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ayeddent
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on
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reat
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is.
..
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ces
s
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alphos
phor
us
Poor
/del
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owt
h
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ional
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gnzofr
icket
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+

I
MM MARCH2012 2.
Vi

Dos
t
a-

e.
D1-

30-
25(
Cal

70ng/
ci

kg/
t
ri

day
ol
)

×BD
3.Gr
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monef
ors
hor
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atur
e -
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all
ook:

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etr
ichi
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phor
usl
ikeas
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ts,c
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lydehydr
ated

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teot
omi
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orBonedef
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ti
es *Si
ckl
ooki
ng

6.Par
ent
alcouns
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ing *Boys
..
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nor
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ia

7.Genet
iccouns
ell
ing -
Lab:

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itancepat
ter
n ↑17-
ohpr
oges
ter
one

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n

F)
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dos
ter
one

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rl
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hor
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atur
ecanper
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icket
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ugarl
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icat
ions -TheACTHs
timul
ati
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estorSynact
hent
est

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seas
einduced.
. -
U/sKUB

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atur
e -
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yot
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ng

Bonedef
ormi
ti
es Tr
eat
ment
:

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iti
on Suppor
tiv
e

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hAbs
ces
s -
admi
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apyi
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.. -
mai
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ine

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ces
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usi
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moni
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tal
s

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par
athy
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m -
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arr
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ces
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ocal
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cal
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2IMM MARCH2012 *Bi
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nsul
in
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-
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t 7.Compl
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igen

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ecanhaveovervi
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ati
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ype .
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tens
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.Speci
fi
c..
.

3betahydrox
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oiddehydr
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las
edef i
ciencyandli
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sex
uali
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li
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agesofthesetypesofc ahar
elow
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eroi
ds
Q.
3IMM MARCH2012 I
VIG

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p Pl
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s

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iti
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cycl
ophos
phami
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azat
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im

Meni
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I
tp (
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B)I
NVESTI
GATI
ON Maj
or:
GI
T:(
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car
dit
is

1.
int
uss
uspt
ion 2.
orchi
ti
s

2.
mes
sent
rci
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a 3.
inf
lamat
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e

3.
pral
yti
cil
eus 4.
tet
icul
art
ors
ion

4.
per
for
ati
on 5.
pul
monar
yhemor
hage

5.
Mal
ena
Q.
4IMM MARCH2012
6.
nons
peci
fi
c..
..
N,V,
abdomi
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n
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lentc
hes
t
Renal
:(
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nos
is
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uri
a
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s
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enui
a
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eofac
ces
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ymus
cle
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HTN
5.
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suspar
adox
icus
4.
franknephr
iti
s
B.
Treat
ment
:
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nephr
oti
vsyndr
om
-
admi
tpti
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6.
acut
eorchr
oni
crenalf
ail
ure
-
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ygeni
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ati
on
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cul
oskel
etal
:(
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-
Mai
ntai
ni.
vli
ne
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art
hrl
gia
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otr
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tal
s
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art
her
ii
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ual
lyl
argej
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-
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tro2s
at
Ski
n:
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trI
/ochr
ting
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pal
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..
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-
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ess
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tocks
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ine
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pet
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um br
omi
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ali
ne
3.
brui
ses
-
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drocor
tis
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v
4.
lar
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is
I
fnoti
mpr
oved.
Cns
:
-
inj
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ines
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y15mi
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es
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sei
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icbl
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Or
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Ter
but
ali
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nfus
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Mi
nor
:
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75mg/
kg/
dos
e3-
4dos
esever
y4hr
ly
Q.
5IMM MARCH2012
I
fptdet
ori
atest
heni
ntubat
enputonmechani
calvent
il
ati
onwi
thket
ami
nsedat
ion
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omer
ular
Ox
ygeni
nhal
ati
on.
.mai
ntai
nox
ygens
atur
ati
onmor
ethan92%
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Pul
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imet
ry
Lupus
Car
diopul
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ymoni
tor
ing
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ganephr
opat
hy
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Al
por
t
Ng
2.
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iz
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thSABAever
y20mi
nut
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or3dos
est
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ery1-
4houral
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lut
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mals
ali
ne
3.
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it
hias
is
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sal
but
amol0.
5mg
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idi
opat
hichyper
cal
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rea
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erol0.
15mg
5.
ttr
auma
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erol0.
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his
tor
y
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but
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est
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ly
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oati
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ect
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daybd
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igur
ia
I
/vs
olucar
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hen5mg/
kg6hour
ly
Headache,
vomi
ti
ng,
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si
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orht
n
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ichol
iner
gic
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er
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roventnebul
iz
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i
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ain
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kg.S/
corI
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oss
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nject
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kgl
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min
Ocul
orabnor
mal
it
ies
I
fpat
ientnoti
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ovedi
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2hour
sthen
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gency
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inueox
ygen
Fr
equenc
y
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requent
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inuous
ly
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ningmi
ctur
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vfl
uidsl
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han70%
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otr
aumaorf
all
I
ntubat
emechani
calvent
il
ati
on.
..
inr
espi
rat
oryf
ail
ure
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oras
hes
,phot
osens
itvt
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cer
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oints
wel
li
ng
I
vmgs
ulphat
e25-
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kg
Bl
ood
Hel
iox
Cbc
ESR ATN/
UTI
???

CRP C.Di
agnos
is:

BLOODCS Cbc

UCE UCE

ANApr
ofi
le RBS

ANTIDSSDNA Bl
oodcs

ANTISMI
THANTI
BODY ABGs

ASOT HbA1c

Compl
ementl
evel Ser
um os
mol
ali
ty

Ser
um I
gAl
evel Ur
ineos
mol
ali
ty

2.
.ur
inar
y Ur
ineanal
ysi
s.

Ur
inedr U.
sKUB

Ur
inar
yel
ect
rol
ytes Ani
ongap

3.
radi
ology Ganal
ysi
s

U/
KUB D.
Management

Xr
ayches
t Admi
t

Echo Npo

4.
.bi
ops
y Mai
ntai
nivl
ine

Renal Moni
torvi
tal
s

Ski
n Sendr
elev
anti
nves
tigat
ion

5.
ocul
orandhear
ingas
ses
sment.
..
. Speci
fi
c

Sl
itl
ampex
ami
nat
ion 1s
thr
..
rehydr
ati
on10-20ml/
kgi
vbol
usns
ali
ne.
.r
eas
ses
s.r
epeati
frequi
red

i
ndicat
ionsofbi
opsy 1.pati
entoresentswi
threnalf
ail
ure.
2.cl
ini
calmani
fes
tat
ionsi
nabs
enc
eof .
kpmanni
tol1gm/
kg
evi
denceofstr
eptococcali
nfection.3.per
sist
anthypocompl
ementenemiaaft
er6to8wks
.
ivpus
hfrcer
ebr
aledema
Q.
6IMM MARCH2012 .
ins
uli
n0.
1u/
kg/
mn

A.
DKA St
artr
bsmoni
tor
ing

B. 2ndhr
..
int
il
ldkar
esol
ve

D.
I 85×wt+mai
ntai
n~bol
us÷23hr
s

RTA Fl
iudus
ed0.
45%ns
ali
ne..
Cont
inuei
nsul
ini
nfus
ion
Q.
8IMM MARCH2012
I
fskl
esst
han3.
.addi
vk80meq/
li
tre
A)or
ganophos
phat
epoi
soni
ng
Moni
torsel
ect
rol
yte4hr
ly
B)
RBCchol
ines
ter
aset
est
s..
.
DoI
/OCHARTI
NG
C)i
mmedi
atet
reat
ment
Moni
torvi
tal
s&f
or
Admi
t
Cer
ebr
aledema
Vi
tal
s
Fami
lycouns
ell
ingabtdi
abet
es
ABC
Di
et
I
vcannul
a
Sel
frbsmoni
tor
ing
Changecl
othes
Regul
arf
ups
Ac
tiv
atedchar
coalf
orgas
tri
cdec
ont
ami
nat
ion
Compl
iance
Readyt
opas
set
t
Pr
eventc
ompl
icat
ions
Mai
ntai
nfl
uidandel
ect
rol
ytes
Ps
ychol
ogi
cals
uppor
t
At
ropi
niz
ati
on.
.
.
I
fser
um gl
ucos
e<300mg/
dlgi
veadd5% gl
ucos
e
Dos
e..
.0.
02-
0.05mg/
kg/
dos
e
I
fser
um gl
ucos
e<200t
hanadd10% gl
ucos
etoi
nfus
ion
Repeataf
terev
ery10mi
nut
es
Mi
lddkar
esol
vei
n10-
20hr
s
Moni
tors
ideef
fect
sofat
ropi
nel
iket
achycar
diaf
evermydr
ias
is
Sdkai
n30-
36hr
s
At
ropi
nef
rmy
scar
ini
caf
fec
t
Af
trdkar
esol
ve..
1stdos
eofi
nsul
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nsul
ini
nfus
ions
toppedaf
tr30mi
ntes
Pr
ali
dox
imef
rni
cot
ini
caf
fec
ts

Q.
7IMM MARCH2012 Cont
rols
eiz
ures
..byant
icomvul
sant
s

Thal
asemi
a Ant
ipyr
eti
c

H.
sphr
ocyt
osi
s f
upf
orl
ongt
ermcompl
icat
ions

Scd Pol
yneur
opat
hy

I
rondef
ici
encyanemi
a Ps
ychi
atr
ici
ssuz

Leukemi
a Fami
lycouns
ell
ing

Chr
oni
cmal
ari
a
Q.
9IMM MARCH2012
Wi
ls
ondi
seas
e
1.
Chr
omos
omalanal
ysi
sofchi
ldaswel
laspar
ent
stodet
ermi
net
rans
locat
ioncar
rier
H.
ell
ipt
ocyt
osi
s
2.
Echo.
.f
rCHD
Pl
zcor
rect
..oraddup.
.?
3.
TFT.
.Forhypot
hyr
oidi
sm
t
womet
hodsofs
creeni
ngf
orDown'
ssyndr
ome: .
.l
if
eex
pct
ancyofdowns
yndr
om i
s50-
55%

1)
ser
um s
creeni
ng .
.chi
ldi
sdevel
opment
lydel
ayd

2)ul
tras
ounds
creeni
ng; .
.s
oci
aldevel
pmenti
arel
ati
vel
yspar
ed

ul
tras
ounds
cancanbecar
riedoutbet
ween11weeks+2day
sand14weeks+1dayofpr
egnanc
y. .
.chi
ldr
espondswel
ltobehavreducat
ionalpr
ogr
ams

(
nuchalt
rans
lucency)
. .
.Comor
bidi
iesex
pect
edar
e:

Pr
enat
alul
tras
oundf
or HEARI
NGANDVI
SIUALPROBLEMS

Thi
ckenednuchalf
old CARDI
ACPROBLEMS

Chor
oidpl
exuscys
t REPEATEDCHESTI
NFECTI
ONS

Nuc
halt
rans
lucency CELI
ACDI
AEASE

Duodenalat
res
ia HYPOTHYROI
DISM

Shor
tfemurl
engt
h27cms D.
M

Shor
thumer
us OBESI
TY

Abs
enceofnas
albone I
NFERTI
LITY(
ESPEC.
..
INMALES)

Ser
um mar
ker
s; I
NCRI
SKOFLEULEMI
ANALZI
MERSDI
SEASE

bl
oods
ampl
ecanbet
akenf
rom mot
herbet
ween10weeksand14weeks+1dayofpr
egnanc
y. REPEATEDJ
OINTDI
SLOCATI
ON

1)
Amni
ocent
esi
sand
Q.
10I
MM MARCH2012
2)
Chor
ioni
cVi
ll
usSampl
ing
A.
Stat
usepi
lept
icus
3)
PAPP-
A:
B.Compl
icat
ionsofs
eiz
ures
:
pr
oducedbypl
acent
als
yncyt
iot
rophobl
ast
s;l
evel
sreduc
edi
npr
egnanci
esaf
fec
tedbyDown'
ssy
ndr
ome.
DURI
NGSEI
ZURES:
:
4)
Bet
a-hCG:
Hypox
ia
pr
oducedbypl
acent
als
yncyt
iot
rophobl
ast
s;r
ais
edl
evel
sinpr
egnanci
esaf
fect
edbyDown'
ssy
ndr
ome.
Lact
icac
idos
is
5)
AFP:
Di
str
ubdaut
onomi
cn.
s
pr
oducedbyf
etalyol
ksacandl
iver
;reducedl
evel
sinpr
egnanc
iesaf
fec
tedbyDown'
ssyndr
ome.
Hyper
kal
emi
a
6)
uE3:
Hypogl
ycemi
a
pr
oducedbypl
acent
aandf
etaladr
enal
s;r
educedl
evel
sinpr
egnanc
iesaf
fec
tedbyDown'
ssyndr
ome.
Hyper
/hypot
hrmi
a
7)
Inhi
bin-
A:
RenLf
ail
ure
pr
oducedbypl
acent
a;r
ais
edl
evel
sinpr
egnanci
esaf
fec
tedbyDown'
ssyndr
ome
Res
pir
atr
yfai
lur
B.
.r
ober
tsi
ont
rans
locat
ioncar
ries5-
7% r
ecur
rencer
isk
Deat
h
C.
Councel
li
ng
AFTERSEI
ZURES:
: Ket
ogeni
cdi
et

1Neur
ologi
caldef
ici
t.
..
.mot
or/
sens
ory Vagusns
timul
ati
on

2.
Behavr
aldi
aor
der
s Hypot
her
mia

3.
Subs
eques
nts
eiz
ures Magnet
ict
rans
crani
als
timul
ati
on

4.
Progr
ess
iveencephl
opat
hy Sur
gic
almanagementwi
thf
ocalr
esect
ion

5.
Ment
alr
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1)
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i
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car
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irs
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Dor
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enal
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ngl
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eas
ess
yst
emi
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cul
arr
esi
stance)

Tr
icus
pid/
atr
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a 13)
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ess
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bed.

Es
simngers
yndr
ome 14)
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ubat
ionandpos
iti
vepr
ess
urevent
il
ati
onmayber
equi
redi
nex
tremecas
es.

Tr
eat
ment
: Qno5-
oct
-2013
1)
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nst
erhi
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amas
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ashock/
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eat
ment
: 15)
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ivemoni
tor
ing(
eg,
cent
ralvenouspr
ess
ure(
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)canhel
ptoas
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cit
ati
on.

Admi
tpat
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CU 16)
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ionrequi
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i
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rys
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ntubat
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tis
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ail
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e).
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das
ses
sment
: 20)r
eas
ses
s/pul
ser
ateandBPr
egul
arl
y(ever
y5mi
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es)
.
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way:
lookf
orandr
eli
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truct
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ftherear
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d
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). Decr
eas
eors
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lui
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usi
on.
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hing:l
ookf
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onchos
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ess
. 22)(
inot
ropes
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ess
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dopami
n/doupat
mine/
inf
usi
on
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cul
ati
on:col
our
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seandBP.
Q6/
apr
il2013
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abi
li
ty:
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esswhet
herr
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cious
.
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ses
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thadequat
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ure,
butavoi
dex
ces
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oss
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ign
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gh-
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ygen-us
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k
or
6)
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lat
:
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oudi
ngofcor
nea
7)
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set
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egs
or
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epi
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eint
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y(I
M)i
nant
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ater
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pec
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ddl
e
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gh ●Deeporex
tens
ivemout
hul
cer
s

9)
repeat
edaf
ter5mi
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fther
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. B)

10)
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rom I
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THEYEORMOUTH

11)
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/m COMPLI
CATI
ON

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eri
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eri
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y
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12)
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ti
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ds ol
uti
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tmann'
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ali
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thi
nthel
ast3mont
hs.
14)
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us20ml
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fors
hock C)
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veVi
tami
nAt
reat
ment 3)
qui
ckas
ses
smentofGCS

200000I
UNow 4)
urgentCTs
canned

Thens
econdday 5)Resusci
tat
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icandAdv
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y6)
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ever
etr
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e
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hly
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lcer
vicals
pinei
mmobi
li
sat
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nort
ender
nes
s/f
ocalneur
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caldef
ici
tpar
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r
ecor
ddos
e
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rwayas
ses
smentby
●I
fpusdr
aini
ngf
rom t
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e,t
reateyei
nfect
ionwi
tht
etr
acyc
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ntment
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li
sten/
feel
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fmout
hul
cer
s,t
reatwi
thgent
ianvi
olet
2)
endot
rac
heali
ntubat
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nser
tionofl
aryngealmas
kai
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oundor
ophar
ynx
.
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ievet
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eRemedy
Br
eat
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acet
amolf
orf
ever
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genwi
thbegi
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ati
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low-
upi
n3days
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ingi
sadvi
sabl
e,ashyper
vent
il
ati
oni
sas
soci
atedwi
thpoor
erout
comesr
elat
edt
o
Qno7-
oct
-2013 cerebr
alvasocons
tri
cti
on.

1)
His
tor
yofi
njur
y Ci
rcul
ati
on-

2)
typeofi
njur
y/hi
ghl
owener
gyi
njur
y 1)
ass
essf
ors
yst
oli
cbl
oodpr
ess
ure

3)
Anyl
ossofcons
cious
nes
sres
ultofi
njur
y. 2)
col
dex
tremi
ti
es

4)
Anyf
ocalneur
ologi
caldef
ici
tsi
ncei
njur
y. 3)
signofs
hock

5)
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iaf
orevent
sbef
oreoraf
teri
njur
y. B)

6)
per
sis
tentheadaches
incei
njur
y. 1)
Per
for
m endot
racheali
ntubat
ionf
orpat
ient
swi
thdecr
eas
edl
evelofcons
cious
nes
sandpoorai
rwaypr
otect
ion.

7)
Anyvomi
ti
ngepi
sodess
incei
njur
y 2)
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ious
lyl
owerbl
oodpr
ess
uret
oameanar
ter
ialpr
ess
ure(
MAP)
butavoi
dex
ces
sivehypot
ens
ion.

8)
frequency/
type/
dur
ati
onofs
eiz
ures
incei
njur
y. 3)
Rapi
dlys
tabi
li
zevi
tals
igns
,ands
imul
taneous
lyacqui
reemer
gentCTs
can.

9)
Ir
rit
abi
li
tyoral
ter
edbehavi
ours
inc
einj
ury 4)
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ubat
eandhypr
vent
il
atei
fint
racr
ani
alpr
ess
urei
sincr
eas
ed;

10)Anysuspi
cionofaskullf
ract
ureorpenet
rati
ngheadi
njur
ysi
nceinjury(
eg,cl
earfl
uidf
rom t
heearsornos
e, 5)
ini
ti
ateadmi
nis
trat
ionofmanni
tol
blackey
ewi t
hnoas s
ociateddamagearoundtheeyes
,bl
eedi
ngfrom oneorbothear
s,newdeafnes
sinoneor
6)
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neuvolemia,
usi
ngnor
mot
oni
crat
hert
hanhy
pot
oni
cfl
uids
,tomai
ntai
nbr
ainper
fus
ionwi
thout
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uisi
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.
ex
acerbat
ingbrainedema.
11)
Vis
ibl
etr
aumat
ohead
6)
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rec
tanyi
dent
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abl
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opat
hywi
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res
hfr
ozenpl
asma,vi
tami
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otami
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atel
ett
rans
fus
ions
.
A)
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ess
ment
;
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ti
atef
ospheny
toi
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ant
iconvul
santdef
ini
tel
yfors
eiz
ureact
ivi
tyorl
obarhemor
rhage,
1)
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atus-pul
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ate/
B.p/
temper
atur
e/f
lui
dst
atus
.
8)
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irac
etam hasshownef
ficacyt
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ors
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ldr
enf
orpr
ophyl
axi
sofear
ly
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ologi
calas
ses
sment- post
hemorrhagi
cs ei
zur
es.

f
ullhi
stor
yandex
ami
nat
ion, 9)
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li
tat
etr
ans
fert
otheoper
ati
ngr
oom orI
CU.

3)
not
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lsi
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eact
iont
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ght Sur
gic
alCar
e,
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idersur
geryforpat
ient
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eat
erthan3cm, f
orpat
ient
swithi
ntr
acer
ebr
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yfordeter
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ei sanyspeci
fi
cdefi
ciencyi
ndens egr
anulenumber
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r
hemorrhageassoci
atedwi
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ructur
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cularl
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oryoungpat
ient
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eg,s
tor
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ease),ors
pecif
icdefect(
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ndegranul
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on( eg,r
eleas
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2)
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ger
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otei
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a-thrombogl
obul
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uredbyELI
SA,r
adi
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atel
etdis
order
.
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ini
calcour
seandt
imi
ng
6)
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tronmi
cros
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orul
tras
truct
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it
iesas
soci
atedwi
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iet
yofpl
atel
etdef
ect
s.
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ient
'sage/
comor
bid/
Eti
ology/
Loc
ati
onoft
hehemat
oma
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ulargenet
icdi
agnosi
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ablepl
ateletdi
sordrconf
irmati
onofdi
agnosisinaffect
edindi
vidual
s,i
n
3)
crani
otomywi
thevacuat
ionoft
hehemat
omai
snots
ucces
sful famil
ymember swherephenotypi
ctest
ingofplatel
etsi
simpracti
calandf
orantenataldi
agnosis
.
4)
Ster
eot
act
icas
pir
ati
onwi
tht
hrombol
yti
cagent
s 9)Bonemarrowexaminat
ion10)
Tes
tingf
ordr
ug-
dependentpl
atel
etant
ibodi
es-
usef
uli
nsever
edi
seas
ewher
e
Endos
copi
cevacuat
ion thediagnos
isi
sindoubt.

ot
hers
uges
tion
Qno8-
oct
-2013
:A.NATP
D/
D
i
soi
mmunei
tp
1)
Neonat
alal
loi
mmunet
hromboc
ytopeni
a
CAMT
2)
Mat
ernali
tp
TAR
3)
pltf
unc
tiondi
sor
der
Pl
atel
atetdi
sor
der(
ber
nar
d)
B)
His
tor
yMat
ernalh/
0sl
eorI
TP
HDN??
Bl
eedi
ng.
B.Hi
stor
y
Ras
hes
.Phot
osens
iti
vit
y.Ar
thr
iti
s.Hxofbl
oodt
rans
fus
ion.
Per
inat
alr
ash
Mat
ernaldr
ughi
stor
y(hepar
in,chl
ort
hiaz
ide,qui
nine,
hydr
alaz
ine)
Del
iver
ypl
ace
Fami
lyhxoft
hrombocyt
openi
a
Hi
stor
yofv
itkgi
venornot
I
nves
tigat
ion:
C/
sect
ionornvd
Mot
her
'saut
oimmunepr
ofi
le:
Dr
ugs
ANA,ANTIDSDNA,ANTIHPAant
ibody
Fami
lyhi
stor
y
Coombt
est
C.
Labs
I
PF
Cbces
ppl
atel
etcount
Ot
her
s
APTT
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ans
mis
sionaggr
egomet
ry:eval
uat
esaggr
egat
ionorcl
umpi
ngofpl
atel
etsi
nres
pons
etoaggr
egat
ing
st
imuli
. Pt

2)
Flowc
ytomet
ry: Bt

Forconf
irmat
ionofGT,BSSus
edt
oinves
tigat
eabnor
mal
it
iesi
ncol
lagenandt
hrombi
nrec
ept
ors
. Coombt
est

3)
Meas
urementoft
otalandr
eleas
ednucl
eot
ides
:pr
ovi
desani
mpor
tantaddi
ti
onaldi
agnos
tict
ooli
nconj
unc
tion Bl
oodgr
oupmot
herndbaby
Mat
ernalant
ibodi
esagai
nstf
etalpl
tsorant
igenHPA-
1a. Pl
zedi
tifneeded

Met
ernalpl
atel
etcount
Q9OCT2013
Skel
etals
ervey
.
Admi
t8vl
ini
vfl
uidsabcs
ecur
e
DNA/
genet
icANALYSI
S.
Cor
ectaci
dos
iswi
dsodabi
car
b
D.
managment
Ox
ygen
1.
NATP
Nebul
izwi
dvent
oli
n3t
imes20mnt
sapar
t
A.PRENATAL
I
fnoti
mpr
ovet
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iz
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dipr
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omi
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)
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vigt
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rom 2ndt
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odel
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Thenor
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Thenepi
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ine
Cs
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I
fnott
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nophl
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Pos
tNat
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I
fnott
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hyl
xant
hinei
v
Was
hdmt
rns
lpl
tsi
fneeded
I
fnott
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o4
Moni
torpl
ts
I
fnott
henvent
.
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tal
s.
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ONASTHMA
2.
ISOI
MUNEI
TP
C.4St
eps
.
i
vignds
ter
iodt
omot
herpr
enat
al
1.
Regul
armoni
tor
ingandas
ses
ment
Pos
tnat
ali
vignds
ter
iodt
obaby
.Les
ssever
econdi
ti
ont
hanNATP
2.Pat
ientandpar
enteducat
ionabtdi
seas
eit
srr
igngf
ctsi
tsacut
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tscmpl
icat
iond
3.
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3.Tr
eatt
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ty
l
eukor
educepl
ts
4.Phar
mac
other
apy
.
I
L-3
Or
HSCT/
BMT
C.I
cumanagmnt
..
.
COUNSELLI
NGABOUTDI
SEASE
Q10oct2013
4.
IFTAR
A.
Cont
inuebr
eas
tfeedbutbef
ores
tar
tingf
eedi
nggi
vepr
ophyl
axi
stobaby.
l
eukor
educepl
ts
B.Prophyl
axisi
nh10mg/k/dayfor3mont
hst
hendomtt
estndcx
rayofbabyi
fnor
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topt
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menti
f
Ami
nocapr
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rans
ami
ne
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inueupto9months
des
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n
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venat3mont
hsofi
nhwhenmtndcx
rayar
enor
mal
.
BMT

couns
eli
ng

Fup
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MM apr
il2014
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ell
ing

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Sol Ventdi
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eeg Venti
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tive Di
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s
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fi
c Dopami
ne

1.
Acut
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Ns
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Sumat
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Ger
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Cons
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Li
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Couns
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Endos
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cbal
loondi
lat
ioni
ncas
eofi
ncompl
etepyl
oromy
otomy Ur
inar
yani
oni
cgap

Cons
ervat
ive(
ifs
urger
ycoul
dnotpos
sibl
e) Ur
inal
ysesf
orhemat
uri
apr
otei
nur
iaphos
phat
uri
aami
noaci
dur
ia

nas
oduodenalf
eedi
ngs Ul
tras
oundkubt
osees
eenephr
ocal
cinos
is

at
ropi
nes
ulf
ate Di
scus
sionej
ust
ifi
cat
ionofi
nves
tigat
ions

c)Couns
ell
ing: moni
torpol
yur
iaorpol
ydi
psi
a(ex
ceedi
ng2L/m2

aboutdi
seas
e,i
tsdi
agnos
is,
treat
mentopt
ionsopt
ions
,nut
rit
ion /
24hr
)orpol
yur
ia(
(>200mL/m2/
hr)

Q2/
oct2015 D.
I

1.
ser
ology:
A)
Na(
>145mel
/L)
1.
D.I
Os
mol
ali
ty>300mOs
m/kg
2.
CKD(
renaldys
plas
ia)
waterdepr
ivat
iontes
t:i
fserum os
molali
tyi
sles
sthan300mOs
m/kg(
but>270mOs
m/kg)es
tabl
is
hthedi
agnos
is
3.
RTA ofDIandtodiffer
ent
iatecent
ralfr
om nephr
ogeni
ccauses
.

