biopsy (lymph node), ADA (ascitic fluid), CT chest/abdomen

• Intensive phase: 2 months HRZE (or HRZ for non-severe)
• Continuation phase: 4 months HR
• Total: 6 months (extrapulmonary/miliary/TBM: 9-12 months)

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QUESTION 8 (10 marks) - ANY FIVE in 2-3 sentences (2 marks each)

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Q8.1: Clinical Features of Zinc Deficiency

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Q8.2: Difference between Caput Succedaneum and Cephalohematoma

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Q8.3: Entitlements under JSSK (Janani Shishu Suraksha Karyakram)

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Q8.4: Hyperkalaemia - Definition and ECG Changes

1. Tall, peaked (tented) T waves (earliest change, K ~5.5-6.5)
2. Prolonged PR interval
3. Widened QRS complex
4. Sine wave pattern
5. Ventricular fibrillation / asystole (K >8-9)

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Q8.5: BMI (Body Mass Index)

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Q8.6: Neonatal Mortality Rate (NMR)

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Exam Tip Summary by Weightage:

• Q1, Q5 (10 marks each) = Full detailed long answers with all subparts
• Q2, Q6 (12 marks = 6 each) = Moderate structured answers with tables/points
• Q3, Q7 (18 marks = 6 each) = Focused short essays with key headings
• Q4, Q8 (10 marks = 2 each) = Exactly 2-3 sentences per topic