4.
Bar
terSyndr
ome(
bczdecKcaus
espol
yur
ia) 2.
Uri
nar
y:

5.
primarypol
ydi
psi
a(bczl
eadt
odi
mini
shedt
oni
cit
yoft
her
enalmedul
lar
yint
ers
tit
ium andNDI
.decNa&pr
oti
en Spgr
avi
ty:
>
i
ntakeleadst
oFTT
Na:
B)
Os
mol
ali
ty:
<300mOs
m/kg
I
nves
tigat
ions
Cent
ralD.
I
Ser
um el
ect
rol
ytes
Pi
taut
aryhor
mones
(dec
)
Ur
ea
s
eri
alMRIs
cans
(tr
auma,
tumor
(Ger
minomas
/pi
neal
omas
/Cr
ani
ophar
yngi
omas
/opt
icgl
iomas
/
Cr
eat
ini
ne
CTSc
anbr
ain
ABGs
α-
fet
opr
otei
nandβ-
HCGhor
moness
ecr
etedbyGer
minomas
Ser
um os
mol
ari
ty
Nephr
ogeni
cD.
I
Ser
um ani
oni
cgap
Ca(
inc)
Ca,
ALP,
vit
D,PTH
K(
dec)
Ur
inepH
U.
SKUB(
PCKD/
CKD/
Obsur
opat
hy)
Si
ckl
ingt
est
(SCD) Ur
inemaybeal
kal
ineoraci
dic
.

pr
imar
ypol
ydi
psi
a Ur
.Na(
inc)

CKD(
Renaldys
plas
ia) Ur
.K(
dec)

U.
SKUB:
Bil
ater
alRenals
izepl
otc
ent
il
esf
orage&s
ex
Q3-
OCT-
2015
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,ALP,
decvi
tD,
PTH,
xraywr
istf
orr
icket
s
A)
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1.
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ionalabdomi
nalpai
n
S.
elect
rol
ytes
(decNa,
decK,
incCl
,decBi
car
b,
2.
cons
tipat
ion
VBGs
:met
abol
icaci
dos
is
3.
esophagi
ti
s
Non-
ani
ongap:
nor
mal
(12-
20)
(Na)
-(Cl
+HCO3)
4.
gas
tri
ti
s
pRTA
5.
inf
lammat
oryboweldi
seas
e
S.
bicar
b(decbczl
ossi
nur
inet
hrupr
oxi
malt
ubul
es)
6.
inf
lammat
oryboweldi
seas
e
S.
PO4(
decbczl
ossi
nur
inet
hrupr
oxi
malt
ubul
esi
nfanc
oni
)
7.
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ver
tic
ulum
Ur
inal
ysi
s:
pH<5.
5bczdi
stalt
ubul
esaci
dif
icat
ioni
sint
act
8.
Leadpoi
soni
ng
ur
ineani
ongap(
Ur.
Na+Ur
.K+)
−(ur
ineCl
)-vegap
9.
Abdomi
nalmi
grai
n
Fanconi
(phos
phat
uri
a,ami
noaci
dur
ia,gl
ycos
uri
a,ur
icos
uri
a,
10.
wor
msi
nfes
tat
ion
U.
lyt
es:
Na(
inc)
K(i
nc)

Xr
aywri
str
icket
ssecto(l
ossofPO4inur i
nefrom pr
oxi
malt
ubul
ess
ect
ofanc
oni
)or(
decpHs
ect
oincl
ossof
bi
car
binur
inefrom pr
oxi
maltubul
esi
diopathi
cpRTA) B)

U.
SKUB(
obsur
opat
hy) 1.
Compl
eteH&E

dRTA ■nat
ure ●dul
l&poor
lyl
ocal
iz
ed(
vis
cer
al)

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inal
ysi
s>5.
5(dRTA) ●i
ntens
e&l
ocal
iz
ed(
somat
ic:
per
itoni
ti
s)

uri
neani
ongap(
Ur.
Na+Ur
.K+)
−(ur
ineCl
)Apos
iti
vegaps
ugges
tsadef
ici
encyofammoni
agenes
is,
thusdi
stal ■l
ocat
ion ●epi
gas
tri
c(l
iver
/pancr
eas
/bi
li
aryt
ree/
RTA.
s
tomac
h/upperbowel
U.
Ca(
incbc
zincl
ossi
nur
inet
hrudi
stalt
ubul
es)
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li
cus
(di
stals
mal
lbowel
/cecum
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SKUB(
nephr
ocal
cinos
isornephr
oli
thi
asi
s)
: appendi
x/pr
oxi
malcol
on/
appendi
x
Xraywri
stri
cket
ss ecto(decpHduet
olos
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nur
inei
ndi
talt
ubul
es)or(
decS.
Cai
nbl
oodduet
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ossodCa
●s
upr
apubi
c(di
stall
argebowel
/ur
inar
ytr
act
/
i
nur i
nethr
udistaltubul
es
pel
vicor
gans
/tr
ans
ver
secol
on
TypeI
VRTA(
CAH/
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sons
/unr
espons
etoal
do)
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iteofl
esi
on(
ascendi
ng&des
cendi
ng
S.
K(i
nc)
col
on&s
ecum
non–ani
ongapmet
abol
icac
idos
is.
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ed ●i
nfer
iorangl
eoft
her
ights
capul
a(bi
li
aryc
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c) Ey
es(
congeni
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auc
oma,

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eat
ic) Lookf
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ori
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nes
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ames
ide) CVS(
mur
murofPDA,
pul
monar
yar
ter
yst
enos
is)

●upperl
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owerl obepnuemoni
a)■f
requency
■sev
eri
ty■as
soci
ated: GI
T(Hepat
ospl
enomegal
y,J
aundi
ce
●headac
hes●anor
exia●nausea●vomiti
ng
I
ntr
aut
eri
negr
owt
hres
tri
cti
on
●excessi
vegas●diarrhea●consti
pati
on●j
ointpai
n,■feverunex
plai
ned■Uri
nar
ys ymptoms●dys
uri
a●ur
genc
y
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equency●■wtl oss ■shorts
tatur
e■dysphagi
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tur
al■emesis ● Bood(
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pur
a(25% -'
blueber
rys
kin'
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itant●bi
li
ous■jaundice■awakeningf
rom sl
eepinpai n;
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eedi
ngPR■wormsi nst
ool Bl
ood(
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yti
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a)Mus
cul
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etal
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e(20%)
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lyH: ●mi
grai
n●I
BS●I
BD●Cel
iac●PUD C
Examintion■edemaNormalgrowthandphys i
calex
amination(i
ncludi
ngar ect
alexaminati
on)andt heabsenceof Long-
ter
m compl
icat
ions
anemiaorhemat ochezi
aarereass
uringinachil
dwhoi ssuspectedofhavingfunc
t i
onalpai
n.■Localiz
ed
tendernessintheri
ghtupperquadrantLoc
ali
zedtendernessi
nt heri
ghtlowerquadrantLocali
zedf ul
lnes
sor Nueropsychiat
rics(
Behav
ior
al,
Lear
ningdef
ect
s,neur
ologi
cals
equel
ae,
Progr
ess
ivepanencephal
it
is,
Ment
al
mas s ret
ardat
ion,auti
s m)

■Hepat
omegal
ySpl
enomegal
yJaundi
ce Speechdef
ect
s

■Cos
tov
ert
ebr
alangl
etender
nes
sAr
thr
iti
s Sens
ori
neur
alhear
ingl
oss

■Spi
nalt
ender
nes
sPer
ianaldi
seas
eAbnor
malorunex
plai
nedphys
icalf
indi
ngs
Hemat
ochez
iaAnemi
a cat
arac
t

2.
Inves
tigat
ions Vi
si
onpr
obl
em

Labtests
CBC■i ncCRPIncESR■decHbs toolforoccul
tbl
ood■stoolforova&cys
tofpar
asi
tes
stoolc
ult
ures
tool Bonyi
ssues
cal
protect
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acpanel■ur
innal
ysi
s■Breathhydrogent
est
ingRadiologi
cal
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Endocr
inepr
obl
ems
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uli
n-dependentdi
abet
es(
20%,
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Endos copi
cEsophagogastr
oduodenoscopy
I
n2ndandt
hir
ddec
adeDM,andt
hyr
oidabnor
mal
it
ies
3.
treat
ment
Hepat
iti
s,
Liverf
ail
ure.
A)Supporti
veeducation&r eas
s ur
anceregul
aract
ivi
ties
Cogniti
ve-
behavior
alther
apyBi
ofeedbac
kGui
ded
imageryRelax
ationtechni
ques Medicat
ionaci
dsuppressant
sspsmolyt
ics
low-dose Feedi
ngpr
obl
em as
pir
ati
onpneumoni
a
amitr
iptyl
ineB)Speci
ficC)
Counc el
li
ngD)Foll
owup
Shor
tst
atur
e
Q4/
oct2015 D.

A) ●Pr
event
ionbyvacci
nat
ion

Congeni
talr
ubel
las
yndr
ome MMR/
MMRV(
2dos
e12-
15moand4-
6yrofage)

B pos
tex
pos
urepr
ophy
lax
isi
fadmi
nis
ter
edwi
thi
n3daysofex
pos
ure.

Ot
hercl
ini
calf
indi
ngs ●i
sol
atat
ion

CNS(
micr
ocephal
y) f
or7day
saf
terons
etoft
her
ash.

CNS(
Meni
ngoencephal
it
is) Cuat
iousupt
o1yrbc
zex
cret
evi
ralr
esps
ecr
eti
ons

Eyes
.(c
atar
act
,mi
cropht
hal
miapi
gment
aryr
eti
nopat
hy50% -s
o-cal
led'
sal
tandpepper
') unl
essr
epeat
edcul
tur
esofur
ineandphar
yngeals
ecr
eti
onshavenegat
ive
●t
ermi
nat
ionofpr
egnacy ASK.
howl
ong

Expos
edpregnancy(
tes
tmot herrubel
laI
gG-specif
icantibodyt
est
ing;
if+ve(
immuned)
if-
ver
epeataf
ter2wks-
ve Lookf
ors
tri
der
thenr
epeataf
ter6wksifal
l-ve(motheri
snotinfected)
Si
ncethischi
ldhav
ewheeze..
givet
rialofr
api
dact
ingi
nhal
dbr
onchodi
lat
or3t
imes15-
20mi
ntsapar
t..
count
i
ffi
rst-
vet
hen2/
3rd+ve(
inf
ect
ed)s
oter
minat
epr
egnanc
y/notwi
ll
ingt
henI
VIG(
0.55mL/
kgI
M) br
thlkfrchesti
ndrwi
ngt
hanCLASSI FY

Q5/
oct2015 B)

Af
ternebr
eas
ses
s
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●I
fst
il
lfas
tbr
eat
hing.
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rmor
ethan50/
min/
ches
tindr
awi
ng.
thancl
ass
ifyasPNEUMONI
A
uns
tabl
eSVT
C)
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●Or
alamox
ici
ll
inf
or5days
Synchr
oni
zedDCcar
diover
sion0.
5-1J
/kges
ubs
equentdoubl
edos
emul
ti
plet
imes
●Soot
het
hroat
,Rel
ievec
oughwi
thas
elfr
emedy
At
tach02
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nhal
edbr
onchodi
lat
or/
oralf
or5days
Mai
ntai
nIVl
ine
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fHI
Vex
pos
edar
eat
hengi
vef
irs
tdos
eofamox
ilt
henr
efer
Mai
ntai
nai
rway
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fcoughmor
ethan14dayst
henr
eferf
orTB/As
thma●as
ses
sment
Sedat
echi
ldemi
daz
olam 0.
2mg/
kg/
dos
e
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cemot
herwhent
oret
urn
Cal
lpedi
atr
icscar
diol
ogi
st
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n3day
s
Admi
tti
npi
cu

Ot
heropt
ions Q7/
oct2015
1.
placi
ngani
cebagovert
hef
ace A)

2.
injadenos
ine50µg/
kgandi
ncr
eas
eby50-
100µg/
kg/dos
e SSPE

3.
res
ist
antt
achycar
dias
(fl
ecai
nide/
propaf
enone/
sot
alolami
odar
one) B)

4.
ant
ifai
lur
etx
(fur
osemi
de,
capt
opr
il
,f
lui
dres
tri
cti
on) H/
OVacc
inat
ion

5.
ref
ract
orySVTswhoar
ecandi
dat
esf
orcat
het
erabl
ati
onr
adi
ofr
equenc
yabl
ati
on(
ti
ssueheat
ing/
cry
oabl
ati
on) H/
Oras
h,f
ever
,fl
u,cough,
cor
yza,
conj
unct
ivi
ti
s,or
alul
cer
sinpas
t

6.
mai
ntai
nencet
her
apy(NonWPW:
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ini
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ant
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abl
ockerDOC(
InWPW bet
abl
ocker
)forupt
o1year H/
Osei
zur
einpas
t
wi
tht
aperi
ng
H/
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pit
ali
zat
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npas
t
Councel
li
ng:
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epar
ent
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omoni
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lowup
1.
CBC

Q6/
oct2015 2.S.
Ant
imeas
lesant
ibody(
IgMnI
gG)

A) 3.ELI
SA/
PCR

Fi
rsts
tepi
sASSESS 4.CSF
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imeas
leant
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es,I
ncgamagl
obul
in,ol
igocl
onalbands
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.
A)
Shows
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sts
uppr
ess
ion
vWD
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CT/
MRIBr
ain
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Shows
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ticalAt
rophyandvent
ricul
ardi
lt
ati
on
Reccur
ent
/chr
oni
cITP
7.Br
ainBi
ops
y
Apl
ast
ic
Shows
..
focalandmul
tif
ocaldens
iti
eswhi
temat
ter
Pl
tdi
sor
derpr
esentatear
li
erage
Tr
eat
ment
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tive
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decHb,
dec/
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nor
mal
)
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tinMI
CU
APTT(
N)
Vi
tal
s
bti
ncornor
BowelnBl
addercar
e
Pl
atel
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unct
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ysi
s
Phys
iot
her
apy
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ivi
ty
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ors
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ivi
ty/
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o
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rit
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ehabi
li
tat
ion
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orVI
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ivi
ty
Speecht
her
apy
Mul
ti
merdi
str
ibut
ion
B)
Speci
fi
c..
cl
ear
anc
edef
ect
s
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nos
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ex/
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inos
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onanal
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s
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tiv
e
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nter
fer
onAl
pha
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stax
is(
nas
alcaut
eryorpacki
ng)
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ront
her
apy
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nter
fer
on+I
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bavi
ri
n
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ic(
dependupont
ypeofVWD)
D)
PROGNOSI
S
●des
mopr
ess
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type1VWDex
cept1CVWD)
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se
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cont
aini
ngconcent
rat
es(
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Deat
hoccur
dus
ual
lywi
thi
n1-
2ye1-
2mgofons
etofs
ympt
oms
●Ant
ifi
bri
nol
yti
cs(
allt
ypef
ormucos
albl
eed)
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tor
ingofVWFandFVI
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evel
s ●i
vli
ne

couns
ell
ing ●Mai
nti
anabc

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ddr
ugst
hati
nter
fer
ewi
thpl
tfunct
ions ●I
/Oc
har
ting

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dimi
nject
ions ●vi
tal
s

●Avoi
dcont
acts
por
ts ●Fl
uidr
est
rict400ml
/m2/
hr

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oct2015 ●Cor
ectm.
aci
dos
iswi
dsodabi
car
b1-
2meq/
kg/
day÷8hr
sly

●Cor
rectki
finc.
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fporwas
hedPCVi
fneeded.
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eatHTN
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mear
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aly
sis
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tdec
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fi
c
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nc
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asmai
nfus
ionorpl
asmapher
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s
Smear
.mi
croangi
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hichemol
yti
canemi
abur
rorhel
metcel
lss
chi
stoc
ytes
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iz
umabi
sanant
i-C5ant
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couns
ell
ing
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odcs+vei
ne.
col
i
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ognos
is.
deat
hoc
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ecl
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up
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nat
ionsaf
terD/
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Ur
inar
yel
ect
rol
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ncr

Ur
ines
pgr
avi
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nc Q10/
oct2015
Abgs
.m.
aci
dos
is A)

Coombs
.-vebutmay+i
npneumo bi
oti
ndef
ici
enc
y

St
ooldrndcs
. B)

Renalbi
ops
y ●Ex
cret
ionof3-
hydr
oxyi
soval
eri
caci
dandbi
oti
ninur
ine

Xcr
yforpl
uer
lorpul
m edema ●Act
ivi
tyofpr
opi
onylcoAcar
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ons heispresentlyweighing4kgandl engthof53c m.
Shei spinkinairandisnotcl ubbed.Heraus cul
tati
onreveal
eda
harshmur mur sont heleftuppersideofches twhichi
salsohear
d
2006(
imm)augus
t wellatbac k.Therearenoc repit
ationsint
hel ungsandno
hepat ospl
enomegal y
Q.Ani nemontholdbabyi sbroughtwithpoorfeedi
ng, pall
or
andr apidbreathi
ngforthelast1day. Onexaminati
on Whatist
hemos tli
kel
ydiagnosi
sinthischi
ld?
res
pi rator
yrate70/min,heartrate240/mi
n,li
ver4c m below Whatfur
therinvesti
gati
onswouldyoul i
ketocar
ryout
?
costalmar gi
n.Therearenomur musonauscul
tati
onofc hest
. Whatist
helikelyoutcome?
Whatmanagementopt i
onsareavai
labl
eandwhichone
Whati
sthemostl
ikel
ydiagnos
is?
woul
dyoupr efer?
Whati
mmediat
estepsyouwouldtaket
omanaget
hischi
ld?

1 2
2009(
imm)s
ept
ember Q.A9year soldboyc ompl ai
nsofi ncr
easingbreathlessnessfor
thelas ts
everalmont hs.Hewasnot i
cedtohav ecyanos i
sand
Q. A3mont hsol dgir
lpresentedtoyouwi thdyspnea.On clubbing.Hisrespi
ratoryrateis30/ minandpulser ate115/min
exami nati
onres pir
atoryrateof40/min,heartrat
e150/ min.On withnor malpulsesandj vpnotr ai
sed.Apexbeati sin6thicsin
auscultati
onther ewasgr adeiisys
toli
cmur muratl owerl
eft mi dclavi
cularl
ine.Pulmonar ycomponentof2ndhear tsoundis
sternalborder.Liver5.
7c msbelowt herightcostalmargi
n.On l
oudandas hortej
ect i
ons ys
toli
cmur muri sheardatl ef
tlower
exami nati
on,xrayc hestshowsc ardi
omegaly.Hb9gm%, tl
c sternalborder.
12,000/ c
umm.
Whatisthemos tl
ikelydiagnosi
sint
hischi
ld
Gi
vet
hemos
tli
kel
ydi
agnos
is Giv
etwodi f
ferent
ialdiagnoses
Whatf
urt
heri
nves
tigat
ionsyouwoul
dli
ket
oor
der Whichfi
ndingsoninves ti
gati
onswil
lconf
irmthedi
agnos
is.
2011(
imm)oct
Howwi
llyoumanaget
hiscas
e?
2010(
imm)–mar
ch Q.A10weeksol dboypres
entswithanepisodeofcyanosi
s.
he
hass i
mi l
arepi
sodesi
npastwhilecryi
ng.Onexaminati
onheis
Q. Apregnantwomanpr esentedat34weeksges tati
onf ol
lowi ng
sti
llcyanosedandhasaneject
ionsystol
icmurmurheardover
as pontaneousr uptureoft hemembr anes.Itwasdec i
dedt hat
upperl ef
tster
naborder
.
l
abours houldbeal lowedt opr oceed.Theinfantwasdelievered
vaginall
y,withoutas s
istanc e,34hour slat
er.Thebabywasbor n Whati
sthemos
tli
kel
ydi
agnos
is
i
ngoodc ondi t
ionwi t
hapgars coreof9at1mi nand10at5mi n.
Birthweightwas2. 6kg. Thebabywasadmi t
tedtospec i
alnursery Enl
ist3s yndr
omeswi
thwhi
cht
hisc
ondi
ti
onmaybe
bec aus
eofpr emat uri
ty .14hour slat
erandi mmediatel
yaf t
era ass
oc i
ated
feed,thec hi
ldwasnot edt obebl uewi t
hr ai
sedrespir
atoryrate.
Whatarethec
har
act
eri
sti
csofec
gfi
ndi
ngsoft
his
Onex aminationt hechil
dwasc ent r
allycyanosed.Therespi
rat
ory
condi
ti
on
rat
ewas100br eaths/min.Ther
ewer enoaddeds oundson
auscult
ation.Femor alpuls
eswer eeas il
yfeltandtheli
verwas Whati
sthedef
ini
tvet
reat
mentoft
hisabnor
mal
it
y
pal
pabl e3cm belowc ostalmargin.Ther ewasanobv oi
ous
syst
olicmur murl oudestattheleftsternaledge. 2012(
imm)oct
ober
Ar
ter
ialbl
oodgas
einai
r: Q.A1y earol dchi ldisbr oughttopedi atr
icemer genc yroom wi t
h1
dayhistor yoflet hargy,irri
tabi
li
ty, f
ev er,respiratorydi st
ressand
Ph 7.
21 ref
usalt of eed.Heal sohadanepi sodeofgener ali
zest oniccloni
c
Pao2 3.
1kpa sei
zuresl astingfor2mi nthismor ning. Onex aminat i
onhei ghtweight
th
areat25 per cent i
lelookspaletemp102fr espiratoryrate70/ min
Paco2 4.
1kpa heartrate180/ mi n,pulsesarepalpabl ebutl owv olume. Bp
Theches
txr
ays
howedcl
earl
ungf
iel
dsandhear
tofnor
mals
ize. 80/60mmhg.Li veri spalpable6cm bel owr i
ghtcos t almargin.Thereis
gall
opr hyt hm andgr ade3/ 6systolicmur muratapi calarea.
A) whati
sthedi
agnos
is?
Whati smos tl
ikel
ydiagnosis?
B) gi
vet
hreei
nves
tigat
ionsyous
houl
dper
for
m? Enl
istfourinvesti
gat
iont osuppor
tyourdi
agnos
isal
ong
wit
hj ust
ifi
cati
onoffindings.
2011(
imm)mar
ch
Outl
inemanagementofc hi
ld

3 4
 2012(
imm)oct
ober Whati st hemos tl
ikelydi agnos i
s
Whati mmedi atemeas uresyouwi lltake,gi
veinor derof
Q. A7mont holdbabyisbroughttoemer genc ydepartmentwi t
hone pri
ority
dayofpall
or.Heisrestl
ess,t
achpneicandf eedingpoorly.Hehasno 2016( i
mm)apr i
l
coughorwheez e.Nosigni
fi
cantpas tmedi calhist
ory.Hiseldersis
ter Q. A3mont holdi nfantwaswel lint hemor ningbutbecameuns et
tled,
hadc ol
d3day sback.Onexaminationhei saf ebri
le,palespo291% at start
edc ryingincons ol
ablyandgr aduallydev elopedmot tl
ing.The
room ai
r,respi
rat
oryrate62breath/ minhear trate270/min, bp babydev elopedapneaonherwayt ot hehos pitalbutrespondedt o
84/44mmhghear tsoundsarenor malandpul sesareequal
lypalpable stimulat
ion.Ther eisnothings i
gni fi
canti nnat alandpostnatalhistory.
li
verispal
pable4cm belowcostalmar gi
n. Onex aminat i
onhert emperaturei s980f ,respirator
yrate60/ minand
Whati
smos tl
ikel
ydiagnos
is? heartrate240/ min. Shehasthr eadpul s
es,gal l
opr hyt
hm andal i
ver
Howwil
lyouinvest
igat
e? of3c m belowcos talmargin.
Howwil
lyoumanaget hi
schil
d? Whati
st hemos tl
ikelydiagnos
is?
2012(
mcps)march Howwillyouinves
tigate?Giveli
kelyfi
ndi
ngs.
Q. Onemont holdneonatehasrespi
ratorydi
stressforoneday .
he Whattreatmentoptionsareavail
abletomanaget
hisbaby
?
isafebri
le.r
espir
atoryrateof70bpm,hr=230,chestiscli
nical
ly 2016(
imm)-apr
il
clear,l
iver4cm,belowt hecoast
almargine.
chestxrayshowed Q.A7y earoldgirli
sbr oughtinerwithc ompl ai
ntsofas udden
cardiomegaly.cbc,crpnormal.
ecgshowedhr =230/minwi t
h syncopalattackwhi l
epl ayi
ngduringas choolmi dbreak.Sher egai
ned
abnor malp-waveax i
s. consciousnesswhi l
es hewasbeingbr oughttot hehos pi
tal.On
Whatisthemostl
ikel
ydi
agnos
is? examinations heiscons ci
ousbutlooksanx i
ous .Shehasapul seof
Whatarethest
epsofmangement? 80/minr egularandlowv ol
ume.Herbpi s90/ 70mmhg. Anej ecti
on
2012(
mcps)october syst
olicmur murofgr ade3/6isheardatupperr ightster
naledgewi t
h
aradiati
ont owardst heneck.Heranthropomet r
icdatashowahei ght
Q.1y earoldc hi
ldwei ghing7.5kg,wasbr oughtt oemer gency of105cm andawei ghtof17kg.
departmentwi thhistoryofs uddenons etofdi f
ficul
tybreathi
ngand
Whatisthepr obabledi
agnosi
s?
rest
lessness.Thec hi
ldwashav i
ngc entralcyanosisandhadc lubbi
ng.
Whatothercl i
nicalf
eat
ureswouldyoulookf
ortoreacht
he
Examinationofc hestrev eal
edfaintejecti
ons ystoli
cmur muratlef
t
di
agnosis
?
uppers t
ernabor der.Hi sabgsar
easf oll
owsph7. 25,po248mmhg,
Enl
is
tthei nvesti
gati
onsrequi
redtoconfi
rmthecl
ini
cal
pco260mmhg. Ureac reati
nineisnormal ,hb10.5g/dl,t
lc11500/cmm
di
agnosis
.
Whatismostli
kelydi
agnosis? Enumeratethemanagementopt ions.
Whatareotherpossi
bil
it
ies
?

Elect
rolyt
e
Howwouldy oumanaget hi
schil
d?
2015(
imm)october
Q. Oney earoldboypr esentswi thv omi
t i
ng,ir
rit
abili
tyand

Imbalance
respi
ratorydi s
tressforlast2hour s
.Onex aminationheisin
severerespiratorydist
resswi t
hpal eandmot tl
eds ki
n.Heis
tachycardiacwi t
hgalloprhythm andbi later
albasalc r
epit
ati
on’
s.
Hisecgs howshear tr
ate250/ mi nregul
arwi thnarrowqrs
complexandc ons t
antr-rinterval.Ther
ei snopwav e. 2008(
imm)j
anuar
y

5 6
 Q. Oney earoldkhurram wasadmi t
tedwithhis
toryoffever, Whati
stheli
kelydi
agnosi
s ?
diarr
heaandv omit
ingf or4days.Heisbottl
efedandhasbeen Howwil
lyoutreatt
hischi
ld?
recei
vingor swit
hf eed.Hehasnotpas seduri
neforthelast6 2013(
mcps)oct
ober
hours.Onex ami
nationhei si
rri
tabl
e.Temp99.6,wt11kg, the
i
nv est
igationsareasf ol
lows: Q.An18mont hol dc hil
di sbeingev aluatedforbowedl egs.Hi
s
pasthost
oryr evealstwoadmi ni
strati
onf orvomi t
tingand
Cp:hb12gm%, t
lc8500,pol
y48%,l
ymph45%,monocy
te3%, metabol
icacidos i
s.onex aminati
onhi swei ghtis8.kg,hei
ght70
ur
ea60mg/ dl
,na160meq/ l
,k3.
2meq/l cm,chestexami nationshowspec tusc ari
natum.restofthe
syst
emicexami nationi snor mal.
initi
alevaluati
ons hows
Howwouldyoumanaget
hisc
ase?Wr
ites
tepsof na=135meq/l, k=2.5meq/ l,cl=110, hco3=10mg/ l,cr
=0.3mg/l
,
management ser
um phosphor usl evel=1.2meq/ lbloodgl ucoseisnormal.
2011(
imm)oct
Whati
stheli
kel
ydiagnos
is?
Q.An11mont hsoldchil
dpr esentswi t
h2day sh/odiarr
hea What2tes
tswil
lconfi
rmthediagnos
is?
andvomi t
ingandf i
tssi
ncemor ning.Onex aminati
ont hechi
ld Whatt
reat
mentwi l
lyourecommendf ort
hischi
ld?
isi
rri
tabl
e.Hisanteri
orfontanelleisfull
.Hisweightis8kg.
Thel
ser
abinv
um pot
es
ass
t
i
i
gat
ionrev
um 4meq/
eal
l,
eds
bl
er
oods
um sodi
ugari
um 165meq/
s230mg%
l,
ENDOCRI
NOLOGY
A)whati
sthemos
tli
kel
ydi
agnos
is 2007(
IMM)augus
t

B)wr
itedown2di
ffer
ent
ial
s Q:Ani nfantisbroughtt
oemer gencydepart
mentwi t
hhist
oryof
vomit
ing, l
ethar
gy,dehydrati
onandf ai
lur
etothr
ive,t
her
ear e
C)ment
ioni
mpor
tants
tepsofmanagement
fewareasofde- pi
gmentationontrunk.
2012(
imm)mar
ch
Ser
um el
ect
rol
ytesNa124meq/
L
q.A6yearol dgirlhaswalkingdi
ffi
cul
tyf orthelas tt
hr eey ears.On
examinationherwei ghtis20kgandhei ghtis102c m. Therei s K6.
8meq/
L
si
gnifi
cantgenuv arum deformi
tyandwi deningofwr i
s t
s. Ser
um cor
tis
olr
educ
ed
Costochondr alj
unc t
ionsarenotprominent .
Herl absr evealc al
cium
9.
5mg/ dl, phosphorus2mg/ dl
,al
kali
nephos phat ase800i u,urea Whatisthemos tli
kel
ydiagnosi
s?
20mg%, creati
nine1.3mg% Lis
tandj usti
fyotheri
nvesti
gati
onyouwi
llcar
ryoutt
o
confi
rm diagnosi
s?
Whati
sdiagnosis
? Bri
efl
ywr itethemanagement ?
Howyouwillconf
irmt hedi
agnos
is?
Whattr
eatmentwi l
lyouoff
er? 2007(
IMM)-Augus
t
2012(
mcps)march
Q.Oneweekoldbabyisbr
oughttot
hecons
ult
ant
’scl
ini
cwi
th
Q. A6mont hol dchil
dhasac utediar
r heaalongwithfi
tsfor2 pr
oblem ofAmbi
guousgeni
tal
ia.
days.Heislethargicandnottakingfeeds .
hehasnotpas seduri
ne
Li
stt
her
elevantques
tionsr
equi
redi
nthehi
stor
y.
for8hours.invest
igati
onsshow, bloodgl ucose55mg/dl,ca
8.9mg/dl,na160meq/ l,k=3.2meq/ l,al
=90meq/ l,withnormal Whati
nves
tigat
ionsy
ouwi
llcar
ryout
?Wr
itewi
th
renalf
unctions.

7 8
 j
ust
ifi
cat
ion. TSH 53uu/
l

Bri
efl
youtli
nethet
reat
ment
. Boneage 5year
s
2008(
IMM)J anuar
y
C) Whati
sthedi
agnos
is?
Q. Amont hsoldbabypr esentedwithhi
storyofambi guousgenital
ia.
D) Whatt
reat
mentwoul
dyous
tar
t?
Itwasanor maldeli
veryatapr i
vat
ehospitalatt
erm wi t
hawei ghtof
3.2kg.Onex aminati
ont herewasnody smor phi
cfeatures,babywas 2011(
IMM)Mar
ch
healt
hylookingandaf ebri
le.Genit
ali
ashowedapr ominentphall
usof
2.5cm,singleuret
hralopeningandnogonadspal pable. Q.A3mont hsoldinfanthasbeenadmi t
tedf orVPs huntplacement
forholopr osencephaly.Onpreoperati
veas sessmentLabshs ows a
Fol
lowi
ngar
ether
esul
tofi
nves
tigat
ionc
arr
iedout serum s odium of165meq/ L.Onex aminat iont hebabyappear stobe
dehydr ated,weightis5kg,HR130/ min,RR30/ mi
n,BP70/ 50mmhg.
Na143,K4.
5,Cl103,HCO324
Furtherev aluat
ionshowsur i
nes peci
fi
cgr avityof1.005,uri
ne
17-
OHP1.
2,Reni
n0.
5,Al
dos
ter
one32,
ACTH24 osmol ali
ty180mos m/ Landserum osmol ality360mos m/L.

Kar
yot
ype45X(
197)
,46X,i
dic(
Y),(
?P11.
32)(
39) Whati
sthemostli
kel
ydiagnosis
Howwil
lyoumanagethi
sc hi
ld
Pel
visul
tras
ound:s
mal
lut
eri
necav
itys
een,gonadsar
enoti
dent
ifi
ed 2013(
IMM)March
Whati
sthedi
agnos
is
Q.A10y earoldknowndiabeti
chaspr esent
edwit
hdrows i
nessand
Whatwoul
dbethesexofrear
ingi
nthi
sc hi
ld
vomit
tings i
ncemor ni
ng.Onex aminati
onGCS12/15,dehydrati
onis
Whatst
epswoul
dyoutakeInthemanagementoft
hischi
ld
posi
ti
ve,r r=35/min.I
nvesti
gationshownais125meq/l,k=3.0.RBS=
2010(
IMM)–MARCH
550mg/ dl,hco3=12meq/l.Aft
er10hour softr
eat
mentserum
Q.A4yearoldgirlwasr eferr
edf ori
nvesti
gat i
onofwei ghtl
os s
, Na=123meq/ l
despi
teanor malappetite.Onex aminati
ons hehadanenl arged Whatisthecauseofiniti
alhyponatremiaandwhatdoest
he
smooththyroidgland.Herwei ghtont he25% c ent
il
eandhei ghton s
ubsequentNal evels
ignify?
the75% centi
le.Therewasnol i
dlagbutt herewaspr optos
is. Whattreatmentplanwoul dyouinit
iat
e
T4 235mmol
/l(
nor
mal70-
180mmol
/l
) Whatcrit
erioni
ndicatesresolut
ionofDKA?
2013(
IMM)Mar ch
TSH 0.
1Uu/
l(nor
mal0.
25–5uu/
l)
Q.A3y ear
soldboyisbroughttoopdf orass
es s
mentofgrowt hand
Ant
ithyr
oidant
ibodi
es pos
iti
ve1i
n1000 developmentasparentarenotsat
isf
ied.Onex aminati
onchil
dispal
e,
Boneage 4year
s anteri
orfontaneli
swideopen.Accor
dingt omot herhepas
sess t
ool
every4-5days
A) Whati
sthedi
agnos
is?
Whatismos tl
ikelydi
agnosi
s?
B) Whatt
reat
mentwoul
dyougi
ve? Howwillyouinvesti
gatet
hechild?
Howwillyoutreatthi
schil
d?
3year
safterfi
nis
hingtr
eatments
hepres
ent
edagai
nwit
hti
rednes
s
Gi
vefoll
owuppl antomother?
andsl
owgr owth.Herwei
ghtwasont
he10%cent
il
eandhei
ghton
2013(
IMM)Oct
ober
25% cent
il
e
Q.
A10yearol
dgi
rlwel
lats
choolhaspr
esent
edwi
thani
nsi
dious
T4 14.
5mmol
/l

9 10
appearanceofasy mmetri
caldif
fusenotenderfir
mf reelymoveabl
e Whati
sthemostli
kelydi
agnosi
s?
swell
ingov erneck.Sheoccas
ionall
ynotesas ensati
onoft r
acheal Howwouldyouev
aluatet
hispati
ent?
compr es
sionbutt herei
snohoar s
enessordys phagia.Shei
safebri
le Howwouldyoumanagethispat
ient
?
wit
hpul seof78/mi n. 2008(
imm)j
anuary
Gi
ve3dds? Q.A12yearol dchil
dc amewi thah/ obreathless
nes sforthelas
t
Whati
nvest
igati
onwouldy ouor
der
? week.Heisaknownt hallesemicandhasbeenonr egular
Howwil
lyoutreatt
hischi
ld? tr
ansfusi
ons i
ncetheageof1y ear.Thefrequencyoft ransfus
ion
2013(
MCPS)Oct
ober
hasprogres
sivel
yincreasedandnowher equir
esat ransf
usion
Q.A7YearOldBoyWei
ghing20kg,Di
agnos
edWit
hIns
uli
n ever
y2- 3weeks.Hehasr equir
edchel at
ionovert heyearsand
DependentDi
abet
esMel
li
tus,HasComeToYouForHi
sDose wasrecentl
ys t
art
edons ubcut
aneouspunct urewith
Adj
ustment. desf
eroxamine.
Cal
cul
atehi
sins
uli
ndos
age? Onex ami nation,hehasfacieswi thdepressednasalbri
dgeand
Whatnut
rit
ionaladvi
cewoul
dyougi
vet
othi
schi
ld? promi nentmax i
ll
a.Hehasady uskycoloroffaceandisf ebri
le,
moder atelyanemi candjaundi ced.Abdexami nat
ionrevealeda
Howwi
llyoumoni
torhi
minf
oll
ow-
upvi
si
ts? distendedabdomenwi t
hal iver6c m andspleen8c m bcm.Hi s
2015(
IMM)Apr
il respiratorys ystem showeds ignsofrespir
atorydist
resswi th
fl
aringofal aenasiandtachypnea.
Q. A3yearol
dadopt edchi
ldi sref
err
edtoy ouforevaluat
ionof
hisshor
tstat
ure.Thedetai
lsoft hepastmedicalhi
storyarenot Hewasunablet
oli
edowncomf
ort
abl
yandhadbi
lat
eral
r
d
known.Hishei
ghtisatthe3 c ent
il
eforage.Thepat i
ent’
supper cr
epi
tat
ions
tolowerbodysegmentrati
oi shigh.
Whataret hepos s
iblereasonofhisr
espir
atorydi
str
ess
Whatar
ethe3mos
tli
kel
ycaus
esofhi
sshor
tst
atur
e? Whatisthemos tl
ikelydiagnosi
s
Howwillfurtherevaluatethem
Whatothercl
ini
calf
eat
ureswoul
dhel
pyoui
n
Howwoul dyoumanagehi spres
entcondi
tion
di
ffer
enti
ati
onofthe3condi
ti
ons?
2009(
imm)s eptember
Howwi
llyoui
nves
tigat
ethi
schi
ld?
Q.Foury earsoldgi
rlcamei nemer gencywit
hepi st
axi
ssi
nce

Hemat
ology
morni
ng. Sheus edtohav esimilarepi
sodesoffandon.On
examinationsheispalebutwel llooki
ngandhav esomebrui
ses
overshins.Restofsystemicexami nat
ionunremarkabl
e

2006(
imm)mar
ch Whati
nves
tigat
ionsy
ouwi
llpl
anf
ort
hispat
ient
Whatdi
ffer
ent
ialdi
sgnos
isyouwi
llc
ons
ider
Q.A3y earoldboyi sbr oughti nt
heopdwi thhistoryofbleeding
fr
om gumsaf terfal
lfrom s tair
s2day sback. Hehaspr evi
ous Howwi
lly
oumanagei
ntheemer
gencyr
oom
hi
storyofprol
ongedbl eedingf ol
lowingmi nortraumaand 2010(
imm)
-mar
ch
i
njuri
es.Onexami nati
onav eragebuiltchi
ld,vit
alsarenormal,
bl
oodooz i
ngf rom gums .Restofs ys
temicex aminati
onisnor mal. Q.A3y
earol
dgi
rlhads
ixepi
sodesofupperr
espi
rat
oryt
ract

11 12
i
nfectionsandt hr
eebout
soft onsi
ll
iti
s.The1stepisodeof att
heageoft
hree3y
ear
s.
tonsi
ll
iti
srespondedtoanti
bioti
ctreatmentbutthel at
er
epis
odesr espondedl
esswell
, ac
cordingtohermot her.Overt
he O/ ehewaspl easantboywi t
hpetechiaeonthehardpal
ate.Hi
s
pastfortni
ghtshehasbecomepal eandt ir
ed.Shealso l
ef teyeappear dt obedev i
atedmediall
y.Hehadasoftabdomen
complainedofpainsi
nherlegsandbr uisedeasi
ly. andi mpalpableliver,ki
dneysandspleen.Therewerewide
spreadpet echiaeandpur puraandecchymosisonhisl
imbsand
Shewasbor natter m weighing3. 2kgbyv agi
naldeliever
yand trunk.
wasful l
yimmuni zed.Shehadr eachedherdevelopment al
miles
t onesattheappr opr i
atet imebutwasbel owt he3r dcent
il
e Hemogl
obi
n 11g/
dl
forheightandwei ght .Onex ami nati
ons hewasirri
tableandpale Whi
tecel
lcount 10.
7*109/
l
withlessionsonherl eg.Ther ewasnol ymphadenopat hy,
hepatomegal yors pl
enomegal y.Herfundiwerenor maland Pl
atel
etc
ount 30*109/
l
generalex ami
nati
onwasunr emar kableapartfr
om s tr
abismus Pr
othr
ombi
nti
me 16s
ec
andshor tenedthumb.
Par
tialt
hrombopl
ast
int
ime 32s
ec
Hemogl
obi
n 4.
6g/
dl
Bl
oodgr
oup ar
hes
uspos
iti
ve
Whi
tecel
lcount 3.
4*109/
l
At
ypi
calant
ibodi
es nones
een
Pl
atel
etcount 7.
0*109/
l
Paul
-bunnelt
est negat
ive
Bloodfi
lm macr
ocyt
osi
s,mi
ld
poiki
locyt
osi
s Bl
oodf
il
m s
cant
ypl
atel
ets
Ser
um s
odi
um 139mmol
/l Whati
stheunder l
yingcondi
ti
ons?
Whathasoc
cur r
ed?
Ser
um pot
ass
ium 3.
9mmol
/l Whatthr
eetreatmentstepsarer
equi
redi
mmedi
atel
y?
Ser
um ur
ea 3.
4mmol
/l 2010(
mcps)–march

Ser
um cr
eat
ini
ne 40mmol
/l Q.A4y roldcircumc i
sed,vacci
natedboyi sbroughtbyparents
forthecompl ai
ntsofbr ui
sesalloverbodyforlast4daysalong
Whatisthehaematol
ogicalpi
ctur
es uggest
iveof
? withpassageofbl oodinstoolandt wiceepis
taxisi
nlast4days.
Whatarethedd? Hehads orethroatandr hi
norrhea2weeksago.Hewasbor nby
Whatinvesti
gat
ionswoul
dy ouperformt or
eacha nvd.
di
agnosis?
2010(
imm)s eptember Onex ami nati
onhei spl
ayful
,afebri
leandhavi
ngpurpur
icspots
alloverbody ,hi
sweightis16kg,heis100cm.Therei
snopallor
,
Q.A4y earoldboypr esentedwi thoneweekhi storyofofbr uis
ing j
aundi ce,lymphadenopathyorarthr
opathy.Li
veri
s2cm but
onhisarmsandl egs.Theboyhadas orethr
oatandr unnynose spleenisnotpal pabl
e.
l
astweekbutot herwis ebeenwel l.Heals
ocompl ai
nedofa
sev
erec ent
ralheadac heandr efusedtoopenhi sey esashes aid Whatisthemostli
kelydiagnos i
s?
i
tmadehi ms eetwoofev erything.Hewasbor nbyv aginal howwillyoui
nvest
igatethec hil
d?
del
ieveryaft
eranor malpr egnancywei gi
ng3.4kg. Ther ewasno Whatmanagements tepswillyoutake
pastmedicalhi
storyofnotot herthangromment sbei ngins
erted Whatconditi
onswil
lyouc onsideri
ndd?
2012(
imm)mar ch

13 14
Q. An11mont hsol dc hil
dwi th3mont hshi storyofpr ogressi
vel
y andwei ghtarebelow50thcent i
le,hr120/min, temp100f,
increas
ingpal lor .Mothers ayst hathehasl ostappetiteand rr
=40/ minandbp110/ 80.
hearts oundsaremuf fl
edwi thbi
lat
eral
bec omes li
ghtlyt achy pnicduringf eeding. Henev erhadany creptsonches tauscul
tati
on.Res tofteexami nat i
onis
bloodtr ansfusion. Hisli
veris4c m belowt hec os t
almar ginand unremar kabl
e.Hb=6gm/ dl,t
lc=5000/ml,platelets=80,000/
m3,
spleen2c m palpabl e.Thereisnoj aundi ce.hislaboratoryreport
s s.
bili
rubin=4mg/dl,sgpt=640,alkali
nephos phat ase=340.
areasf oll
ows :c bchb7gm/ dl,s mears howshy pochromi a++,
anisocytosis+andpoi kil
ocytosis+andaf ewt argetcell
s, r
eti
c Whati
sli
kelydi
agnosi
s?
countis1. 5% Howwil
lyouinv
esti
gate?
Howwil
lyoumanage?
Whatarethelikel
ydiagnosis 2014(
imm)apri
l
Whatimportantinvest
igat
ionyoupl
ant
oreacht
he
di
agnosi
s? Q.A6y earoldboypr esentswit
hpetechialr
ashandepi
stax
is.
2012(
mcps)mar ch Shehasapreceedingurtifewweekago. Sheisot
herwi
sewell.
Bloodt
estreveal
ss ever
et hrombocy
topenia
Q.A4y earoldchil
dhasbeenbr oughtforeval
uati
onofpallor
andnotgr owingwell.
onexaminati
onhei sgr
oos l
ypalewit
hc afé Whati syourmos tl i
kel
ydi agnosis
-au-l
aits potsontrunk.
hiswei
ghtis13kgandhei ghtis85cm.on Give3di f
f er
ent i
aldiagnos is
labevaluationhishbis5.7gm/dl
.mc v100andplatel
etcountis Give3i nvesti
gationwhi chwi llhelpyoui ndiagnosi
s
79,000/m3. Whati streatmentopt i
ons
2015( i
mm)apr il
Whati
stheli
kelydi
agnosi
s ? Q.A2½ y earoldgi r
lpr esentedwi thh/ opallor.Shehasrecei
ved
Howwil
lyoutreatt
hischi
ld? i
rons upplement sfor2mont hsandwasc ompl ianttotr
eatment.
2013(
imm)march Onf oll
owuphherex ami nati
onr evealsweight11. 5kg,hei
ght87
cm, moder at
elyanemi c, andliverisjustpalpable.Hercurr
entcbc
Q.A3y earoldboypr es
entswi t
h10day shi
storyofweaknes s
reportshowshb7. 5gm/ dlandmc v68f l.
andfeverf orwhichtheparentstooks omemedi cati
onf rom a
generalpracti
ti
oner.Twoday sagohedev el
opedpal lor,yell
owish Giv
e4dif
ferent
ialdiagnoses
ofeyesanddar kc ol
ouredurine.Onex aminati
onhei ght93c m, Whatf
urtherhi
storyy ouwil
lel
eici
t
weight13kg, hc49c m,heispale,s
pleen5cm bel owc ostal Howwil
lyouinvesti
gat e
marginwi t
hnor maltemperature.Hb5g/ dl
,peripher alsmear 2015(
imm)october
showss pherocyt
esandpol ychromas i
aalongwithnuc leatedrbcs
.
Reti
culocytecount20%. Tl
chi gh,plat
eletcountsarenor mal. Q.An8yearoldgir
lpres
ent
swit
hrecur
rentepi
s odeofepis
taxi
s.
Exami
nati
onreveal
sfewpet
echi
aeandbrui
ses.Sheispalewit
h
Give3differ
entialdiagnoses? nohepat
ospl
enomegaly.
Whatot hertest
swoul dyouperfor
mt oconf
irmthe
di
agnosis? Whati
sthemos tli
kelydiagnosi
s
Giveanout l
ineofs pecif
icther
apyforthemostl
ikel
y Giv
e2dif
ferent
ialdiagnoses
di
agnosis. Howwil
lyouinvesti
gatethischi
ld
2013(
mcps )october Giv
est
epsofmanagement .
2016(
imm)apri
l
Q.An11y earoldknownt hal
ass
emiaisr
effer
edwi thfeverf
or2
days.Hehasbeenr ecei
vingbloodtr
ansfus
ioneveryfort
nightl
y Q.A1½ yearoldgirlbr
oughtinpedi
atr
icopdwit
hcomplaint
s
withi
nfrequentcheal
ati
on. onexami
nati
onhei sanemic,hei
ght ofi
ncreas
ingpal
lorandbleedi
nggumsf ort
hepast2days.
Mothergi
veshis
toryoffeverf
orthel
ast1½ monthsfor

15 16
 whichs hehasbeent reatedsympt omat icall
ywithnor el
ief.On Giv
est
epsofmanagementoft
hemos
tli
kel
ydi
agnos
is?
exami nations heismar kedlypale.Febr ilewithat emperature 2006(
IMM)Augus
t
0
of101fandapul seof140/ min. Therei ss omeooz eofbl ood
Q.7yearol dboywasadmi ttedi npedi at r
icwar dwi th20days
fr
om t hegumsandaf ewpur purics pot sont hetrunk.Spleen
historyofmoder atef ever .Tempwasv ari
ablerec ordedupt o101
i
spal pable6c m belowt heleftcostalmar gin.Her
9 F.Ther ewasnohi st
or yofc ough, diar
r hea,vomi ti
ngoranyr ash.
i
nves tigationsshowat lcof2.9*10/ l
, apl at
eletcountof Hewasgi venvariousant ibioticsandant i
-malarialdrugsbuthe
3
40,000/ mm andhbof5gm/ dl.Hers er um ferri
ti
nlevelsare didn’trespond.Fort hel as t5day shewascompl ainingofbody
3000ng/ dlands hei shavingat ri
gly ceridelevelof300mg/ dl
. achesandpai ns, hasdev elopeds well
ingofr ightkneej oint
.On
Whati
sthemos
tpr
obabl
edi
agnos
is? exami nati
onhewaspal e,l ethar gicwitht emp100. 5F. Post
erior
cervicalandaxil
larylymphnodeswer epal pable,largestbeing
Name2ot
heri
nves
tigat
ionst
oconf
irmyourdi
agnos
is. 2.5cm. Theywerenont ender ,dis cr
ete, mobile.Rightkneej oint
Enl
is
tthedi
agnos
ticcr
iter
ia. wass wol l
enbutnont enderandl ocalt empnorr aised.
Investigat
ionHB 8. 5gm/ dl,TLC30, 000,pol ys15,l ympho80
Namet
hedr
ugsus
edf
ort
reat
ment
. withmanyi mmat urec ell
s ,plat elet75000, Xr ayr i
ghtknees hows
softtissueswell
ing,ESR65.

I
nfect
iousDi
seas
e Wri
tedownt
Howwoul
2007(
I
hr
eedi
dyoui
MM)February
nv
f
f
es
t
er
i
ent
gat
i
aldi
ethi
agnos
schil
d?
es
?

2006(
IMM)mar
ch
Q.A6yearol dboycomest oyouf orcomplainsofmigrat
or ypai
n
Q. Af iveyearoldc hildpresentswit
hc omplaintofswelli
ngof andswell
ingofj oi
ntsinv olvingr i
ghthand,kneeandr i
ghtankle
rightkneej ointandoc casi
onalvomitingfor10day s
.Hehadan forl
astsevendays .Onex ami nationv i
talsi
gnsarenormal.There
episodeofs orethr oat2weeksago. Fort helast2day shehas i
smar keds welli
nger ythema,t ender nessandli
mi t
edmovement
dev elopedr ashov erabdomenandl owerl i
mbs .Onex aminati
on ofri
ghtankl ejoint
. Therei saf aintras hwit
hirregul
aroutl
ineon
hear trate110l/mi n,throatisnormal,abdomens howsmi ld thel
eftthigh. Labinves t
igat ionsr eveals
:
gener ali
zedt endernes s,r
ightkneejointisredands wollen.The
rashi serythemat ous ,maculopapul
arandnon- pruri
ti
c. Tot
alwhi
tecount8000/
mm3,Hb11gm/dl,Pl
atel
et295000/min,
ESR40mm,Radiogr
aphoft
heri
ghtankl
eisnormal.PRint
erval
Whatarethreemostli
kel
ydi
agnoses
? onECGis>0.
2sec.
Whatinvesti
gat
ionswoul
dyoucar
ryoutt
oreachaf
inal
di
agnosi
s ? Whatisthemos tli
kel
ydiagnosisandwhy?
2006(
IMM)mar ch Whatotherpointsinhi
storyshouldbeasked?
Howwillyoumanaget hi
sc as
e?
Q. An8yearsol
dboyi sbroughtinemer gencyfor2episodesof 2007(
IMM)Februar
y
hematemesisduri
nglast12hour s.Hehashistoryoffeverand
runnynosefor4-5days.Onex aminati
onheisanemi c,pulse Q.8year soldboywasbr oughtt otheemer gencyroom witht he
100/min,BP90/64mmhg, smallamountofas ci
tesisseen. his
t oryoffeverfor8days.Hedev el
opedar ashont he7thdayof
feveronhi sl
egsandhands .Hecompl aintsofsevereheadac he
Whatisthemos tli
kel
ydiagnosis
? andi sunabletoopenhisey esinli
ght.Onex aminati
onaver age
Whatotherpointsint
hehi s
toryandex ami
nat
ionoft
his buil
tt oxi
clookingboywithat emperatureof102F,BP90/ 50
pat
ientareneededforfurt
herevaluati
on? mmhg, respi
ratoryr
ate30/min. Hehasaf ai
ntreddishmacul ar
Howwoul dyouinvest
igat
et hi
spatient?

17 18
r
as honhi
sarmsandf
eet
.Li
verands
pleenar
enotpal
pabl
eand Q.Seveny earol dboyr ef
erredf rom adi st
ricthospit
altoOPD
chesti
scl
ear
. withcompl ai
nt sofhighfev erandl impinggai tf
orlastthree
weeks.Grandf atherli
vingwi t
hf ami l
yhashi storyofchronic
Givet
hemos tli
kel
ydi
fferenti
alsf
ort hi
scase cough.Onex ami nati
onhei spaleandhasf ewpal pablecervi
cal
Whatinvest
igat
ionwi
llyouorder l
ymphnodes .Hehasdemons t
rabl etendernessatrightkneeand
Whatpreventi
vemeasuresyouwilladvi
setothef
ami
ly anklej
oint.Bloodr eportfrom loc all
abs howsHb7. 4gm/ dl,
TLC
2007(
IMM)Augus t 15000,platel
et s450000,ESR80.
Q.A3y earoldboyhasbeenadmi tt
edwi t h10dayshis
toryof Whatpossi
bil
it
iesyoucons
iderinorderofpr
efer
enc
e?
pers
ist
entfeverwithdiffi
cul
tyintakingf oodduetoulcer
ationi
n Whatinv
esti
gationsy
ouwillcar
ryouttoconfi
rmthe
mouth.Examinat
ions howsinject
edc onjucti
vae,wit
hrashon di
agnosi
s?
tr
unk,bothkneesjointsarewarm andt ender,chi
ldhasmild 2010(
IMM)–MARCH
edemaands omepeel i
ngofs kinonbot hhands .
Q.A3y earoldboywasbr oughttoERf oll
owingageneral
ized
Lis
tthreedif
fer
enti
aldiagnoses
?
convul
sion.Hehadbeenwel lunti
l4day spri
ortoadmis
s i
on,
Lis
tnecessar
yinves
tigati
onstoreachadi
agnos
is
whenhehaddevel opedmal ai
se,vomi t
ingandpyrex
iawhichhad
Bri
efl
youtli
nethetreatment.
notrespondedtoparacetamol.I
nt hepasthehadpneumoni a
2008(I
MM)–J anuary
associ
atedwithmeaslesandwasci rcumscri
bed6months
Q.An11y earol dchildpres entedwi thahist
oryofpainand previ
ously.
swell
ingofhisr i
ghtkneej ointf orthelast3weeks.Hehas Whi l
stbeingas s
es sedhehadaf urthergeneral
ized,convulsi
on,
consult
edmanydoc t
orsbef orebutt herei
snoi mprovement.On whichr equir
eds everalanticonvulsantstocontrol.Hisperfusion
examinati
ont hejointisswol lenandt enderwit
hl i
mited andr espir
ator yeffortswer enot edtobepoorandhewas
movement s.Thereisalsot ender nessovermetacarpophal
angeal thereforeintubat edandt ransferredt oint
ensivecareunit.On
j
ointsinhisl
ef thand exami nati
onhewaspy rex
ial(39c)wi thamacularr as
honhi s
Whatf
urt
hercl
ini
cali
nfor
mat
ionyouwoul
dli
ket
oobt
ain trunk.Therewer eaf ewpet echiaeonhi schest.Therewasamas s
palpableinbot hf lanks.Hisopt i
cdi scmarginswer eblur
red, his
What3i
nves
tigat
ionswoul
dyoul
iket
ocar
ryout tonewasi ncr easedi nhislegsc ompar edtohisar msandhi s
Whati
sthemos
tli
kel
ydi
agnos
isi
nthi
schi
ld refl
exeswer egener all
ybriskwi thmar kedankleclonus.
Nameothert
wopos
sibi
li
ti
eswoul
dyouc
ons
ideri
nyour Hemogl
obi
n 10.
2g/
dl
pat
ient
s.
Whi
tecel
lcount 15.
2*109/
l
2009(
IMM)Mar
ch
Pl
atel
etc
ount 61*109/
l
Q. Asi
xy earoldboypr esent
edwi t
h3day shi
stor
yofhighgr ade
fever
,vomi t
ing,retr
orbit
alpain,myal
giaandtr
ansient I
NR 1.
6
maculopapularrashes.CBCs howedHb8, TLC10,
000,Plat
elet Whati
sthemos tlikelydi
agnosi
s?
count150000. Whati
stheunder l
yingabnormali
ty?
Whati
stheli
kelydiagnos
is? Whatf
urtherhi
stor ywouldyoutryt
oexpl
ore?
Whati
nvest
igati
ony ouwouldl
iket
oor
der
? Whatt
woi nves
tigationswouldyouper
for
m next
?
Whati
sthetreatment? 2011(
IMM)March
2009(
IMM)March Q.An8year
sol
dboybr
oughtwi
thpr
ogr
ess
ivel
ethar
gy.Hehas

19 20
 recenthistor
yofc hi
ckenpoxandhast wouni mmunizedsi
bl i
ngs Q.A8yearol dchil
dpr esentedwithbreathl
essnesssince10days
athome. Onex aminati
onc hi
ldisdrows y
,GCS9/ 15.Vit
alsigns worseningdaybyday.Hewasac t
ive.Playf
ullchil
dandhad
showsahaemody namicalystablechil
dwithnormaltemper atur
e. sat
isfactoryschoolperformancebeforethisepisodeofill
ness
Skinshowsheal i
ngchickenpoxr ash.CNSex ami
nati
onr evealed
mothers aysthatchil
dvi si
tedENTdepar tment4t i
mei nprevi
ous
briskref
lexesandequivocalplantar
s.Restofsyst
emic
examinationwasnor mal. 3mont hs .Chil
dhass wollentenderkneejoint5day sbackwith
gotbet t
erafterusingibuprofenprescr
ibedbyGP.
Givet
wopos si
bledi
agnoses
Howwi l
lyoumanagethiscas
e Onexaminati
ontemperatur
e99F,r
espi
rat
oryr
ate50/
minand
Whatadvicewouldyougivet
othepar
ent
sregar
ding edemafeetpres
ent.Puls
eis140/min
managementofothersi
bli
ngs
I
nves
tigat
ionHb12mg/
dlTLC15000/
cmmes
r100ur
ineanal
ysi
s
2012(
IMM)Mar ch
i
snormal
Q.A4y earoldc hildhasreportedwith12hour shist
oryofpetechi
al Whatisthediagnos i
s?
ras
hovert hebut tocksandlegs .Hei
sc onsci
ous,i
rri
tabl
e,andfebr
il
e Whatfindi
ngf avorthediagnosis
102havingmi l
ds welli
ngofey es.Thereisnoelici
tablesi
gnof Whichfurt
heri nves
tigat
ionwillbeneeded?
meningealir
rit
ation,examinationofli
ver,spl
eenandl ymphnodesis Giv
emanagementpl anforthischil
d?
unremarkabl
e. 2015(
IMM)Apr i
l
Whatismos tl
ikel
ydiagnos
is? Q.A10yearol dboyi sreferredt oyouwi thh/ obodys welli
ngf or6
Offer3DD? weeksanddecr eas edur inev olumef orlast2weeks .Hewasbei ng
Givestepsofmanagement? treatedbyaGP. Pas thi s
t oryisnots ignifi
cant.Onex aminat i
on
Enli
st2c ompl
icat
ions? hei saf ebri
le,res piratoryr ate24/ min,heartrate100/ min,BP
2012(
IMM)Mar ch 120/ 80andhasgr os sasc it
es.Today’ sinvesti
gationUr inalysis
Q.A2y ear
soldunv acci
nat
edchi
ldisbr
oughtbymothertoopdput showeds p.
grav ity1. 010,Ph6. 5,protei
n+++, leukocyt eest er
ase
onsteroidsfortreat
mentofnephrot
ics
yndromeel
dersibl
inghas andni t
r i
tenegat ive, WBS20- 30HPF,RBCnumer ous ,RBSna
devel
opedc hickenpox. dgr anularcas t
sar epr esent .CBSs howedHb10g/ dl
, TLC
14600/ cm, N70%, L220%,M5%, E3%. Ches tX-rays howed
Whati
mmediat
es t
epwillyoutaket
hischi
ld? bilateralpleuralef fus i
on.Hi ss erum totalprotei
n5. 2g/ dl,
Wri
tedownt
hev acci
nat
ionschedul
eforthischi
ldbas
ed albumi n1. 5g/ dl,chol esterol260mg% ands erum cr eati
nine
onEPI
. 2mg/ dl.
2012(
MCPS)
Whatisthemos tli
kel
ydiagnosis
Q.A6yearol dgirli
sbroughtwi t
hhi ghgradefeverof36hour swit
h Giv
ethreeunderlyi
ngconditi
on] sr
espons
ibl
ef orit
obtundati
on.Shehashad2v omitingbutisnotdehy drated.On Howwillyouconfir
m yourdiagnosi
s
examinati
onherr espi
rat
oryr at
eis60/ mi
n,HR.=130/ minand Whataretheopt i
onsfortr
eatment?Givel
ogicalreasoni
ng
peri
pheralpulsespoorl
ypalpable.Therearetwoar easofc r
imson 2016(
IMM)–Apr i
l
di
s c
olorat
ionoft heski
nonherl egs.
Q.A11yearol dboywasadmi ttedi
nthepediat
ricwardwi
th12
Whataret
he3pos s
ibledi
agnosis? dayshi
storyoffever.Feverisaccompani
edbyheadache,
Howwouldyouproceedtoinves
tigateher
? myalgi
as,anorex
iaandpai nabdomen.Onex aminati
onheis
Givet
hemanagementofthemos tlikel
ydi
agnos
is? havi
ngac oatedtonguewi thmilddehydr
ati
onands omepall
or.
2014(
IMM)October

21 22
 Gast
roi
ntes
tinal
Thel iverisenlarged3c m bel
owt hec ostalmarginandt ipof
spleeni salsopal pable.Restoftheex aminati
onisunr emar kable.
9
Hisinv esti
gationatadmi ssi
ons howedaTLCof4. 9*10/ L,Hbof
9gm/ dlandALTof50I U.Heisbeingmanagedonempi ri
cal

Tr
act
ant i
bioticswhilet hereportofbloodc ult
ur ei
ss t
il
lawai ted.On
rd
3 dayofadmi ssionthepai nabdomeni si ncr
easedi nintensit
y
andhei shav i
ngf requentv omiti
ngaswel l
.Thereismar ked
tender nessint her i
ghtlowerquadr antofabdomen. Ther eisa
suddenr i
seinpul serat
eandhi sbloodpr essureis100/ 70mmhg. 2006(
imm)augus
t
9
Hisr epeatTLCi s20*10/ Lwit
has hifttowardslef t
.
Q.A6mont hsol dgirlwasbroughtinemer gencywithhi s
toryof
Whati
sthemos
tli
kel
ydi
agnos
is? diarrheaf orthel ast5days.Shewast reatedbys omehaki m.
Init
iallythes toolswer ewateryassociatedwit hvomiti
ng.Nowf or
Namet woi
nves
tigat
ionst
oconf
irmy
ourdi
agnos
iswi
th thelas t1days hehasbecomeex t
remel yirr
itabl
eandhas
expect
edfi
ndi
ngs. devel opedi ntermittenti
ncons ol
ablec r
y .
ehashs hehasal s
o
Howwoul
dyoumanaget
hecondi
ti
on? pass edbl oodys toolstwic
ei nlas
t6hour s.Onex aminati
ons hei
s
palewi thhr130/ min,andwasmoder atel
ydehy drat
ed. Her

I
MNCI
abdomeni stenseanddi stendedwi ths l
uggishbowels ounds.

Whati
sthemos
tli
kel
ycompl
icat
ions
hehasdevel
oped?

2012(
mcps
) Wr
itedownt
hedi
ffer
ent
ialdi
agnos
es

Q. A6dayoldnewbornwei
ghi
ng2.9kgpr
esentswi
thjaundi
ce Wr
itedownt
hemanagements
teps
uptoarmsandlegs
.heal
sohaspus
yeyedischar
gefr
om eyeand 2007(
imm)
febur
ary
oralt
hrus
h
Q.Aonemont holdmal einf antisbr oughttotheemer gency
Cl
assi
fytheil
lnessaccor
dingtoi
mnci
?
room withthehistor
yofcons t
ipati
onf oroneweek.Hi sbirt
h
Wri
tedownt hestepsofmangement?
hist
oryisunremarkableex ceptf ordelayedpas sageofmeconi um
Whatadvisewil
lyougivetothemot
herf
or“
whent
oret
urn
on4t hdayoflif
e.Accor di
ngt omot herhepas sess mallamount
i
mmedi at
ely”
?
ofstoolevery4thdayandt hatal soafteruseofgl yceri
ne
2013(
imm)october
supposit
ory.Onex aminationwei ghti s3.4kg,vitalsi
gnss hows
Q.A2y earoldunvacci
nat
edchi
ldcamewit
hahist
oryof heartrat
e130/ min,respir
ator yrate40/ min,pulseox i
meterreads
asaturat
ionof90% onr oom ai r.Hisabdomeni sdi st
endedand
macul
opapularras
hs i
nce2days
.Thechi
ldhasahi
stor
yoff
ever
rect
um isempt yondi gi
talex aminat i
on.
andcoughsince5days.
Whatar
ethepos
sibl
ecaus
esf
ort
hispr
esent
ati
on?
Whatfindingsinthi
spatientarer equi
redfori
mmedi at
e
ref
err
alacc or
dingtoimnci? Howwi
lly
oumanaget
hiscas
e?
Ift
hechildhasnoneedofr eferr
alhowwoul dyouclass
ify
onthebas i
sofphy s
icalf
indingsacc or
dingtoimnci
? Whi
chinves
tigat
ionswi
llhel
pines
tabl
is
hingadi
agnos
is?
Whattreatmentwoul dyougi vefortheacuteprobl
em? Out
li
nethetreat
ment.
2007(
imm)august

23 24
Q.A3y earoldgi rlwasbroughtt ohospit
alforbloodtransfusi
on Q.afi
vemont holdi
nfantpresent
edwit
hoffandonnon
foranemia.Ther ewashi stor
yofpas si
ngt woormor elarge proj
ecti
levomit
ingmos tmarkedaft
erf
eed,i
rri
tabi
li
tyandf
ail
ure
mot i
onsdail
yf ort helastfewmont hs.Cl
inical
lyshewaspal e tothri
ve.
weight9kgandhadmi ldabdominaldist
ension.No
hepatospl
eenomegal yoras ci
tes
.Bloodrepor tshowedhb5. 5 Gi
vet
hemos
tli
kel
ycaus
eoft
hiss
ympt
oms
gm%, t
lcnormal ,plat
eletnormal,mcv98f l
.Hbel ect
rophoresi
s Name3inves
tigat
ionwhi
chwi
llhel
pyout
oreac
hthe
wasnor mal,t
es tforg6pddef ici
encyalsonor mal. di
agnos
is
Whataretheli
kelycausesofthiscondit
ion? 2010(
imm)–mar
ch
Whatotherrel
evantinvest
igat
ions houl
dbeper
for
med?
2008(
imm)january Q.At woy earol
dc hi
ldishav i
ngf everof3daysdur at
ionwi t
hno
l
oc al
iz
ings i
gn.Hewaspr es
cribedor alpr
omet haz
ine,ampi c
ill
in
Q.Sixmontholdbabys
uff
eringfr
om diar
rheaf
ort
hel
ast10 andpar acet
amol.Pyrexi
albout shavef ai
ledtorespondt o
dayspres
entswit
habdominaldi
stens
ion. repeateddosesofant i
pyreti
c. Nowt hechil
dishavingex t
ens i
ve
vomiti
ng. Heisdehydrated,li
veris3cm palpableandt her
ear eno
Namet
hreedif
ferent
ialdiagnoses
neurologi
calfi
ndings.
Howwi
llyouf
urtherassessthisbaby
Howwi
llyoumanagehi m A) whati
syourdi
agnos
is?
2008(
imm)j
une
B) howwoul
dyoumanaget
hechi
ld?
Q.Aneightyearol
dc hi
ldi
sbr
oughti
nemer
gencywi
th
compl
aintsofhematemesi
s 2010(
mcps
)–mar
ch

Whatques ti
onswouldyouli
ketoaskinhis
tory Q.An11y rol
dgirlbeenbr oughttoyououtdoorcl
ini
cwit
h
Whatwoul dyouli
ketolookspeci
fi
cal
lyonphysical tr
emor sofhandsands peechdiffi
cul
tyf
ort hel
ast8months
.
examinat
ion Parentsal
socomplaintofdet er
ior
ati
oninherschool
Giveappropri
atei
nvest
igat
ionswit
hjust
ifi
cat
ion perfor
mance.
2009(i
mm)mar ch Onexaminati
onsheisatax
icandemoti
onall
ylabil
e.Shei
s
Q. An8y ear
soldboyc ompl aintsofr ecurrentabdomi nalpain j
aundi
ced,li
veri
s2cm andspleeni
s4cm pal
pablewithevi
dence
whichmakehi mt akeof ffrom s choolocc asi
onall
y.Hehadpoor off
reefl
uidinabdomen.
appet i
teandpr ogressi
v ewei ghtl oss
. Heal sohadintermittent A) whati
syourdi
agnos
is?
diarrheawi t
hoc casi
onalbl oodandmuc us .Onex aminati
onhe
hasper iumbili
calguardingandt ender nessbutabdomeni snot B) whatf
urt
heri
nves
tigat
ionswi
llyouor
der
?
distendedonperr ect
alex ami nationanusi spatul
ouswi t
hf ew
C) whatwi
llbey
ours
tepsofmanagement
?
analf i
ssuresaround.Hei spal ewi thwei ghtandhei ghtat3r d
cent i
leforageandear lyclubbi ng. Hi
shb7. 5,tl
c6500, poly54, 2010(
mcps
)–mar
ch
lympho40, esr55.
Q.A10weeksoldbabypres
ent swiththeh/onon-bi
ll
ious
Whatist hel
ikelydiagnosis? vomi
ti
ngfor3weeks.Hepassesstoolever
yotherday.
What3i nvesti
gationsy ouwillcar
ryoutt
oconfi
rm
di
agnosis? Onexaminati
onheisaf
ebr
il
e,l
ethar
gicanddehy
drat
ed.
Whatarey ourfirs
tf ourstepsofmanagement? I
nves
tigat
ionsrev
eal
s:
2009(
imm)s eptember Na130mmol
/l

25 26
 K2.
0mmol
/l devel
opmentall
ynormal.Fundos
copywasnormal.
Aft
erates
tfeed
babybecamedistr
essedandupset.dur
ingt
hist
imebabyt
urnedhi
s
Cl73mmol
/l headrepet
iti
vetoback.
Hc
o335mmol
/l S.
na136mmol
/ls
.k3.
4mmol
/lpt12s(
11-
15)apt
t27(
24-
35)
Cbc9200/
cumm Whati
sdiagnosi
s?
Cr
p<5 Whati
sunderlyi
ngcaus
eofpr
obl
em?
Howwil
lyouconfir
m?
Ur
ineex
ami
nat
ioni
snor
mal
Howwil
lyoumanage
A) whatbi
ochemicalabnormalit
iesarepres
ent
? 2013(
imm)october
B) whati
nvesti
gati
ons houldbeperformed?
C) whati
smos tli
kel
ydi agnos
is? Q. A3y earoldgirlhaspr esentedwi t h1y earhi storyofcons t i
pation.
D) whati
streat
mentopt i
on? Sheopensherbowelonceev ery5day s
. Sheals os oi
lshercl otheson
mos tofthedays .Shepas sedf reshbl oodperr ect um recently.She
2011(
imm)mar
ch compl ai
nsofabdomi nalpainof fandonwhi chi sr el
ievedaft er
Q. A5y earsoldboywasadmi ttedint heemer genc yroom wit
h defecati
on.shewasdel iveredbyc- secf orfetaldi str
es sandmeconi um
fever,per si
stentvomit i
ng,ands evereupperabdomi nalpainf
or stai
ning.Shepas seds toolafter2hour sofbi rth.Herwei ghtison50th
thelas t2day s.Parentsreportedthathepl aceshishandabov e centil
eandhei ghtison25thc entil
e. abdomenex aminat i
onr ev eal
s
theumbi li
cusandbendshi shipsandkneesduet opain.On mas sinlef
tili
acf ossa.Ondi gitalrectalexami nat i
ons toolispal pable
exami nationpul s
er at
ei s120/min, r
r30/mi n,temo101f .Heis inrectum.
i
s r
itableanddehy drated,abdomenmi ldl
ydi s
tendedwi th
Whati
smos tli
kel
ydiagnosi
s?
tender nessint heupperquadr ant.Thereisno
Howwouldyouinves
tigatet
hechi
ld?
hepat osplenomegal yandbowels oundsareaudi ble.
Whati
streatment
?
Whatisthediagnosi
s 2013(
mcps)october
Whataretheot heri
mport
antinv
est
igat
ionswhi
chmay
Q.a3yearoldtoddl
erweighing14kgpr esent
swi thdiff
icult
yin
hel
pindiagnosis
passi
ngstoolwit
hintermitt
ensmallamountoff ecalsoi
ling.
Howwillyoumanaget hschi
ld
Accordi
ngtothemot hershenoti
cedthisproblem about2
2011(
imm)mar ch
monthsbackwhens hes t
artedt
oil
ettraini
nghim.hispas thi
stor
y
A4weekoldi
nfantpr
esent
swi
thpr
oject
il
evomi
ti
ngwhi
chi
s i
sunremarkable.
pr
ogres
siv
e.
Whatpoi
ntsi
nhist
oryofexaminat
ionwoul
dyoul
ookf
or?
Whatinvest
igat
ionsmaybehelpf
ulindiagnos
ingt
he Whati
stheli
kel
ydiagnosi
s?
cas
e?Giv ef
indi
ngs Howwil
lyoumanagethischi
ld?
Whatwillbethemostl
ikekl
yabgfindi
ngs? 2014(
imm)apri
l
2013(
imm)march
Q.A4mont holdinfantpresentedwithhistoryofthrowingupof
Q.A3y earoldbabyisref
eredbygpf oreval
uati
onofs ome mil
ks oonafterfeedi
ngs i
ncet heageof3weeks .Hewasbor n
neur
ologicalpr
oblem.Mothercomplai
nsofabnormalheadmov ement ful
lterm.Wasputonac ombi nati
onofbr eastfeedingand
andarchi
ngoft hebodywithexcessi
vecry.t
hereishi
storyof for
mul af
eeding.Hehasgi venmul ti
pleantiemet i
candhadgone
vomit
ingaf t
erfeed.Onexaminat
ionweightisbel
r
d
ow3 per cent
ile, thr
oughr epeatedformulami l
kchanges.Onex aminati
onhis

27 28
 weightis5.
2kglength60cm headsi
z e39cm andabdominal feverandgeneral
iz
edt onicclonics ei
zuresforthelastoneday.
examinati
onisunremar
kabl
e.Oni nvesti
gati
onhbi s8.
9mg/dl. Onex aminati
onheiscomat os ed,havingpallorandmi l
djaundi
ce.
Na135. K3.4urea20mmol s
c r
eati
nine0.9mmolandnor mal Abdomi nalex
aminati
onr evealedliver1c m andspleen3cm
bl
oodgas sanal
ysi
s bel
owcos t
almargi
n.
Givet
hemos tl
ikel
ydi
agnos
iswithonediff
erent
ial Giv
ethreemos tprobabledi
agnos
es.
Howwi l
lyoumanagethemos tl
ikel
ydiagnosi
s Whatthreeinvesti
gat
ionswil
lhel
ptoreachanappropr
iat
e
2014(
imm)oct ober di
agnosi
s?
Bri
efl
youtli
net henurs
ingmanagementofthi
schil
d.
Q. A5y earoldgir
lbroughttooutpat i
entdepar
tmentbecauseof 2008(
imm)january
repeatedepisodesofvomitingoverlast2years
.Eac hepi
sode
lastsfor2-3daysitbegi
nsuponwal keni
ngfrom s
leep.Pati
ent Q.Ani neyearoldc hil
df rom baluchistanpr esentedwi thh/ o
bec omespaleandhasnaus eaandpai nabdominatbeginni
ngof abdomi naldi
stensionfort helast3year s,jaundice6mont hs,
attack.Inbetweentheattackpatientisnormal
.Herheightand feveroffandon. Inhos pitalt
hec hil
dhast ransfused1.5y ears
weightar e50thpercenti
leandbp. 100/75mmhg backandal sorequiredt wot r
ansfusionofpac kedcel li
nt he
presentadmission.Ther ehasbeennot r
ans fusi
onpr evious l
yand
Whatisthemos tli
kelydi
agnos i
s his3ot hersi
bsarenor mal .Onex ami nati
onhehasadus kycol or
,
Whatdif
f er
enti
aldiagnosi
swillyouconsider wass ti
llmil
dlyanemi c,ands li
ghtlyjaundiced.Ther ewasno
Whatinvesti
gati
onwi l
lyousugges t l
ymphnodepal pabl eongpe. Hi
sabdomenwasdi s t
ended, l
iver
Keepi
nginmi ndthemos tli
kel
ydi agnos
ishowwi
llyou palpableabout5cm bcm ands pleenwaspal pableabout17c min
managethisgir
l thedirecti
onofr i
f.
2015(
imm)oct ober
Enumer
ate5dif
ferenti
aldis
gnosi
sinthi
schi
ld.
Q.A1½ mont hol di nfantpres
ent edwith1weekhxofnonbi ll
ous Howwouldyouinv
es t
igatethi
schi
ld
vomiti
ngaf t
erev eryf eed.Ther
ei s nohxofdi ar
rheaand 2009(
imm)march
i
nfantislosi
ngwei ght.O/ eheisafebril
eandmi l
dlydehydrat
ed.therei
s
noorganomegal yandabdomeni ss oft
.Examinat
ionofothers ys
temsis Aneightweekoldinfantpr
esent
edwithdeepjaundi
ce.On
unremarkable.I
nv estigati
onsrevealedhb=12gm/ dl
,wbc10x 109/ l
, examinati
onchi
ldhadmi l
dabdominaldi
stens
ionwit
h
na+=135mmol /l
,k+=3. 2mmol /l,hco3=30mmol /l
,cl
=83mmol /l
. hepatospl
enomegaly.

Whati
sthemos
tli
lel
ydi
agnos
es,j
ust
ifyi
t. Namet womos tli
kelydiagnoses
.
Whatques ti
onsyouwoul dli
ketoaskinordert
oreacht
he
Enl
is
t3di
ffer
ent
ialdi
agnos
es. di
agnosis?Givereas
ons .
Whati
nves
tigat
ionswoul
dyoudot
oreacht
hedi
agnos
is? Whatinvesti
gati
onsy ouwouldliket
oc ons
ider
.
2009(
imm)s eptember
Howwi
llyoumanaget
hec
ase?
Q.An11yearoldboyaknowncaseofcldpres
ent edwit
hfrank
haemetemesi
s.Onexami
nati
onhisgcs13/15,l
iverwasnot

LI
VER palpabl
eands
Whati
pl
eenwas5c
mmedi
ates
t
m pal
pable.
epsofmanagementyouwi
lladopt
?
2006(
imm)augus
t Howwi
lly
oupr
eventf
utur
ebl
eedi
ng?

Q.
A5yearol
dchi
ldpr
esent
swi
th3dayshi
stor
yofhi
ghgr
ade 2010(
imm)–mar
ch

29 30
 Neonat
ology
Q. A10y earoldgir
lr eferr
edtoopdwi th4weeksh/ oprogres
sive
deteriorati
oni nspeec handgai t
.Shehadh/ odeat hofone
si
blingatageof5y ear s.Onex aminati
ons hewass hy,pal
ewith
nos ki
nr as hormar gin.Bp110/ 70mmhg, hearts oundsnormal
andl i
veredgepal pabl e4cm belowc ostalmargin. Shewasableto 2006(
imm)augus
t
compr ehenc edallthatwass aidtoher ,butsher epeatedquesti
on
severaltimesov erbef oreeventuall
yans wer
ing. Shehadf i
ne Q.A3weeksol dboyi sbroughtwi
thpersi
stentvomiti
ngforthe
tremor s
. Liverpr
ofileisderanged. l
as tt
hreeday s.
Onex aminationwei
ghtis2.
8kg, heisl
ethar
gic
anddehydr at
ed. Hi
sinvesti
gati
onsshowsserum sodi
um 125
Whatisthediagnosi
s? mmol /l
,serum potass
ium 6mmol /l
,ser
um chlor
ide101mmol /l
,
Whataretheinvest
igat
ions? bloodglucose4mmol /l
/
Howwoul dyoumanaget hechi
ld?
2012(
mcps)mar ch Whatisthemos tli
kel
ydiagnosi
s?
Wr i
tethr
eediff
erenti
aldi
agnoses?
Q.A6weekol dc hi
ldhasj aundices i
ncebirth.Hei safebril
e, Wr i
tethr
eefurt
herinvest
igat
ionswoul
dbehel
pfult
o
active,passingy ell
owc oloureds tool.Hehas 10c m palpablel
iver
, confi
rmthediagnosis
.
whichi sfirm andnon- tender ,s
pleeni s2cm, palpable.
lab 2006(i
mm)august
investigati
onss howeds erum bili
rubin10mg/ dl(conj
ugat ed
7mg/ dl)
.Alt100i u.Al
kal i
nephos phatas
e512i u.
pt/apttare Q.A12day soldbabyi sbroughtwithhistoryofvomiti
ngand
normal .uri
neex aminati
onpusc el
l5- 7hpf.
reduc i
ngs ugar++ feedingdif
ficul
ty.Thedeliver
ywasunevent f
ulwithgoodapgar
scores.Herbirt
hwei ghtwas2. 5kg.Thereisals
ohi s
toryofj
erky
Whatist heli
kelydiagnosi
s? movement s. Onexaminationsheisjaundicedwithhepatomegal
y
Whatar eacutec ompli
cati
on? at3cm belowr ightcostalmargin.
Howwi llyouconf i
rmthediagnosi
s?
Whatc omplicati
onsdoy ouexpectatadol
escenceeveni
f Whataretwomos tli
kelydiagnosi
s?
adequatetreated? Whatthreerel
evanti
nv es
tigati
onsyouwoul
dor
dert
o
2013(mcps)october r
eachafinaldi
agnosis
.
Wri
tedownt hestepsofmanagement .
Q.A6y earoldc hi
ldpr es
entswithahistoryoff ever,weightloss
, 2007(
imm)february
anorexiaandabdomi nalpainfor2mont hs.Hishistoryis
unremar kabl
e,fatherisac att
lefar
merandmot herisahous e Q.Aheal thyneonat eisbroughtt ot heneonat alclinicfor
wife.Onex aminationhei sfebri
lewit
hmi ldjaundice,abdominal j
aundi cepersiti
ngat21daysofl ife.Hei sbornt ogr avi
da4
exam revealstenderhepat omegalywithapal pablemas sinthe mot herandwasdel i
veredatt erm withoutanycompl icati
ons.He
ri
ghtupperquadr ant.Laborator
yinvesti
gati
onar easf ollows: weighed3. 4kgbi rt
handnowi s3.7kg,hei sonex clusi
v ebreast
feeding.Onex aminationhehasaf l
atnas albri
dgeandas i
ngle
Cbc;t
lc=12000/
mm3,
n=53%,l
=20%,e=20%,m=7% palmarc rease.Cardi
ovas cul
arex ami nati
onr ecelasamur mur
alongleftsternalborder.
Res tofex ami nati
oni snor mal .
Bi
li
rubi
ntot
al7mg/
dl,di
rectbi
li
rubi
n4mg/
dl.
Sgpt
=200i
u
Givef
ourdi f
ferenti
aldiagnosesofj
aundi
cei
nthi
sbaby
Whatisthemos tli
kelydiagnosi
s?
Lis
t6relevantinvest
igations
Gi
ve2di ff
erent
ial
sdi agnosi
sforthi
schil
d?
Howwi l
lyouf oll
owt hi
scas e.
Whatinvesti
gati
ony ouwi l
lperf
ormtoconfi
rmt
he
2007(i
mm)augus t
di
agnosis(gi
ve3)?
Howwi l
lyoumanaget heli
kelydi
agnosi
s? Q.Ababyi
sbor
nat36weeksofges
tat
ionbycaes
areans
ect
ion

31 32
havi
ngweight2kg,babydevel
opedr es
pirat
orydi
str
essonhour repor
tthatchi
ldr
endevel
opfever,di
arr
hea,andcoughatt
heage
aft
erbi
rthandgett
ingpale.Motherhadtemperat
ure38candan of3,5and7mont hs
.Physi
calexaminat
ionreveal
sanor
mal1
off
ensi
veli
qor. dayoldnewborn.
Listthreedif
fer
enti
aldi
agnoses? Whatprevent
ivecounsel
li
ngmessageswil
lyougivet
othe
Whati nvesti
gat
ionshoul
dbec ar
riedoutt
oconf
irmt
he par
ent
st okeeptheirnewbor
ninahealt
hyc ondi
ti
on?
diagnos i
s? 2008(
imm)june
Whatt reatmentyouwil
lstar
t?
2007(i
mm)augus t Q.Youar easkedtoexamineanewbor
nbabyboyyest
erday
.Thi
s
i
st hefi
rstchil
dofhisparent
s.Hi
swei
ghtis3.
5kgandphysi
cal
Q.A6day soldbabyisbroughtwit
hhis
toryoffrequentvomiti
ng examinati
ondoesnots howanyabnor
mali
ty.
aft
erfeed.Havi
ngt emper
aturesi
ncel
ast2days.Birt
hhistor
yis
normal.Onexaminati
onweighti
s3kg,hasjaundicewith Whatadvi
ceandcounsel
li
ngmes s
agesyouwoul
dli
ket
o
hepat
os pl
eenomegaly. gi
vetothepar
entsatt
histime?
2009(
imm)march
Whataretwomos tl
ikel
ydiagnoses
?
Whatrel
evantinvest
igati
ony ouwil
lcar
ryout
? Q.A20y earol dpr imigr avidamot herhadr hinorrhea, sor
e
nd
Out
li
nethet r
eatment . throatandgener alizedachesandpai ni n32 weekof
2007(
imm)august pregnancy .Treat mentf r om l ocaldoc tordi dn’thel pedher
compl ains.Af ter5daysoft hi sillnes ss hes t
ar t
edhav i
ng
Q. A3dayol dnewbor nwasbr oughti nemer gencydepartment laborpai nsanddr ainageofmec oni um s tainl i
quor .Same
withhi s
toryofyell
owishgreenv omi t
ingaftereachf eed.Famil
y days hegav ebi rtht oagi r
lwei ghi ng1. 15kg.Babyneeded
alsonot i
cedthathehadnotpas s edmeconi um sincebirt
h. res uscitati
onwi thbagandmas kf or4mi nut es.Herapgar
Pregnanc yanddeliver
ywasunev ent f
ul.Onex aminationhis at5mi nuteswas7/ 10.Shewass hiftedt onur sery.
weightwas3. 2kgwi thnodysmor phi
cfeatures.Thereisno Exami nationi nneonat aluni tr eveal edmar kedches t
respirat
orydist
ress.Abdominalex aminati
onr eveal
edmoder at
e rec essionsandgr unt i
ngwi thr espi ratoryr at eof80per
distensi
onands luggis
hbowels ounds . mi nut e.Per i
pher alpul seswer epal pabl ebutf eeblewi t
h
hear tr ateof150permi nut e. Liverands pl eenpal pable2
Whatarethreemostlikelydiagnos es?
cm bel owr espect ives ubc os talmar gins .Babyal s
ohad
Whatinvest
igati
onswillbehel pfulfordiagnos i
s?
diffus epus tularr as h.X- rayches thadbi l
at eraldiffuse
Writ
edownt hemanagementpl an?2008( i
mm)–j anuary
infilt
rat esandabgss howedph7. 2,po250mmhg, pco248,
Q.A5day sol
d34weekspr eterm babyt aki ngformulafeeds
hc o315mmol , hb16, tl
c14500, pol y40, lympho44,mono
al
ongwithbreas
tfeedi
ngpres entswi t
har edc ol
ouredstools
.On
15.
exami
nati
onbabywasl et
hargicandhasmi ldlydist
ended
Giv et hreepos siblec aus esf orherr espirat orydistressin
abdomen.
orderofpr eference.
Whatisthemos tl
ikel
ydiagnos
is
Whatar
eyourf
irs
t4s
tepsofmanagement
?
Give3dif
ferenti
aldiagnoses
What5inves t
igati
onsarerequi
redi
nthi
schi
ld Name2dr
ugsf
orempi
ri
calus
e.
Howwillyoumanaget hi
sbaby
2008(
imm)january 2010(
imm)–mar
ch

Q.Par
ent
sc omingfr
om avi
ll
agebri
nga1dayoldnewbornbaby
. Q.Anewbor
npresent
edinerwithcyanos
isandr espi
rat
ory
Thr
eeoftheprevi
ouschi
ldr
enhavediedi
ninf
ancy.Par
ent
s di
str
ess
.Hei
sborntopri
migravi
daatgestat
ionalageof37

33 34
weeksbyc -s
ection.Dur
ingst
ayinni
cuc yanosi
sincreasedandi
s Whatisthemos tl
ikel
ydiagnosi
s?
rel
ati
velyunres
ponsivetoo2admini
str
ati
on. Hi
sc ondit
ion Whatinvest
igat
ionswouldhelpyoui
nconf
irmi
ngt
he
i
mpr ovedbygivinghim(pap) di
agnosis(
givei
nterpret
ati
on)?
Bri
efl
ydescri
bes t
epsofmanagement
Givethreedd? 2010(
mcps )–march
Whatar ethemos ti
mportanti
nvest
igat
ionst
oreachatt
he
fi
naldiagnosis
? Q.Parentsbri
nga10dayoldf ullt
erm neonatef
orthecomplai
nt
Givethreestepsofmanagement. ofshakingmovementsofal
lthef ourli
mbsalongwithabnor
mal
2010(
imm)s epet
ember eyemovement swi
thoutanyres pi
rat
orydist
ress
,but
accompaniedbycol
orchange. Heisbornbynvdwithuneventf
ul
Q.Youar ecalledtot helabourwar dforresuscitationofaf ul
l- deli
very
.
ter
m babywhohasf etaldi
stress. Thedeliver
yi sv aginalandt he
babyonlyrequiresfacemas kox ygenandnas ophar yngealsuc ti
on. Onex aminat i
onheisweighing2.9kg,l
engthis50cm,ofci
s
Theapgarscoreat1mi n,9mi nand10mi n.Themi dwi f
einfor ms 34.5cm,h/ r133/ minwit
hnor malpulsewithoutanydys
morphi
c
youthatmot herhasbeeni nc ontactwithhepat i
t i
sb, andatt he facialfeat
ur e.Anter
iorf
ontanel
laeissoft
.Liverandspl
eenar
e
ti
meofbi r
ths heispos iti
vet othehepat it
isbs urfac eantigen. notpal pable.
Negati
vetot hehbeagandhasant ibodi
est oec omponent .
Whataretwol i
kel
ydiagnos i
s?
Whattr
eat
mentdoest
hebabyneed Whatotherconditi
onwi l
lyouconsi
derindd?
2010(
mcps)–march Whatinvest
igati
onswillyoucarr
yout?
Whatmanagements t
epss houl
dbetaken?
Q.At er
mi nfantnotedtobehavi
ngprogress
ivej
aundi
cebeyond 2011(
imm)mar ch
the1stpostnatalweek.Attwoweeksofagetheres
ult
sofserum
bil
ir
ubinnotedar easfol
lows: Q.A28day sol
dbabyc amewithas horthistoryoffever,
i
r r
itabil
it
y,vomitingandlosemot i
ons.Pr egnancywasunev ent
ful.
Ser
um bi
li
rubi
n27.
8mg Nos i
gnifi
cantproblem atbi
rth.O/eneonat eishavingtemp39. 3
Ser
um bi
li
rubi
n(di
rect
)2.
15mg c,pulserateof180/ minandhei smot t
ledwi thcoldex t
remiti
es.
Hisant eri
orfontanell
eisful
l.Hi
sumbl i
c alcordiscleananddr y.
Al
t110i
u/l Investi
gationsshowshb13. 6gm/ dl,wbc32*103/ l,plat
elet
98*109/ l
Al
kal
inephos
phat
ase530i
u/l
Whati
st hel
ikjel
ydiagnosi
s
Nametwomaindi
agnosi
softhiscl
ini
cals
cenar
io.
Lis
t4otheri
nves ti
gati
onsthatar
ewar
rant
ed
Nametwomosthelpf
uli
nves
tigat
ion.
Whati
syouri nit
ialt
herapy
Howwil
lyoumanagethi
schi
ld?
2011(i
mm)oct
2010(
mcps)–march
Q.A5day soldbabyisadmi tt
edt hr
oughemer gencyf orfever
,
Q.A2daysoldfemalechi
ldpr
esentinout
patientwit
hh/o
vomiti
ngandjaundiceforthelas t3days.Thereisnoh/ ol oos
e
vomit
ingfr
eshbloodandpassi
ngdarkcolour
eds t
oolss
ince
motionorconsti
pati
on.Thebabywasbor natterm, wei
ghed3kg,
morni
ng.Shewasdeliv
erednormal
lyathomebyt baandwas
hadnodimorphicfeaturesandf edwellforthefir
s t2day s.On
bei
ngbreastf
ed.
examinat
ionthebabyisdehy drated,deeplyj
aundi cedwith
Onex aminat
ionshei
swelll
ooki
ngbabywi
thawei
ghtof3.
2kg, moderatehepatomegalyandj i
tterywithabodyt empof39c
ther
ear enobrui
sesorpet
echi
ae
A. Whati
sthedi
ffer
ent
ialdi
agnos
is

35 36
 B. Whatkeyi
nves
tigat
ionwoul
dyoul
iket
ocar
ryout normalandther
eisnohepat
ospl
eenomegal
yandpet
echi
es/br
uis
es
areabsent
.
C. Howwoul
dyoumanaget
hisbaby
Whatismos tli
kel
ydi
agnosi
s?
2012(
imm)mar
ch Writ
e3pr edis
posi
ngfact
orsfort
hiscondi
ti
ons
Q.3weeksoldboypr esentedinni
cuwi t
hcomplai
ntofv omit
ingand Writ
e3dd?
fai
lur
etothri
ve.Heissev er
lydehydr
atedandoninves
tigati
onhis Howwi l
lyoumanage?
ser
um na:130serum potassi
um 7.
1ph7. 2 2012(
imm)october

Whatisdiagnosi
s? Q.At erm babyisdeli
veredbyemergencyc-secduet osevereante-
Howwillyouconfir
mi t? partum haemorrhageandr equi
resful
lres
uscit
ation,hypoxicis
chemic
Whattreatmentwillyouof
fer
? encephalopathyensuesandhei sonventsupportat48hr sofagewith
2012(
imm)march nos pontaneouseffor
t.Ecgisdoneanditshowst al
ltentedtwav es
withwidenedqr scomplexes.
Q. Whil
eper f
ormi
ngfi
rstphys
icalex
ami
nationofnewbor
n,you
diagnoseddownsyndr
ome. Motheri
s32yearsol
dandthisi
sthe Whatar etheecgfindi
ngsuggestiveof
?
secondissue. Whati sthecauseofthes
ec hanges?
Givesixkeyelementsint
reatmentofthisdi
stur
bancewi
th
Enlist3es sentiali
nv est
igati
onsyouwouldrecommend? reasoning
Thec hromos omalr eportshows14/21tr
anslocati
on.What 2012(
mcps )mar ch
i
sr ecurrenc erisk?
Whati mpor tantaspecty ouwoul
dl i
ket
ohighlight Q.A25day soldfemal ehasbr oughtwithh/ovomi tt
ingforlas
tone
regardingf uturegrowt handdevelopmentofthischi
ld week. Thebabyi sonf ormul amilk.
thevomit
tingoccuresallofsudden
duringc ouns eli
ng? aft
erf eedingandisfor ceful.Thebabydemandsf eedssoonaf t
erthe
2012(i
mm)mar ch vomitting.
onex aminationt hebabyhasmi l
ddehy drati
onwi t
hno
obviousf i
ndingonex ami nation.
Q. Ababywasdel iveredat3weeksofges tationbyc-sec. Mot herhad
laborpainswithfouls melli
ngv agi
naldischarges i
nce4day s
. Mot her Whati
sthediagnosisanddif
fer
ent
ial
s?
hadpoor lycontr
olleds ugarandbloodpr es s
ur eduri
ngpr egnanc y. Howwil
lyouinvest
igate?Whatdoyouexpectt
ofi
nd?
Babyhadapgars coreof5/ 10at1mi nut
eand7/ 10at5mi nutesand Howwil
lyoumanaget hischi
ld?
temper at
ureof35c .Fivehoursafterdel
iverybabys tatedgr unting 2013(
imm)october
andc yanosi
s.At4hour sbabydev elopedfev er38c.Wei ghtis2kg, Q. 2daysoldf emalebabywei
ghing3.5kgpresent
edwithhi
s t
oryof
respi
ratoryrate70/ minutes. petechialr
as handmelena.Onexaminati
onbabyisacti
vealer
tand
Whatar etwol i
kel
ydiagnos i
s? thereisnohepat ospl
eenomegal
y.Invest
igat
ionshowshb13gms ,t
lc
Whatr i
skfactorsarepresentc ontri
buti
ngt
othei
ncr
eas
ed 8500/m3, platel
ete30,
000,peri
pheralsmearshowsnoother
i
ncidenceoft heproblem? abnormalc ell
s.
Writethreeimportantinvest
igations? Giv
et hreedd?
Whatpr eventi
vestepsy ouwillsuggest? Whatf urt
herinf
ormati
onandinvest
igat
ionsar
eneededt
o
Whatist hemanagement ? ar
riveatadiagnosi
s?
2012(
imm)october Howwoul dyoumanaget hechi
ld?
Q.A4daysoldboybor
nat36weeksges
tat
ionathomepresent
ed 2013(
imm)october
wi
threc
talbl
eed.Onexami
nat
iont
empis98fanter
iorf
ont
anelis

37 38
Q. A1dayoldbabyt erm babydeliver
edtoamot herwhowas Expl
aintheabovef indingswit
h3diff
erent
ial
sinor
derof
diagnpsedands tar
tedt r
eatmentf orpul
monar yt.
bat36weeksof pri
orit
ywi t
hjust
ifi
c ati
on?
gestati
onisbroughtf orevaluat
ion.Motherissput
um posi
ti
ve.
On Howwoul dyouinv esti
gatethi
sbaby?
examinati
onwei ghtis2.6kg, rr40/min,li
ver2cms,spl
eennot Writedownt hestepsofmanagementoft hemostl
ikel
y
palpabl
e98t empf . di
agnos i
s?
2014(
imm)apr il
Whatf
eedingadvi
cewouldy ougi
ve?
Howwil
lyoumanagethebaby? Q.Aonedayol d3.0kgful
ltermi nfantwhowasbor nbya
Whenshouldt
hebc gvacci
nebegivent
othebaby
? dif
ficul
tforc
epsdel i
ver
yisalertandact i
veshedoesnotmov e
2013(
imm)mar ch herleftar
m whichs hekeepsbreat hi
ngdiff
icul
ty.Hercx
riscl
ear
hb15mg/ dltlc11000/cmm platelets350,
000
Q. Anewbor nbabybornbyel ecti
vec -s ecafter37weeksgEs tation
pr esent
edwi thtachypneaandgr untingatonehourage. On Cr
ples
sthen6
ex aminati
ont hebabyhasr es
piratoryr ateof100/minwi th
Whati
stheli
kelydiagnosis
hy pothermia,pul
serateof110/ minut esands ubcost
alrecessions. X-
Giv
eanyaddi
tionalinves
tigat
ion
rayches tshowsf l
uidinthe110/ minut esands ubcos
talrecession. X-
Howwil
lyoumanage
rayches tshowsf l
uidinthetransversef is
surewithhyperinfl
atedl ung
2014(
imm)apri
l
fields.
Q.A30y earoldg6p5del i
veredahealthyneonatewho
Whatismos tli
kelydi
agnosi
s?Twodd?
presentedon3r ddayofl if
ewi thgener
al i
zedseiz
ures
.Thechil
d
Whatinvesti
gati
onwillyouadv
ise?
wasonex clus
ivebreastfeeding.Thepr egnancywascompl
icat
ed
Whatistreat
ment ?
bys everebackacherestr
ictingherdail
yact i
vit
ies
.The
Whatisprognosisofthi
sprobl
em?
i
nv est
igationsareasfoll
owed
2013(
imm)march
Cbcnor
mal
Q.Ater m babygi
rli
sbornt oaprimigravi
damot herat39weeksof
gest
ation.Sheweighs3923gramsanddi dnotneedanyr es
usci
tati
on. Cal
cium 7.
5mg/
dl.
Shehasagoodbr eastfeedandpas sesmec oni
um at12hoursofage.
At17hour sofageshebec omeslethargi
candappear anc
edusky.Rr: Phos
phor
us.4mg/
dl.
nd
70/minandhasal oud2 hear ts
oundwi t
hnoaudi bl
emur mur. Magnes
ium 2mg/
dl.
Whatismos tli
kel
ydi
agnosis
? Al
bumi
n3.
5g/
l.
whatist
hebes tmanagementfort
hiscondi
ti
on?Gi
vegener
al
andspeci
ficmanagement. Gl
ucos
e.90mg/
dl
2013(mcps)october Whati
sthelikel
ycauseforconvul
si
on
Q. Ababywasbor nafterat erm deli
verywi themer gency Whati
sthes peci
fi
ctreat
ment
c.
sectiontoapr i
migravidaduet of etaldis
tress.Themot herhas Whati
sthelikel
yreas
onf orneonat
e'spr
obl
em
oneant enatalv i
si
stat35weekaandanul t
rasounddones howed 2014(
imm)october
scalpedemaandas ci
tes. Thebabthasaweekc ryatbi rt
h.On cq.Anemergencycesareansect
ionwasdoneat0400hoursanda
examintaion, hr=240/min, weight=3.
8kg,r r=70.minc aprefi
ll l
impmec onium s
tai
nedt er
m babywasdeli
vered.Hewasnot
was>3s ec.
li
v erwas3c ms, spl
eenwasnotpal pable.Labss how breat
hingandhisheartrat
ewasl es
sthan100/min
hb=13.0gm/ dl,wbc14000/ mm3, platelet
s200,000/ mm3.

39 40
 Howwil
lyoumanaget
hisbaby? dis
c ordanceandbradycar
diaint
heothertwin.Fir
sttwi
n
2014(
imm)-october weighing900g,palewithapgars
core2at1mi nuteandsecond
twinwei ghi
ng2.2kg,plet
hori
cwithapgarsc
or e4at1mi nutear
e
Q.Aninfantpresent
edat72hourswithexces
sivecryi
ngmot her deli
v er
ed.
i
salsoconcernedfordecr
easeduri
neoutputanddelayed
st
ooli
ng.Onex aminati
onbabyisdehydr
atedandjaundiced. Whatpr
oblemswillyouati
cipi
atei
nbothtwins
?
Babywasbor nat38weeksofgestati
onwithnormalperi
natal Whati
stheunderl
yingcause?
event
s.Bir
thweighteas3kg Whati
stheprenat
almanagement ?
Whati
stheprognosisforatwinpr
egnancy?
I
nves
tigat
ions
howshb15mg/
dls
.na152meq/
l,s
.K5.
5meq/
l
Bl
oodur
ea=44mg/
Whati
st
Whatf
act
dlandc
hemos
orsc
ur
tl
i
anl
r
entwei
kel
yc
eadt
ght=2.
aus
ot
e
hi
sc
8kg

ondi
ti
ons
Neur
ology
Howwil
lyoumanage 2006(
imm)mar
ch
2015(
imm)apri
l Q.Anei ghtyearoldchi
ldi
sbroughtwithhist
oryofunsteadygal
l
Q. Amotherbr
ingsher9dayol
dneonat
ewi
tht
hef
oll
owi
ng forthelast4days.Therei
shi
storyofprecedi
ngcough,vomiti
ng
repor
tsdoneadayearli
er. andr unnynoseforwhichhehasrecei
vedmedi cat
ionf
rom a
generalpract
iti
oner.
Ser
um t
4=8µgm/
dl(
6-15µgm/
dl)
,ser
um t
sh=20(
1.7-
9.1ml
/ul
)
Whatar ethreediff
erent
ialdi
agnoses?
Gi
ve2pos
sibl
econdi
ti
ons
. Bri
efl
yout li
neinvesti
gat
ionstoreachanappropri
ate
di
agnos is
.
Whatf
urt
heri
nves
tigat
ionswoul
dyoul
ikei
nthi
scas
e?
Howwi llyoumanaget hi
sc hi
ld?Giv
es t
epsonly.
Howwi
llyoumanaget
hiscas
e? 2007(
imm)f ebruary
2015(
imm)apr
il Q.A5yearol dc hi
ldisbroughtt otheemergencyr
oom wi t
h
hi
storyofataxia,r
ecurrentoti
tismediaandchestcongesti
on.He
Q. A5dayol dbabypresentedwi thl
ethargyandrel
uc t
anceto i
sons yrupepivalforfebri
lefi
ts.Heisafrai
dtowalkorstand.He
feedforoneday .Hewasdel iver
ednormal l
yaft
eranunev et
ual i
sco-operati
veandwel lor
iented.Onlyfi
ndingonexaminati
onis
pregnanc yandapgarscorewasnor mal.Onexaminati
onbabyi s hor
izontalnys
t agmus.Restoft hehist
oryandexaminat
ionis
palelooking,t
oesareblue,temp37c ,hr170/min,rr60/min,cr
t unr
emar kabl
e.
i
s3s ec onds.
Whati
st hedi
fferenti
aldi
agnosi
s?
Whatdi
fferenti
aldi
agnos
iswilly
oucons
ider Howwillyoui
nv est
igat
ethiscas
e?
Whatot
herex aminat
ionwouldyoul
iket
odo 2007(
imm)februar
y
Whati
sthei mmediatemanagement
2016(
imm)april Q.A7yearol dboy ,st
udentofsecondgr adepresentswi t
h
dif
ficul
tyinwalki
ng.Heisunabletostandf rom squatti
ng
Q.Youar eaneonatalpgrondut yandatt
endedac al
lfrom ot
. positi
on.Famil
yhistoryr
eveal
stwomat ernalunclesdiedwhen
Obstetri
ciani
sgoingtodols csofanunbookedcasewitht wi
n theywereabout14year sofage.Theywer ebedr iddenandwere
gestat
ionat28weeksi nemergencybecauseofpolyhydramnios unabletowalk.Hehasa2y earsoldsis
ter .Sheishealt
hyand
i
ns acofonet wi
n.Shealsoinformedyouthatther
eisgr owth developmental
lynormal

41 42
 Whatisthemos tli
kel
ydiagnosis? Howwoul
dyoul
iket
oscr
eent
hef
ami
ly
Whatisthemodeoft ransmissi
onoft hedisease?
2010(
imm)-mar
ch
Whichinves
tigat
ionswil
lhelpindiagnosis
?
Whatisthechanceofnex tsi
bli
nghav ingas i
milar Q.An8y earoldgirlhasbeenbr oughttoy ouwithsevere
condi
ti
on? pulsatingheadachef ort helas tonehour .Sheispointi
ngt oher
tempor alregion,avoidinglightandget ti
ngdi stur
bedwi theven
2008(
imm)j
anuar
y sli
ghtnoi se.Shehasv omitedoncei nyourwaitingroom ten
Q. 1yearoldisadmi ttedwithhi s t
oryofl owgr adefeverand minut esago. Thereish/ o10- 12s uchepisodesamont hf orthe
vomitingfor3mont hs,unsteadygai tfor2mont hsanddi pl
opi
a l
as tthreemont hs
.Herb. pi s110/ 60mmhgwi thnoneur ologic
for20day s.Motherisonant ituber c
uloust reatmentf or7 defici
t.
mont hs.Onex aminationhehasnopal lor,jaundiceor Whati
syourdiagnos
isandclas
sif
ythet
ypesofi
ll
nes
s?
l
y mphadenopat hy.Neur ol
ogic alexaminat i
onr eveal
edat axi
cgai
t Howwouldyoumanaget hechi
ld?
withny s
tagmusandi ntenti
ont remorswi ths i
gnof 2010(
imm)september
i
nc oordi
nati
on. Fundos copyr evealedbilateralpapil
ledema
Q.An8y earoldchildhaspresent
edwithrapidl
yprogr
ess
ive
Li
stt
hreedi
ffer
ent
ialdi
agnos
es quadri
paresisoverlastt
hreedayswit
hinabili
tytohol
dherneck.
Thecranialnervesfunct
ionsarei
ntac
tandt herear
enosignsof
Li
sti
nvesti
gat
ionswhi
chwi
lll
eadt
oanappr
opr
iat
e meningealirr
itati
on.
di
agnosi
s
Whatar
etwomaj ordiagnoses?
Givei
niti
almanagement Howwouldyoudiff
erentiat
ebtweent
het
womaj
or
2009(
imm)s eptember di
agnos
es?
Q. Niney earoldboybr oughttoy outoyouropdc omplaini
ngof Howwouldyoumanaget het wo?
notf ocusingins t
udi esforlastonemonth. Bothparentsand 2010(
imm)september
teacher shads i
milarobs ervat
ionaboutthec hi
ld.I
nt hecli
nicyou Q:a10mont holdboyhaspr esentedwiththr
eeepisodesof
obs ervedthatpat i
entwhi letalki
nghads uddenlyst
aredblankly afebr
il
egeneral
iz
edt onicsei
zureseachaweekapartandl as
ting
forawhi l
e.Onc all
inghi snamehet ookf
ews econdt oresponds. 2-3minut
eswithnofami lyh/osei
zures.Hi
selders
isterwas
Hedi dnotr ecallwhathewasl ooki
ngat.Examinati
onis tr
eatedforbonedis
eas eattheageof11mont hs.
otherwi seunremar kable
Whatisthemos tl
ikelydi
agnos
iswi
thanydi
ffer
ent
ial
Whati
stheli
kel
ydiagnosis di
agnosis?
Whati
nvest
igat
ionyoucarryout Howwillyouinves
tigatet
hechil
d?
Nametwodrugsofchoice Whatwillbeyourmanagement?
2009(
imm)sept
ember 2010(
mcps)–mar ch
Q. Afiveyearoldunvacci
natedboypresentedwi t
hlowgr ade Q.A5y roldboyhadanor malearl
ydevel opmentti
lloneyearof
fever,malais
eandheadac hefortendays.Ex aminati
onshowed age.Afterwardshestar
tedhavingdiffi
cultyi
ncli
mbi ngst
air
s,
st
nuchalrigidi
tytlc20,
000/min,es
r60mm 1 hour ,cs
f assumedal or
doticpost
urewhilestandingandhaswaddl i
nggait
.
examinations howedprot
ein120mg,c el
ls250, 85% lymphos,cs
f
glucose15mg/ dl Whati
syourdiagnosi
s?
Whatfur
theri
nvesti
gati
onswil
lyouorder
?
Howwi
llyout
reatt
hepat
ient Whatwil
lbeyourstepsofmanagement?

43 44
 2012(
imm)mar
ch Howwi l
lyouinv
es ti
gatethi
schil
d
Howwi l
lyoumanaget hischi
ld?
Q.5yearoldboywasbroughtwi
thint
ract
abl
esei
zur
esandl
ossof 2013(i
mm)oct ober
cons
cious
nessfort
helast1½ hour Q.A6yearol
dpresent
edint heerwithhis
toryoff
all,adayback.He
Whatismos tl
ikel
ydiagnosis? i
snowdrowsyandhadoneepi sodeofseiz
ure?
Enl
ist5li
kel
ycompl icat
ion? Whatf ur
therasses
smentwoul
dyouli
ketodoint
his
Givetr
eatmentoptionsinorderofpr
ior
ity
? pati
ent?
2012(
imm)october Whatimmedi at
es t
epsar
erequi
redi
nthi
spati
ent
?
Q.9yearsol
dboypr esentswit
hhistor
yofdiff
icult
yinwalki
ngs i
nce 2013(
imm)october
oneday.Chi
ldhadat hroati
nfecti
on12daysbac k.Onexaminat
ion Q. A3y ear
soldc hildwasbroughtt oerdepar tmentwithc omplaints
power,t
onerefl
exesarediminis
hedinbothlowerlimbs. off i
rsttimer i
ghts i
deds ei
zureswhi chwer econti
nousfor1hourat
Whati smostli
kelydiagnosis? nightwi thhighgr adefever.Afterseiz
urest hechi
ldhaddis t
urbed
Givethreedds? sleepandpoorf eedingatnight .Hewass eizuresf
reeduri
ngr estof
Howwoul dy oui
nv est
igatethechil
d? theni ght.onex ami nati
on,childisfebril
es omewhatbreathlessand
Howwoul dy outr
eatt hethischi
ld? notact ive.Theel derbrotheralsohads eizureswit
hhighgr adefev er
Givethreecl
ini
calfeaturespredi
cti
veofpoorout
comewi
th atoneyearagebutnowhei swel l.
sequel? Whatismos tlikelydi
agnosi
s?
2012(
mcps )march Whatimpor tants i
gnswil
lyoulookonex
ami
nat
ion?
Q. A6y earol
dbpyhaspr esent
edwi thdiffi
cul
tyi
nwalki
ngfor1 Whatadv i
sewi llyouadvi
se?
year.
hislowerl
imbpoweri sdecreased,refl
exs
esareabs
entand Whatinvesti
gat ionwil
lyouadvis
e?
plant
ersupgoi ng.Rombergtestisposit
ive.Hehasfewcaf
é-au- Howwi l
lyout reatthi
schil
d?
l
aitspots.Chestxr
ays howedcardiomegaly. 2013(
mcps)oct ober

Whati
sthemos tl
ikelydiagnosi
s? Q.A12yearol dboycamet oy ourcl
ini
cwi t
hcompl aintof
Whatf
urthuri
nvestigat
ionwoul dy
oul
iket
odo? recurr
entepisodesoff
rontalheadachelast
ingforonet otwo
Whatt
reatmentwillyouoffer? associ
atedwi t
hnauseawhichs ometi
mesal socausesschool
2013(
imm)march absenteesi
m.Onex aminat
iont emp=98f,r
r=30/min,hr=90/mi
n,
bp100/ 80.Fundosc
opynormal .
Q.A10mont holdc hi
ldwasbr oughtt otheemer genc yroom
with4day shistoryofv omi t
ing, feveranddi arrhea.Thec hil
d Whataret hedif
fer
enti
alsdi
agnosis
?
developedgener al
izedt oniccloni cseizurethi
smor ningwi th Whatrelevantquest
ionwoul
dyoul i
ket
oas
kint
hehi
stor
y?
alt
ereds ensori
um. Hehasbeenbr eastfeedi
ngandt hemot her Howwillyoumanaget hi
spatient
?
gavehim or sathome. Thec hi
ldi spas si
ngur i
ne. Onex aminati
on
2014(
imm)apr
il
weightis8kg, height70c m, hei ss everel
ydehy dratedwi t h
doughys kin.Heartrateis180/ mi n,weakpul s
es ,anterior Q.A10yearboypr esentedinoutpati
entdepartmentwi thas i
x-
fontanel
leisnotbul gi
ng, respirator yrate50/mi n,bp70mmhg mont hhist
oryofrecurrentheadaches.I
tisgradualons etsright
systol
ic.Random bloods ugarisnor mal. si
deandof tenprecededorac companiedbynaus eaandv omi ti
ng
Whati
sthemostlikel
ydi
agnos
is? .hebec omepaleandqui teduri
ngepisodes.Onex aminationhei s
Whatot
herques
tionyouwil
lasktor
eacht
hedi
agnos
is? heal
thyandwi l
lgrowhi sbp95/60mmhghi sex aminationofcvs
.res
pirator
yandgi tsystemsarenormalfundos copyis

45 46
unr
emar
kabl
e.Ther
ear
enof
ocalneur
ologi
cals
igns
. Enumer
aterelevantinves
tigati
onwithint
erpr
etat
iont
obe
donei
nthischildfordefi
niti
vediagnos
es
Wr
ite3di
ffer
ent
ialdi
agnos
is
Giv
est
epsofmanagementoft
hisc
hil
d
Whati
sthemos
tli
kel
ycaus
eint
hiscas
e? 2015(
imm)apr
il
Whatt
estyouwi
lladvi
set
oev
aluat
e Q.A11yearol ds choolboypr esentedwi thheadache, vomit
ing
andal ter eds ens ori
um f orlast3day s.Hehadf ebril
eill
ness
Howwi
llyoumanage?
associat edwi t hras hscatteredal loverbodyabout10daysback.
2014(
imm)oct
ober Twos ibsal sos ufferedf rom similaril
lnessandhadunevent f
ul
recover y. Onex aminationhi sgcsi s7/ 15,temp99. 40f,rr20
Q. A2y earoldboyi strans f
erredf rom dhqhos pi
taltoy our breaths /mi n, h.r100/mi n,bp110/ 70.Hi spupi
llaryreacti
onis
tert
iarycaresetup.Hehasl owermot orneuronpar alysi
sofupper equalonbot hs i
deswi thupwar dgaz e.Hehashy pertoni
awith
andlowerl i
mbs .Itstarted5day sbac kfol
lowingepi sodeof extensorpl ant arrespons e.
diarr
heawhi chisper s
isting. Hei spas si
ng6- 7loos estoolof
grade3and4c ons i
stingdai l
y.Hi swei ghti
s7. 5kghb8. 5mg/ dl Whati
sthemos tl
ikelydi agnosis
tl
c8000/ cmm pol ys70% l ymphoc ytes20%.Ser um na132 Giv
e3labor
ator
ytes ty ouwi l
lcarryoutwi
thj
ust
ifi
cat
ion
meq/ lserum k2.3meq/ lserum ur ea20mg/ dl.Serum creati
nine Howwil
lyoumanaget hispatient
0.3mg/ lserum cal
cium 8. 4mg/ lbloods ugar60mg/ l Whati
stheprognosis
2015(
imm)apri
l
Abg'
sph7.
27
Q.An8yearoldgirlpres
entedwithpaininthebackand
Pco260mmhgpo255mmhg di
ffi
cul
tyinwal
kingf orl
ast3weeks .O/etemp=37c,t
ender
nes
s
i
nlowerthor
acicregionandbil
ateralankl
eclonusi
s+ve.
Bi
car
bonat
e25mmol
/dl
Gi
ve3di
ffer
ent
ialdi
agnos
is.
Be+1
Whatotheri
nfor
mat
ionwoul
dyoul
ikei
nhxand
Whati
sthemos
tli
kel
ycaus
eofhi
spar
alys
is? ex
aminati
on?

Whatdi
ffer
ent
ialdi
agnos
isy
ouwi
llcons
ider Whatcompl
icat
ionsar
eant
ici
pat
edi
nthi
schi
ld?

Howwi
llyout
reatt
hispat
ient
? 2015(
imm)apr
il
Q.An8yearol dchil
dpr esent
edinerwithgeneral
iz
eds ei
zures.
2014(
imm)oct
ober
Hehashxofnoct urnalenuresi
sforwhicht
reatmentwass tar
ted
Q.A6y earoldchi
ldpresentedwi t
htingli
ngs ensat
ioni
nt oes 10daysago.Thereisnohxoft r
auma.Ther
eisnopas torfamily
anddiffi
cul
tyinwalki
ngwi t
hs everepai
ni nlegsandback. On hxofsei
zures.O/etempt =37c,bp=98/
50mmhg, gcs=13/15and
examinati
onheisfull
yconsciousandaf ebri
le.Hi
sheartrateis pupi
lswerereact
ive.
150/min.Hisbl
adderisdis
tendedhehadanepi s
odeofdi arr
hea Whati
sthel
ikel
ycaus
eofs
eiz
ures
?
twomont hsago
Whati
mmedi
atemeas
ureswoul
dyout
ake?
Whati
sthemos
tpr
obabl
edi
agnos
isgi
ver
eas
on?
Whatadvi
cewi
llyougi
vet
othepar
ent
s?
Whatr
elevantex
ami
nat
ionwi
llyouper
for
mint
hischi
ld?

47 48
2015(
imm)oct
ober Q.A6mont holdbabygi rlpres entedinemer gencywith
mul tipl
eepi sodesofs ei
z uresl asti
ng1- 2mi nutesalongwi t
h
Q. A10y earoldunv acci
nat
edanddev elopment all
ynormalbiy fever.Ther eiseyebl inking,lips macking, tonicpos tur
ingand
presentedwi th3mont hsh/odeterior
at i
onins chool ret
r actionoft hehead.Phy si
c alexami nationr evealedan
performanc efol
lowedbymy ocl
onicfi
t s
.Rec entlyhehasalso i
rri
tabl ebabywi thincons ol
abl ec r
y i
ng.Herof cis43c m,
developeds omei nvol
untar
ymov ement sanddy stoni
cposturi
ng. weight6. 5kgandl engthi s63c m. Font anelleiswideopenand
Onex aminat i
onhei sconsci
ous,ori
entedandhei shavi
ng fl
at. Therei sanor althrus hwi thnot eether uptionasy et
.Rest
choreathethoidmov ements.Therearenos i
gnsofmeni ngeal ofthes ystemicex ami nationisnor mal.Mot hergaveahi st
ory
i
rrit
ationandr efl
exesarenormallyell
icitable.Thereareno t
h
ofs eizuresat6 dayofl ifeforwhi chs hewast reatedata
sti
gmat aofc l
dandey esmov ementdoesnots howanykfr i
ngs.
l
ocalhos pital
.Birth,dev elopment alandf amilyhistori
esare
Whati
sthemos
tli
kel
ydi
agnos
is? normal .

Whatot
herques
tionwoul
dyouas
kinhi
stor
y Li
stt
hreedi
ffer
ent
ialdi
agnos
es.

Enl
is
tinves
tigat
ionst
oconf
irm yourdi
agnos
is Gi
vef
ourr
elev
anti
nves
tigat
ions
.

Wr
itedowns
tepsofmanagement Gi
vet
hes
tepsofmanagement
.

Nephr
ology
Whati
sli
kel
ypr
ognos
is
2016(
imm)apr
il
Q. A12mont holdgi rlhasbeenbr oughtt ot hepedi atri
c
2006(
imm)augus
t
emer genc ywithepis odesofs uddenons ets tiffnessoft he
whol ebodyf ort helas t3days . Thereishi storyoff everand Q.An8year soldmal ec hi
ldisbroughtt otheopdwithhi s
t oryof
coughi nthelastweekwhi c hs ettledwi t
hs ympt omat i
c recurrenthighgr adef everforthel astfourmonths.On
treatment. mot heralsogi veshi storyofdeepj aundi ceatt he exami nationhist empi s101f ,weight8kg, wi
thnoot herpos i
ti
ve
timeofbi rthanddel ayi nac qui ri
ngageappr opr i
ate cli
nicalfinding.Hi sini
t i
alinvesti
gat i
onr eveal
:hb12gm%, tlc
mi l
estonesofdev el
opment .Onex aminat i
ont hec hil
di s 18ooo/ cmm, polys70%, l
ympho28%, mono1%,eos i1%, uri
ne:
havingepi sodicarchingoft hewhol ebodyal ongwi t
hf i
s t
ing colourpal eyell
ow, ph6. 5,specif
icgr avit
y1015,al
bumi n+,wbc
.
shei shav i
nghy perref l
exi
ai nal lfourlimbs .Herf oci s 25-30/ hpf,rbc10- 15/ hpf.
40cm. weightis9kgandl engt hi s72c m. Rout ine
investigati
onsi ncl
udi ngbloods ugar ,serum c alci
um and Whatisyourdiagnosi
s?
electrolyt
esar ewithinnor mall i
mi ts
. Whatfurt
herinvesti
gati
onsshoul
dbecar
riedoutt
ofi
nd
outt
hecause?
Whati
sthemos
tli
kel
ydi
agnos
is? Whatarepossibl
eunderlyi
ngcauses
?
Gi
vet
wodi
ffer
ent
ialdi
agnos
is. Howwouldyoumanaget hi
schil
d?
2006(
imm)mar ch
Whatotheri
nves
tigat
ionswoul
dyouadvi
set
oreacht
he
di
agnos
is? Q.A5yearol dgir
lisbroughtint heemergencywi thhistoryof
abdominalpai
ns i
ncemor ning.Shehashistoryoff everand
Howwoul
dyoumanage? coughfor2weeksandpuf f
inessoffaceandf eetfor4days .
In
2016(
imm)apr
il thepastshewashos pi
tali
zedt wicefors
omer enalproblems.On
examinat
ionsickl
ookingchi l
d,temp101f ,weight16kg, has

49 50
puffi
nessoff
aceandedemabot
hfeet
.Abdomeni
sful
land Giv
ethecompl
etedi
agnosi
sforthi
schi
ld?
tender. Howwil
lyoumanagethi
scase?
2008(
imm)oct
Whatist
hemos tl
ikel
ydiagnosi
s?
Whatfur
therinfor
mat i
onisrequir
edint
hehi
stor
yand Q.A13yearol dgirlwasseenbyapedi atricianoneyearagowi t
h
exami
nati
on? compl ainofpal l
orandjointpai ns.Shei mpr oveswi thanal gesics.
Howwouldy oumanaget hispat
ient? Sixmont hlater
,shedevel opedabdomi naldi stensionwhi chwas
2007(i
mm)february
foundt obeduet oas ci
tes.As i
citi
cf l
uidwasex udativeonl ab
Q.2y earoldgi r
lpresentst ot heout patientdepartmentwi th exami nation.Shewasgi venat twi ths t
eroi dsandbl ood
his
toryoff ail
uretothrive. Accor di
ngt ot hemot hergi rldoesnot transfus i
on.Girlshowedper iorbitalpuffines swi thwei ghtlossof
r
d
haveappet it
e.Onex ami nationherhei ghtisonthe3 per centi
le 2kg. Ex aminati
ons howspal lor+ve, pulse100, li
veis4c m
rd
andwei ghtislessthan3 c ent i
le.Res tofexaminationi snor
mal. cervicallymphadenopat hy.Inves t
igat i
onss howhb7, esr90,
Theinvestigati
onrevealanor malc omplet ebl
oodpi ct urewithhb mi cr
oc ysti
chypoc hromicanemi a.Urinalys i
ss howspuscel l5- 8/
8hm/dlandur eaandc reat i
ninear enor mal,el
ectrolytess howna
hpf,r bc42- 45/hpf,albumi n+.Bl oodur ea40mg, creati
ni ne1.3,
138meq/ l
,cl114meq/ l
, k2.5meq/ l
,hco313meq/ l,ur inedr
showsmi croscopichemat uri
a. anaandr hemut oi
df act
orar enegat i
ve.

Howwi
llyoui
nves
tigat
ethi
scas
e? Mos tl
ikel
ydi agnosis
Givespecifi
ci nves
tigat
ionswi
thj
ust
ifi
cat
iont
oreac
hthe
Howwi
llyoumanaget
hischi
ld? fi
naldiagnosis
2007(
imm)augus
t Writestepsofmanagement .
2009(
imm)mar ch
Q. A3y earsoldchil
disbr oughttotheopdwi thhist
oryof
recurrenthighgradefeverforthelast6mont hs.Cli
nical
lyheis Q.Afourmonthsoldboypr esentedwithret
entionofuri
neof
f&
febril
eweight10kgandmi ldanemic,f
ewi nvest
igat
ionswhich on,wi
thpoorurinar
ystream,fail
uretothri
ve,nauseaand
mot heriscarryi
ngshowshb10gm%,t lc12000/ cmmm wi t
h vomit
ing.
Onex aminat
ionurinarybladderwasfull
.
i
nc reasedno.Ofpolymor ph, ur
ineexam s
howi ngwbc25- 30/hpf,
Whati
syourdi
agnos
is?
rbc10- 15/hpf,al
bumin+
Howwoul
dyoumanaget hi
sboy?
Whatist hemos tl
ikel
ydiagnosi
s? 2010(
mcps)–march
Whatf urtheri
nvesti
gati
onsshouldbecar
riedoutt
ofi
nd
Q.A9yroldgi
rlpr
esent
sinerwit
hcompl
ainofol
igur
iaand
thecause?
shor
tnes
sofbreat
h.Shehadloos
emoti
onwithpaini
nabdomen
Howwi llyoutreat
?
twoweeksago.
2008(
imm)j une
Onexaminations heispalel
ethar
gicandhavingh/r130/
min,r/r
Q. A3mont hol dmal ebabyisbroughtwi ththecompl ai
ntsof
40/mi
n.Investigati
onreveal
shb6gm/ dl,bl
oodurea80mg/dl,
highgr adef everf orthelast2day sandinabil
ityt
ot akefeedsf or
ser
um cr
eatinine2.9mg/ dl
,ret
iccounti
s4%
oneday. Hewasadmi ttedtohospitalforsi
milarcomplaintsand
treatedforec olisepsislastmonth. Onexaminati
on, hi
swei ghtis Whati
sthemos tli
kel
ydi agnosi
s
r
d
lessthan3 per centil
e.Heartrat
ei s110/min,temp102degr ee, Whatot
herinv
es t
igat
ionsyouwouldl
iket
ocar
ryout
?
anteriorfont anelleisdepressed.Thereisapalpablemassint he Howwil
lyoumanaget hisgirl
?
rightlumbarr egion. 2011(
imm)march

51 52
 Q. A5y earoldc hil
dpr es
entswi th3dayshis t
oryofbl oodi
n bp=120/
80andhasgr
ossas
cit
es.Today’
sinves
tigat
ions
:
urine.Onex aminationhei sconsciousandc ooperati
ve.His
t
h Ur i
nal
y s
iss howeds pgravit
y=1.010,ph=6.5, protei
ns =+++,
heightandwei ghtar eon25 c entil
eforage.Vital
ssignsare
l
eukocy tees teraseandni tr
ite–ve.Wbc=20- 30/hpf,rbc
stable.Restofex aminati
onisnor mal.
numer ous,rbcandgr anularcastsarepr esent.Cbcs howed
Whatpoi
ntsi
nhi s
toryandexaminat
ionyouwillel
ici
t hb=10gm/ dl,tl
c=14600/ cm, n70%,l =22%, m=5%, e=3%.Ches
tx
Howwil
lyouinvest
igat
ethi
sc hi
ld?Givej
ust
ifi
cati
on. -rayshowedbi lat
eralpleuraleff
us i
on. Ser
um t otal
2012(
imm)march protei
n=5.2gm/ dl,al
bumi n=1.5gm/ dl,cholesterol
=260mg%,
serum creatinine=2mg/ dl.
Q.12yearol
dgirlhasbeenbroughttoy ouwithhis
toryof
puff
ines
soffac
ef orthelas
t5day s.Ur
ineanalys
isshowsreddi
sh Whati
sthemostl
ikel
ydiagnosi
s?
col
or,pr
otei
n++, s
pecif
icgravi
ty1020,rbcsnumerous,wbcs6-
8 Gi
ve3under
lyi
ngcondit
ionsres
pons
ibl
efori
t?

Whatfurtherpointsi
nhi
stor
yyouwouldl
iket
oeli
cit
? Howwi
lly
ouconf
irm yourdi
agnos
is?
Enl
ist5dd?
Whatar
etheopt
ionsf
ort
reat
ment
?Gi
vel
ogi
calr
eas
oni
ng.
5rel
evantinvesti
gati
ont
oestabl
is
hthedi
agnosi
s?
2012(mcps)mar ch 2015(
imm)oct
ober
Q.A9y earol
dboyi sr
eferredtopeadsopdforbedwett
ing.He Q.A2yearol dchi l
dpr es
ent edwithhxofex cessi
vethrustand
wetsthebedmos tofthenight
sandi sups
etaboutthi
s.On feveronandofff orthepas t8mont hs.
O/ eherheightand
exami
nationnor
malgrowt handdev el
opmentwit
hblood weightar
th
eon5 per centi
le(fal
lfr
th
om 25 per centi
leduringfi
rst
pr
essureof112/70mmhg. Syst
emicex ami
nat
ionisnor
mal . year)
.Hersepti
cs creenisnegat i
veandrbsi swithi
nnor malli
mits.
Whatfurt
herhi
s t
oryisr equi
red? Gi
ve3di
ffer
ent
ialdi
agnos
isf
ort
hiscondi
ti
on.
Whatfurt
herexaminationisnecess
ary?
Whataretheopti
onsf ormanagement? Howwi
lly
oui
nves
tigat
ethi
schi
ld?
2013(
imm)mar ch 2015(
imm)oct
ober
Q.8mont holdchild(
male)isbroughttopedi
atr
icemergencywit
h Q.A5year soldboywhoi sbei ngt r
eatedforami nimalchange
histor
yofpoorur inar
ystream.Forthelast2dayshehasdevel
oped l
es ionnephrotics yndromef orthelast2mont hs.Ac cordingto
fever,r
efusalt
of eed,i
rri
tabi
li
ty,vomit
inganddiar
rhea.On dietaryadvicegi v
enbyapr ac t
iti
oner,motheri sgivert hechild
examinationweight7kg,length60cm eggwhi tesint heform ofr aweggs4- 5t i
mesaday. Nows he
Whatotherrel
evantcli
nicalfi
ndingswouldyoulookf ori
n compl ai
nsherc hil
dhasbec omepr ogressi
velyc l
ums yand
thi
spati
ents
? l
et hargi
calongwi ththinningofhai randex cessivehai rloss.O/e
Howwoul dyouinves
tigatethischil
d?Givej
usti
ficat
ionfor childiswithdrawnandhy pot onicwithareasofal opec i
aov erthe
each? scalpands calyper i
-orifi
cialder mati
tis.
Howwoul dyoufol
lowupt hi
sc hi
ld? Whati
sthemos
tli
kel
ydi
agnos
is?
2015(i
mm)april
Whatar
ethedi
agnos
ticcr
iter
iaf
ort
hiscondi
ti
on?
Q. A10yearoldboyisreferr
edtoy ouwithhxofbodys wel
ling
for6weeksanddec reaseuri
nev ol
umef orthelast2weeks
.He enl
is
tst
epsofmanagement
.
wasbeingtreatedbyagp. Pasthxisnotsigni
fi
c ant
.O/eheis
afebr
il
e,res
pirator
yrateis24/min,hear
trate=100/min,

53 54
 POI
SONI
NG
Q.A4yrol
dboyfoundunconsci
ousi
ncountr
ysi
deandbr
ought
toerwi
thonehourh/
otoniccl
onics
eiz
ures
.
Onexami nat
ionheisrunni
ngat emperatur
eof104f(40c)having
2007(
imm)f
ebur
ary anunusualgarl
icl
ikeodouraroundhim wit
hexcess
ivesal
ivat
ion
andperfusesweat
ing.Hish/ris80/
minandpupilsare
Q.5mont hol dbabyi sbroughtt oemer gencydepart
mentwi th
cons
tri
cted.
dif
fic
ultyinbr eathi
ngforoneday .Accordi
ngt omotherheis
suff
eringfrom c oughandc oldforoneweekf orwhi
chs hewas A) whati
syourdi
agnos
is?
usi
nghomer emedi es.Onex aminat i
onthebabywaswel l
nouri
she,lethargicandhavings hallowrespi
rati
on.Puls
e B) whatar
ethes
tepsofmanagement
?
oxi
met erwas85–90% onr oom ai randbp70/ 40mmhg. 2011(
imm)mar
ch
Anteri
orfont anell
ewasopenandf lat
,pupil
swerebilat
eral
ly
equaldil
atedwi ths l
uggi
shr eact
iont oli
ght. Q.A2½ y ear
soldboybr oughttoerwi t
hh/ oi
ngest i
onof6
tabl
etsofpar
acetamolabout6hour sback.Onex aminat
ionhi
s
Givet
hr eeli
kel
ydiagnos
es? weighti
s10kg,gc s11/ 15,vi
tals
igns:hr120/min,rr20/
min,bp
Howwi llyoumanagethecase? 90/50mmhg. Physicalexaminati
onisnormal.
Howc any ouconf
irmthediagnos
is?
2008(
imm)j une Howwi
lly
oumanaget
hischi
ld
Q.A3yearoldisbr
oughttoemer
gencywi
thh/
oint
akeofr
at Whatpar
amet
ersyouwi
llmoni
torf
orl
atecompl
icat
ions
poi
sonaboutonehourback
2011(
imm)oct
Howwi
llyouev
aluat
ethi
schi
ld
A3½ yearoldboybroughttoerashehasi ngest
edabout15-20
Whats
peci
fi
ctr
eat
mentyouwi
lldof
ort
hischi
ld t
abl
etsofcertai
ndrugs.Ondetail
edhist
oryitwasfoundthatthe
mot
heristaki
ngpil
lsofironbecauseofpregnancy.
Whatcouns
elli
ngy ouwil
lgi
vet
othepar
ent
stopr
event
f
urt
hersimi
larinci
dents
. A) howwi
llyoui
nves
tigat
ethi
schi
ld
2009(
imm)mar
ch B) howwi
llyoumanaget
hischi
ld
Q. Af ouryearoldboybr oughttoemer genc ywi t
ht oni c-
c l
onic C) whatar
ethedi
ffer
entphas
eofi
ronpoi
soni
ng?
seizures.Hehaspec ul
larodourar oundhi m. Onex ami nationhis
2013(
mcps
)oct
ober
tempwas37c .Hehasr espirat
orydistress,hyperhidros i
s, hyper
salivati
onandmi osis.Beforehisarri
valhehasr ecei veds ome Q.A10yearol dcametoerwi t
hthehistor
yt hs
tdhes tart
ed
i
nj ecti
onbygener alpractit
ionerwhichdi dnotwor ked.Mot her vomitti
ng1hourbackwhens hecamehom f rom herfri
ends
giveshi s
torythathewashel pi
nghisfat herinthef iel
dbef orethe house.s
healsocomplai
nedofabdominalpainandt i
ghtnessof
i
llnes s
. chestwithdi
ffi
cul
tyinbreat
hing.Onexaminati
ons heispale,bp
i
s80/ 45mmhg,hr =140/minandther
eiscircumoraledema.
Whati
sthemos
tli
kel
ydi
agnos
is?
Examinati
onofrespi
rati
onshowedprolongedex pi
rati
on.
Howwi
llyoumanaget
hiscas
e
Whatist
hemos tl
ikel
ydiagnosis
?
2010(
mcps
)–mar
ch Whatfur
theri
nfor
mat i
onwoul dyouli
ket
oaskinhis
hi
stor
yandhowwoul dyouc onfi
rmthedi
agnos
is?

55 56
 Howwoul
dy oumanaget
hisc
ase? Whati sthemos tprobablediagnosi
s
2012(
imm)march Enumer atethrdi
fferenti
aldiagnos
iswithreasoning
Howwi llyouevaluatethi
sboyi ncl
udingwithinterpr
etat
ion
Q.A12y ear
sol dboybroughti
nemer gencywith10hourshist
oryof Chalkoutamanagementpl antoaccordi
ngt ot hemos t
drowsiness,s
hallowbreathi
ngandmar keddi
aphoresi
s.Hewas probablediagnos i
s
perf
ectlywellinmorning,whenhelefthomeforworkinginfarm.I
n 2016(
imm)-apr il
next3-4hour sinwardhehad2epi sodesoff
itswit
hex ces
sive
fr
othingandgener al
izedhypot
onia. Q.5y ear
sol dboy, sonofaf ar
mer ,present swithbreathingdiff
icult
y,
nois
y,breat hi
ng,ex ces
s i
vesal
ivati
onandl acri
mat i
on.Hei sconscious
Whatisdiagnosi
s? butcompl ainsofgener al
izedmus cul
arweaknes s.Hisbreathsmells
Giveanyotherdd? li
kegarli
c.Ittookt hem 3hourst oreacht hehos pit
al.Theattendants
Whatares t
epsoftreat
ment
? arenotsur eofintakeofanypoi sonouss ubs t
ance.
2013(
imm)october
A) whati
sthedi
agnos
is?
Q.10y earolddev el
opedacuteonsetofvomit
ingaftervi
si
tinga
chi
nes eres
taurant. Twohourslat
erhehasdevelopedchestti
ghtnes
s. B) howwi
llyouc
onf
irmi
t?
Onex aminati
onr espir
ator
yrate38/minhear
trate120/min.bp
80/50mmhg. C) whati
sthemanagement
?

Res
pir
ator
y
Whatismostli
kel
ydiagnos
is?
Whatimmediat
emanagementwoul dyougi
ve?
Whatadvi
sewouldyougivetopat
ient
?
2013(
imm)march
2006(
imm)augus
t
Q.A14y earsoldment al
lyret
ar dedboywasbr oughttoemer genc y
depar
tmentbyhi sfather.Hefoundhi schil
dinneighborsplasti
c Q.At woy earoldboyi sbr oughtinemer gencywi thcompl ai
ntsof
manufactur
ingfactor
ywi thanunknowns ubst
ancei nhismouth. The noisybreathing,poorfeedi ngandfeverf orlas
t1day .On
chi
ldfi
rsthadheadacht henbec ameagi t
atedandc onfused.Whi l
eyou examinationhewass i
ckl ooking,i
rri
rtabl
ewi thtempof103f ,his
wereexaminingthechildhads eizur
esanddy s
rhythmiaonc ardiac respi
ratoryratewas62/ minwi t
haudibles tr
idor,heartrat
e
monit
oring.Thebloodgas esshowss everemetaboli
cac i
dosis. 130/min,s po288% inr oom air.Hewaspal eandi rri
table.

Whatismos tl
ikelydi
agnosi
s? Wri
tedown4diff
erenti
aldi
sgnosesi
nor derofpr
ior
ity
Whatotherphy si
cals
ignswouldyoul
ookf
or? Whati
mportanti
nvest
igati
onsyoudo?
Howwillyoufurthermanage? Wri
tedownemergencymanagements t
eps .
2014(
imm)oct
ober 2006(
imm)march

Q. Afiveyearol dboywasf indingwithhispregnantmother '

s Q.An8year soldboy ,knownas t
hmat i
cf orlast6y earsis
medic i
nec abinetinthemorning.Atnoom hes tar
tcryi
ngex cessi
vel
y broughti nemergencywi t
hr es
pirator
ydi str
ess .Accordingtot he
developedgr eenishblackl
oos estool
sandpr ofusevomit
ing.I n fatherhewasonr egularsteroi
di nhalerandb2agoni s
tt herapy.
eveninghewasl ethargi
candhadqui tetachypneawithclearlung Fort helast4dayshewashavi ngmoder atecoughandus ingb2
fei
lds.Hishear trateis150/minwi t
hcrtgreaterthan6sec onds.Heis agoni s
tmor efr
equent ly.Onex aminationi nemer gency
passi
ngs cant yuri
ne. Healsohadanepi sodeofmas si
veepi st
axis
.His depar t
menthewasi ns evererespir
ator ydistres swithbluelips.
random bloodgl ucoseis150mg/ dl Rrwas50/ minwithmovementofal aenas l
.Ches tex
ami nati
on
showeds cat
ter
edr honc hionleftsi
debutonr i
ghts ideairent r
y

57 58
wasmar
kedl
yreduced. Q.At hreeyearoldgir
lpresentedt oemergencydepar
tmentwith
suddenons etcoughanddi f
ficult
yinbreathi
ngsince1hour.On
Whatcompl
icat
ionhasoccur
redi nt
hisboy ? examinati
onanot herwisehealthylooki
nggirlwi
threspi
rat
ory
Whati
sthemos ti
mportantr
elevantinves
tigat
ion? rate45/min,temperatur
e37degr ee.
Wri
tedownthemanagements teps.
2007(
imm)augus
t Gi
veyourdi
agnos
is?
Q.Oney earoldgirlweighi
ng10kgi sadmittedwithhistoryof Howwi
lly
oumanaget
hiscas
e?
excess
ivecryingandwheez ingforl
ast3days ,onexamination 2010(
imm)–mar
ch????
hasrespi
ratorydistr
esswithwheezingandpoorper ipj
eralpulses
.
Sheiscyanosed,febril
e,herheartr
ateis152/minandr espirat
ory A7y earoldchildpr esentedt ohos pi
t alwithhi s3rdsevere
rat
e80/ min.Shehashepat ospl
enomegaly. asthmaticattack.Hewast reatedwi thr egularnebul i
zedb2
agonistandintrav enousami nophy ll
ine. Duet ohisrespirat
ory
Wri
tethreediff
erent
ialdi
agnos
is?
dif
ficul
tyandpai nons wallowingduet oapht housul cersinhi
s
Enl
is
trelevanti
nvest
igati
on.
mout h.Hewasgi venani ntravenousi nfusion( dext
rose04%
Wri
testepsofmanagement .
sal
ine0.18%) .Thirtys i
xhour slaterwheez eandr ecessi
onswere
2008(
imm)june
sti
llmoderatelys evere.Hisox ygens aturationinairwas91% and
Q.A7y earol
dgirlpres
entswithh/ orecur
rentchestprobl
ems. hewasapy r
ex i
al.Att hisst
agei nvestigationr eveal
s:
Shewasbeenonnebul iz
ertherapyandant i
biot
icsinthepast
.On
Hemogl
obi
n=13gm/
dl
examinati
onhehaspurulentnasaldis
charge,cl
ubbingand
general
iz
edwhhez i
ngwithdecreasedairentryonleftsi
deofthe Whi
tecel
lcount=9*109/
l
chest
.
Sodi
um =123mmol
/l
Givethr
eemos tlikel
ycausesf
orherprobl
em
Howwi l
ly oufurthereval
uatethi
schi
ld Pot
ass
ium =4.
5mmol
/l
Giveessenti
alfeat ur
esofmanagement Ur
inemi
cros
copy=noabnor
malf
indi
ng
2009(
imm)mar ch
Chestx
ray36houraft
eradmi
ssi
on=c
ons
ider
abl
ehyper
inf
lat
ion
Q. I
nemer gencywar dy ous eea5y earoldboywi th butnootherabnor
malit
y
i
nc reasingdi ffi
cult
yi nbr eathi
ng;theboyhadmi l
dc ough
andf everint hemor nings owass endhomebyc lass A) whatt
wochangest
ohi
smanagementwoul
dyoupr
opos
e?
teacherasi ntensi
tyofc oughandcoughhaspr ogressively
B) whati
sthemos
tli
kel
ycaus
eofhi
shyponat
remi
a?
wor sened. Fatherhasec zemaandbr otherisasthmat i
c. O/e
boyl ookt ox i
c,fever103f ,hewasanxiousandc annot 2011(
imm)mar
ch
swal l
ow. Hehasmar keds ubcos t
alands upracl
avicul
ar
recession. Ches twascl ear Q.A3yearol dboypresentedwi thonedayh/ ohi
ghgradef ever
Whati st hel i
kelydiagnos i
s? andsorethroat
.Healsoc omplainsofdif
ficul
tyi
nbreathingand
swal
lowing.Onexaminati
ont hec hi
ldhast ox
icl
ook,s
tridorand
Gi
vethreei
mmedi
ates
tepsofmanagementi
nor
derof l
aboredbreathi
ng.Chestiscli
nicall
ycl
ear.
pr
efer
ence
Whatist
hemos tli
kel
ydiagnosi
s
Name2dr
ugsf
ori
mmedi
ater
eli
ef. Enl
is
teti
ologi
calor
ganis
msr es
pons
ibl
efort
hisi
ll
nes
s
Wri
tedowns t
epsofmanagement
2009(
imm)s
ept
ember

59 60
 2012(
imm)mar
ch Whatist
hediagnosisandwhatot heri
nformati
onwould
youl
iket
oas kt
hemot hertoarr
iveatadiagnos
is?
Q.4y ear
soldboyhavingmoder at
epersis
tentasthmanowpresent
ed Whatfur
therexaminationwouldyouli
ketodointhischi
ld?
wit
hac utesev
ereatt
ac kandhisbloodgasesshowspo255,pco260, Howwouldyoui nv
esti
gat ehi
m?
ph7.15serum el
ect
rolytesna128meq/l 2014(i
mm)april
Whatot
her5importantcl
ini
cals
ignsyouwil
llookf
or?
Q.A6mont hsoldchi l
dbr oughtt oerdepart
mentwith
Enl
is
tst
epsoftreat
mentinorderofpr
iori
ty?
complaintsoffeverfoe2day sandfastbr
eathi
ngforoneday.He
2012(
imm)october
i
sirr
itableanddiffi
culttof eed.Onex aminat
ionthehear
tratei
s
Q.A4y earsoldgirldiagnos
edc as
eofpul monarytb,wasputonatt 180/mi n.Respi
ratoryratei s70/mint emp101fapexbeatisat
(t
hreedrugsf s
t
or1 t womont hsandthent wodrugsfornextsix 5thi
csl ater
altomi dclavi
c ularli
ne
months)theparentsar ecompli
anttotreatment.Butaftert
hree Whati
sthediagnos
is
monthsshec onti
nuest ohavefever,c
oughandanor exia. Nametherel
evanti
nvesti
gat
ions
Whatdoy outhinkisthemos tl
ikel
ycaus
eofhercont
inous Howwil
lyoumanaget hecas
e
symptoms ? 2014(
imm)apri
l
Howwi l
lyouconf i
rmy ourdi
agnosi
s? Q.A31/ 2yearoldboyhasahi storyofc oughandfeverfor2days
Giveout
li
neoft reatment hisvacci
nati
onisupt odat
e.Onex aminati
onheisfibri
leto103.2f
2013(
imm)oct ober witharespir
ator
yr ate42breath/minhischestauscult
ation
Q. Par entsbr i
nga10y earsboyi nr es pirat orydistresstopeadi atri
cs reveal
sscatt
eredralesinl
owerl ungfiel
dsanddecreasebr eat
h
emer gencydepar t ment.Hehasbeenc oughi ngandhav ingr apid soundsattheleftbaseposteri
orly.Thereminderofsystemic
breat hings i
nc e2hour sandc ompl ainsofc hesttightness.Hi smot her examinati
onisnormal
gav ehi mt wonebul i
zertreatmentathomewi thoutimpr ov ement .She Whati
smos tl
iklydiagnosi
s
tel
lsy out hati ti
sf ourt
ht imei n3mont hst hathehasr equi red Whati
snextstepi neval
uati
on
emer gencydepar t mentvisitforsimi larc ompl aints.Ini
tialex amination Howwil
lyoutreatthispati
ent
reveal saf ebril
emaewi thar espirator yr ateof60br eath/mi nand Whati
spulmonar yandextrapul
monar
ycompl
icat
ions
hear tr at
eof20br at
s/min. Hisrespirat or yrateof60br eaths /mi nand 2015(
imm)apri
l
hear tr at
eof20beat s/min.Hi sbloodr es sureandc apil
laryref il
lare
normal .Hei spaleappear sdr owsyhasmi ldper i
-oralcyanos i
sandi s Q.Hea3½ yearol df emalechil
dwasbr oughttotheemergency
usingacces soryc hestmus clestot obr eat h.Youhearonl yf aint departmentwithsuddenons etofnoisybreat
hingforafewhours.
wheei ngonc hestauscultati
on. Shehadr unnynoseandmi ldcoughf or3days.O/ehertemp=38c
,resp.Rate=58/min.Thereisstr
idorandonaus cul
tat
ionai
r
Whatarei
nit
ialstepsinmanagementoft
hispat
ient
? entr
yisequalonbot hsideswithnoc rackl
esorwheeze.
Whatismostli
kelydiagnos
is?
Whataret
hes tepsofmanagement? Whati
sthemos
tli
kel
ydi
agnos
is?
2013(
mcps)oct
ober
Gi
ve3di
ffer
ent
ialdi
agnos
is?
Q. A6y earoldhaspr esentedwitht hec omplaintodrecurr
ent
Whatar
ethei
mmedi
ates
tepsoft
reat
ment
?
ri
nor rheaandi saper sis
tantmout hbr eather.Hehasalso
receivedant i
bioticstwiceinthelastsixmont hsforot
iti
smedia. 2015(
imm)oct
ober
Hei sus uall
yirr
itableinthemor ning.Onex aminati
on,temp98f,
chestc lear,rr
=28/ min. Q.A7mont
hsol
dchi
ldwi
thc
oughanddi
ffi
cul
tyi
nbr
eat
hingi
s

61 62
ass
essedbyatrainedheal
thworker
.Ther
earenogener
aldanger Whatisthemos tl
ikelydi
agnos i
s
si
gnsandches
ti ndrawi
ng.Hehaswheezeandrri
s56 Howwillyouinvest
igatethischi
ld
br
eaths/mi
n. Whatcomplicat
ionsar el
ikelyt
ooccuri
nfut
ure?
2011(
imm)mar ch
Whats
houldthehealt
hworkerdoasaf
irs
tst
ep
Howwil
lyouclas
sif
yhisi
ll
ness Q.A21/ 2year soldimmuni zedc hil
dreportstoemer gency
Whati
sthetr
eatment servi
cewi thc ompl ai
ntoffeverf orpast8days.Shei sir
rit
able,
temp102f ,andhr130/ min.Shehasagener al
ized

Rheumat
ology
mac ulopapular,erythematousr ash,bi
lat
eralconjuncti
val
i
njection,hyper emicoralmuc osaandpal msandr i
ghtsided
cervic
allymphadenopat hy.Shei scomplaini
ngofr ecurr
ent
abdomi nalpainandhasdi arrhea.
2006(
imm)augus
t
Whati sthedi agnosi
s
Q.A7y earoldboywasadmi ttedwi thdif
ficult
yi nwalkingf
orthe Whatcondi t
ionswouldyouc ons
ideri
nt hedi
ffer
ent
ial
l
astyear .Forthel
ast2mont hs,fami l
yhasnot icedt hewors
ening diagnosis
ofcondition.Onexaminationtherewasar ashov erfaceand Listi
nvestigationswit
hrelev
ancetothiscase
dorsum ofhandswhi chhasnotr espondedt os teroi
dc r
eams. Enumer atestepsoftreat
ment
Thereisal s
oweaknessofnec kmus c l
esandi nabili
tytogetoff 2012(i
mm)oct ober
fr
om thef looranddif
ficul
tyincli
mi bingstair
s.
Q.Pedi atri
ct ertiarycar euni twasr eques t
edt oeami nea7year
Whataretwodi f
f er
entialdi
agnos es
? oldc hil
dadmi t
tedi ns urgi
c alunitwithacut eabdomen.
Writ
ethreerelevantinvesti
gati
ont oreachaf
inaldiagnos
is Appendec t
omywasdone44day sbac kandappendi xwasnot
Whattreatmentwoul dy ougivefotthemostl
ikely i
nf l
amed.Chi ldcont inuedwi thsever eabdomenpai n. On
di
agnosis exami nati
onpat ienthadr as hesondi stalextremiti
es. Afew
2007(
imm)augus t rasheswer el argeecc ymot i
cbutmaj or i
tyofr asheswer epink
Q. 7yearol
dgir
lhasbeenunwellforsi
xweekswithl
ethar
gy, mac ules,pet echialandpur pur i
c.Someedemaofhandsandf eet
feverandpaini
njoint
s.Onex
ami nati
onshehastemperat
ure wasal sopr es ent.Rightkneewast enderwi t
hl i
mi t
ationof
38.5g,eryt
hematousras
hontrunkandbothwr i
star
ewar m and movement . Bp140/ 90,ur ineanal ysi
ss howednumer ousrbc,
painful
. albumi n++,bl oodur ea50mg/ dl,

Wharot herrelevantfindi
ngsyouwouldli
ketocheckon Pl
atel
etec
ount175000/
mm3.
examinationformaki ngdiagnosi
s? whati
smos tlikel
ydiagnos
is
Give3differenti
aldiagnoses? howwillyoui nterpr
etfi
ndi
ngoncl i
nic
alex
ami
nat
ionand
Whati nvesti
gati
ony ouwoul dli
ketoper
form? i
nvest
igation?
2008(i
mm)–j une howwillyout reatthi
scondit
ion?
Q.Youaresit
tingi ntheopdc l
ini
c .Parentsbringa5y earsol
d whati
spr ognos is
?
boy.Theyar
ec onc erenedabouthiswal kingont i
ptoesand 2013(
imm)–oct ober
dif
fic
ult
yingett i
ngupf r
om si
tti
ngf orthel as
t2mont hs.Hehas Q.A10yearoldboyhascomet oyouwit
hsymmetr
icalar
thr
iti
s
twonormalsis
t ers.Hispastmedicalhistoryisunremarkabl
e. ofboththekneesandwristf
orthel
astt
womonths
.Hehasbeen
Whatwoul
dyous
peci
fi
cal
lyl
ookf
oronex
ami
nat
ion havi
nginter
mittentf
everoft
enashi
ghas39–40degree

63 64
 typi
cal
lyocc
urr
ingonceortwiceaday.Hehasgeneral
iz
ed aprecedi
ngh/ ogenerizedac hesandpainandeas yfati
guabili
ty.On
l
ymphadenopathyandhepatospl
enomegal
y.Cbcshowshb6.
0 examinat
ionsheisfebrile,pale,withs
ymmetricalswell
ingofbot h
gms,tl
c15000,pl
atel
ets170,
000/cmm. wris
tmet acar
pophalngeal;proximalanddi
stalinterphalangealj
oint
s.
Herlymphnoddear epal pablewi t
hnohepatosplenomegal y.
Givetwodi f
ferenti
aldi
sgnosis
.(note:i
fmorethant he
requi
redd/ daregivenonlyt st
he1 t wowil
lbec onsi
dered) Hercbcr
epor
tshowshb8g/
dl,t
lc2500c
umm,pl
atel
ets160000
Whati nvest
igati
onswouldyouor der? cumm,andesr75.
Whati sthetreatmentofthemos tli
kel
ydiagnosis
?
Whatsisthemos tli
kelydiagnosis
2013(
mcps )october
Giv
ediffer
entialdiagnosis
Q.A7yearoldhas beenadmi
ttedwit
hahi
stor
yofri
ghtswoll
en Whatinvesti
gationsy ouwi l
lorder
l
egfor5days
. Heisinext
remepainwit
hhi
ghgradef
everandis Whatisthemamagementpl anforthemos
tli
kel
ydi
agnos
is?
l
impi
ngwithrest
rict
ionofmevement. 2016(
imm)apri
l

Whatdiff
erenti
aldi
agnosisyouwouldc onsi
derithi
schild? Q anunv ac ci
nated3year soldboydev elophighgr adefeverof3day s
Whatdiagnosti
capproachisneededinev al
uat
ionthi
sc hil
d? duration. Examinati
ons howedami serablec hil
dwi thbil
ateral
Whatmanagementpl anwouldy ourecommendf orhis conjunct i
v i
tis
,rashandcer vi
call
ymphadenopat hy.Hismot herwas
ai
lment
? reassur edandwass enthomeonant ibiotics
. Hepres ent
edagai nto
2014(i
mm)oct ober thehos pi
tal4day slater
.Hewasf oundt ohavec r
ackedr edlips.
Investigationsshowedwbc15*109/ l
,pl atel
etcount800*109/ land
Q. A2y earoldboyhadanepi sodeoff everandloosestools
.Fi ve esr125.
dayslaterloosest
oolshads ettledbuthi ghgradefeverpersi
sted.
Hiseyesbec ameredandhi st onguebecamer edands woll
en.He A) whati
sthemos
tli
kel
ycl
ini
caldi
agnos
is?
alsodev el
opedmul t
ipl
eswel l
ingar oundhi sneck.Hishandand
B) gi
vet
hreepos
sibl
edi
ffer
ent
ialdi
agnos
is?
feetshoweds omedegr eeofs wel l
ing.Ther ewasno
hepatos pl
enomegaly.Oni nvestigati
onhi shb8mg/ dl C) whati
nves
tigat
ionswi
llhel
pyout
oreac
hthedi
agnos
is?
tlc.
15000/cmm withleftshif
ti nthewhi tecell
s.Crpis24mg/ dl.
Esris40mm f al
lattheendof1s thour .Bloodcult
urewas D) howwi
llyout
reatt
hisc
hil
d?
negative.Throatcult
ureisnegat ive.As otwasnotrais
e
Det
s
ai
pec
notc
l
t
r
edsyst
emi
um ant
hange
i
bi
cex
oti
c
ami
nat
sandr
i
onwasnor
outi
neant
i
mal
py
r
.Hewasgi
et
icbutc
v
ondi
t
ebr
i
oad
ondid Mi
scel
laneous
2006(
imm)mar
ch
Whatisthemos tprobablediagnos i
sgi
vereason
Whatotherexaminati
on/ i
nvestigati
onwouldyouli
ket
o Q.
Lis
tfourdi
seas
est
rans
mit
tedaut
osomaldomi
nanti
nher
itanc
e.
perf
ormin gi
vether
iskofrecur
renceofdi
seas
eorcar
riers
tagei
fthedi
seas
eis
Thi
sboy tr
ans
mitt
edthrough;
Howwi l
lyoumanaget hispatient
Whichcompli
c at
ioncanoc curint hi
spati
ent Autosomalrecessiveinheri
tance
2015(
imm)apri
l Autosomaldomi nantinherit
ance
X-l
inkedreces
s i
vei nheri
tance
Q.A7yearol
dgir
lpresentswi
thoainandrest
rict
edmovement
sof 2006(
imm)mar ch
mul
ti
plej
oint
sinvol
vingbothwri
staandhandsforsi
xweeks
.Ther
eis

65 66
Q.Atthestartofexchangetr
ansfus
ionforhyper
bil
ir
ubineami
a Givetheepischedul
eofvacci
nati
onsforpaki
stni
cchi
ldr
en
thr
oughumbi li
calr
oute,bl
anchi
ngofrightl
egwasnot edsoonaf
ter Whatot hervacci
nesar
eavai
labl
eandcanbehel pf
ulf
or
cat
heter
izati
on. ourchil
drenandwhattimetheseshoul
dgiven.
2008(
imm)j une
Whatistheli
kelyexpl
anat
ion/causeofthi
scondi
ti
on?
Writ
estepsofmanagingthiscondit
ion. Q.Aut
osomaldomi
nantpat
ter
ninher
itance
Howwillyoupreventt
hiscondit
ion?
2006(
imm)august Li
stf
ivedi
seas
ewi
tht
hisi
nher
itance

Q. (
imm)march
Pedi
gree--??X-l
inkeddomi
nant(s ect
ion–geneti
cs)
Lis
tfourdi seaseswhicharetrans
mittedthr
oughx -
li
nked Whati
sthemodeofinher
itanceinshadedchar
act
eri
sti
cs?
reces
siveinheritance
Giveatleastfourdiseas
eswhi chchi
ldrenwi
thtr
isomy21 Whatar
eyour3obs
ervat
ionsi
nthi
spedi
gree?
arepredisposedt odevelop. Gi
ve2ex
ampl
eswi
tht
hisi
nher
itancepat
ter
n?
2007(
imm)feburary
2009(
imm)s
ept
ember
Q.An18mont holdgirlbroughtt ooutpat ientdepar t
mentwi ththe
complaintsofrighteyepr otrusi
on. Ac cor
dingt othemot herthechild Q.
wasf i
neaboutamont hbac kwhenf orthefirsttimeshenot i
cedthat Def
ineneonatalmor
tal
ityr
ate(
nmr)
herdaught erwasseeingout war
dwi thherlefteyeandatt imes Whatarethecommonf act
oraff
ecti
ngthenmr
sparkl
inggl owformt her i
ghteyei ndar k.Onex aminationherhei ght Whatstepsshoul
dbetakentoreducet
henmrinpaki
stan
andwei ghtareon50t hper centi
leforage. Herr ighteyehaspr optos
is 2009(
imm)september
withabs entredrefl
ex.Cranialnervesar egross l
yintact.Restof
examinat i
onisunremar kable. Q.Fiveyearoldboybroughtbyf atherwi t
hc omplainsofnot
behavingproperl
y.Heav oidscont actswithotherdidnotplay
Whichcondit
ioncanpr es
entwithleukoc or
iainthi
sage wit
hhi ssibl
ingandexami nati
onheav oidscontactwi t
hdoctor
/
group? parentsandc o-
operat
ive.Hisvac cinati
oniscompl ete.
Whatisthemos tl
ikelydi
agnosi
sint hiscase?
Howwi l
lyouinves
tigatethi
scase? Onex aminat
ion,hei ow10thcent
sbel il
ehiandwi,
hb10gm%,tlc
Whatisthemodeofi nherit
anceifthiscondit
ion? 10,000/
cumm, e.0.5%,cnsor
ient
ed,gai
tnormal
,ref
lex
esnor
mal,
2008(
imm)june tonenormal
Q.Writ
eas hortes
sayonglobalpol
ioer
adi
cat
iondes
cri
bingi
ts Gi
veyourdi
agnos
is
hi
stor
y,st
rategyandpres
entstatus
.
Howwi
lly
oumanaget
hiscas
e
2008(
imm)j
une
2010(
imm)–mar
ch
Q.Descri
bet
hehealt
hcarestr
ategi
esthatwoul
dhel
pinr
educi
ngt
he
Q. Atenyearoldboystudyi
nginmader s
ahatl y
aripres
entedwith
underf
ivemort
ali
tyi
npakis
tanichi
ldr
ens
abdominalpai
nandi nabi
li
tytowalkproperl
y.Onex aminat
ionhewas
2008(
imm)j
une febri
leandpale,notcooperat
ivebutwellor
ientedinti
mepl ac
eand
person.Hehadahaemat omaons cal
p.
Q.
A) gi
veat
leas
tthr
eedd.

67 68
B) whati
nves
tigat
ionwoul
dyoul
iket
oor
der
? mildl
ydehy drat
ed,aneri
orfontanel
laewi
deopen,ands l
ightl
y
depressed.Therei
smac ulopapul
arandscal
yrashoverelbowand
(
imm)s
ept
ember knees.Abdomeni sscaphoidinshapeandchesti
scli
nicalcl
ear.
Liv
er
Q: 2cm, spl
eenisnotpalpable.
A)whati st hes igni f
icanc eofneonat altetanust oc hil
dheal t
hin
paakis t
an? A) whati
sthemos
tli
kel
ydi
agnos
is?
B)whatr ec ents t rat
igieshav ebeenus edt oelimi nateneonat al
tetanusf rom paki s t
an? B) whatot
hercondi
ti
onswi
llyouc
ons
ideri
ndd?Ex
plai
nver
y
(i
mm)s ept ember br
ief
ly.
Q. A4mont hol dboypr esent edwi thf ail
ur etot hr i
ve.On C) whatwi
llbet
hemanagements
tepst
obet
akenf
ort
hischi
ld?
exami nat ionmi c rocephal y,l
iv er4- 5c m,c ardiomegal ywithgall
op
rhythm, engor gementofpedalvei ns. 2011(
imm)mar
ch
Investigat ionss hows Q.
Wri
tes
hor
tnot
eson;
Hb4. 9
Tlc10*109 Mi c
ronut ri
entdef i
cienc iesofpaki stanichildren, their
Platelet300*109 diagnos isandt reatment
Mcv100f l Epiinpaki s t
anwi t
hr ecentr ecommendat ions
Bmanor malc ell
ul ar
itywi thr educenor mobl ast 2010( i
mm)s ept ember
Urea30 Q. A1¼ yearol dboywasbr oughtf orr out ineimmuni zati
on. In
Creatinine0. 4 thepas thedev elopedr ashest houghtt obeas s
oc i
at edwi theat i
ng
Ret i
c0. 5% eggs .About30mi nf ollowi ngadmi ni s trationofmmrv accinehe
A) whati sdi agnos i
s? dev el
opeds inust achycar diaof130beat s/mi n.Ani ntens l
yi tchy
B) mos tlikelyunderl yingcaus e? rashr apidlydev elopedonhi sf ac eandbody. Ther ashhadr aised
C) howwi l
ly oumanage? erythemat ousedgedandwasur ticar ial.Hebec amehy pot ens i
v e,
2010( i
mm)s ept ember hisbloodpr es sur ebei ng60/ 25mmhg.
Q. A2y earol dc hildpr esentedwi t
hamas sint hel eftabdomen. Whats tepsmus tbet akeni mmedi at ely?
Themot hernot i
c editwhi l
ebat hingt hechi l
d. Onex aminationthe (i
mm)oct
childlookswel l
. Bpi snor mal ,mas sins moot handnont enederbut Q .
fixed. A) enumer ate4c ommonmi cronut rientdef i
cienciespr eval ent
A) whatar et hel i
kelydi agnos i
s ?Whatf urtherques tions inpaki stanichi ldren.
woul dy oul ike\et oaskt opoi ntt odi agnos is? B) ment ionr daofeac honeoft hi snut ri
ent
B) what5i nv estigationswi llyouor der?Gi v ejustif
icati
onfor C) outli
nepr ev alents trategi esf oreac honoft hem
each. (i
mm)s ept ember
Q: a18mont hsol dchi ldwasr efer r
edt ot hepedi atr i
cs urgicalt eam
foll
owi ngdr ainageofal arges taphy l
oc oc calabces sonhi sr ight
2010(
mcps
)–mar
ch
thigh. Historyr ev ealedhehads uf f
er edf rom r ecurrents mal lboi ls
Q.A7monthol
dc hi
ldi
sbr oughtbyherparent
switht
hec omplainsof andhadt hreeepi sodeofi mpet igowhi chs eemedt os preadf r
om
of
fandonwaterydi
arr
hea, someti
meswithmuc us
,al
ongwit hpoor hisnos e.Hehads ufferedt wopr ev iousabces sesonhi sbut tocks
wei
ghtgai
n.Hehasulcer
ationaroundmouthandperi
analarea.Heis butt hes eres pondedt ohi ghdos ef l
ucl ox acill
in,therewasno
onbuf
fal
o’smi
lkandweani ngisi
mproper
. evidenceofecz emaoranyot hers kinl es i
on,andonex aminat i
on
therewer enoabnor malf i
ndi ng.Hi s5yearol dbrot heral s
ohada
Onex
ami
nat
ioni
rri
tabl
echi
ld,wei
ghi
ng5.
2kg,l
engt
h59c
m,pal
e,

69 70
 historyofl es ss everebutr ecurrentboi lstothelegs,buttocksand andnootherphys
icalf
indi
ng.Onfurt
herquer
yshes
ayst
hats
hehas
nec k.Thes ewer et r
eatedwi thf l
uc l
ox acil
li
nwithgoodr esults
. tol
eavet
hechildfor8hoursdai
lyi
nadaycare
Hemogl obin 13g/ dl
Mcv 80f l Whatmeasureswouldyous
ugges
ttor
educe/
prev
ent
Whi tec ellcount 13*109/ l i
nfect
ionsi
nthischi
ld.
Bloodgl ucos e 4.3mmol /l 2014(
imm)april
Liverfunc tiont es t nor mal Q.Amot herbring6y earolds ontoyouwi thaconc ernthathe
Bloodur eac reat i
nineandel ectrolyt esarenormal cont i
nuest ohav enightti
mewet ti
ngs everaltimesaweek.Hei s
Bloodc/ s nogr owth thes econdchi l
doft hree.Hei sinfri
stgr adeands truggli
ngwith
Culturef rom abc essdraineds urgic all
yshowss taphyl
oc occus hisper formance.Hehadnomedi c
alpr oblems .Nohi st
oryof
aureusgr owt h. dev el
opmentdel ayandwast heproduc tofanor mal
A) givet hreeinv es
tigati
onsy ouwoul dperform. uncompl i
catedpr egnancyanddel i
very.Hi sbehaviourhasbeen
B) howwoul dy outreatrec urrents taphyl
ococcalskin sincet hebirthoft he3rdchildtheexami nat i
onofot herbody
infecti
ons ,assumi ngnoabnor mal itieswer ef
oundonf ur t
her systemsi snor malhedoes n'thavelaborator yevi
denceofur i
nary
investigation? tractinfecti
on.
2012( imm)oct ober
Whatisyourl
ikel
ydi
agnosis
Q. A5y earsoldboyi sbroughtt oopdwi thparent
alconc ernfor Enumerat
etheunderl
yingcaus
es
growt hfai
lure.Thereisnohi st
oryofdi ar
rheaandnor malper i
natal Gives
tepsofmanagement.
event s.
Hehasnor maldevelopment almilest
ones.Hehast woot her 2014(
imm)october
sibl
ingswithnor malgrowt hparamet ers.Onexaminati
on, heisnormal
l
ooki ng,acti
veandal ert
.Wei ghtis14.5kgandhei ghtis85c m.Renal A51/ 2yearoldboyhadamonkeybi
te2hoursbackwhil
e
functiontestarenormalandt i
ssuet r
ansglutami
naseantibodyi s seeni
ngamonkeys howinst
reet
.Hehadprimarycour
seofepi
negat i
ve. vacci
nat
ionfrom bi
rth.

Gi
ve3dds Howwil
lyoumanaget
hischi
ld
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 DR M AKHTAR VIRK DRAKHTARVIRK@YAHOO.COM

1. Abdominal mass crossing midline

a. WT
b. Neuroblastoma
2. 5 y old pallor from 1 month hepatosplenomegaly Hb 5 Retics 15% which test preferred
a. Hb electrophoresis
3. 3 month old Hb 9 MCV 72 peripheral film normal
a. Physiological anemia
b. Iron deficiency anemia
4. ABO INCOMPALIBILTY MOSTLY
a. First child
5. Rh --------------
a. Mostly 2nd
6. F-13 deficiency ( PT/APTT NORMAL ) treatment
a. Cryoprecipitate
7. Polycythemia treatment option
a. Partially exchange with normal saline
8. Atypical N.S
a. LOW C3 AND HTN
9. Diaphragmatic hernia
a. Ambubag contraindicated
10. Contraindication of Ambubag
a. D.H MAS TEF
11. Diaphragmatic paralysis
a. 345
12. On USG RT sided hydro ureter and hydronephrosis investigation of choice
a. IVU
b. MCUG
c. DTPA
d. DMSA
13. ON X RAY chest ground glass appearance
a. RDS
b. Sepsis
c. Pn
14. Hypernatremia rapid correction symptoms occurred treatment option
a. 3% N/S
15. PT presented with meningitis FITS not controlled
a. SIADH
16. PT Presented with fever drowsy hepatosplenomegaly SOMI negative CSF normal
a. Cerebral malaria
b. Viral meningitis
c. Brain abscess
17. Not causes cirrhosis
a. Cholidocal cyst
b. B.A

DR M AKHTAR VIRK CH&ICH LAHORE

 DR M AKHTAR VIRK DRAKHTARVIRK@YAHOO.COM

c. Neonatal hepatitis
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19. Side effects of inhaled steroids
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20. 15 month old sudden onset of distress with ronchi
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22. Strept Pn and H. Influenza _____ Lobar
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b. GAS ________ Interstial Pn
23. 4 Hr old Preterm presented with hypothermia bradycardia cyanosis apnea
a. Apnea of prematurity
24. Newborn presented with persisting hypoglycemia last step of treatment
a. Partially pancreatectomy
b. 25 % IV GLUCOSE
c. GLUCAGON
d. OCTREOTIDE
25. BCG shows
a. Definitely vaccinated
26. Egg allergy
a. MMR
27. SEA food allergy
a. Anaphylaxis
28. BEE sting -- peripheral edema and no voice treatment opt
a. Intubation and ventilation
29. Rabies DOG vaccinated
a. Observe
b. Vaccination
c. IVIG
30. Ventilation ↓PO2, ↑PCO2 due to
a. ↓PIP And ↓RR
31. PERMESSIVE HYPERCAPNEA FOR RDS
a. ↑PCO2 _____ High limit 60
b. ↓PO2 ______ 80-89%
c. ↓RR
d. ↓PIP
32. Newborn HR 70 AND gasping
a. Bagging and chest compression
33. Rubella vaccine

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 DR M AKHTAR VIRK DRAKHTARVIRK@YAHOO.COM

a. S
34. Zinc max absorption
a. Jejunum
b. Duodenum
c. Ilium
35. Breast milk baby vit K given
a. Prophylactically
BREAST MILK COW MILK
↑CHO ↑Protein
↑IORON ↑ Na
↑ VIT K ↑P
↑ Ca
36. BREAST milk
a. Low solute food
37. H/O of sibling death presented with jaundice
a. Crigler najjar
38. 10 y old thalassemia Liver 10cm Spleen 16 cm never chelated next step
a. Splenectomy
b. Chelation
c. BMT
39. Differences of B.P
a. COA
40. HYPERKALEMIA symptomatic definite treatment
a. Dialysis
41. Shock
a. R/L
42. Organic academia
a. A
43. 6 y old PNTED with decreased school performance
a. EEG – 3 sec /spike and waves
44. Most common viral causes of diarrhoea
a. Rota virus
45. Chronic diarrhoea with bitots spots
a. Gluten Enteropathy
46. Pt pnted with PYO +SIADH S / Na 120 and asymptomatic
a. Fluid restriction
47. Chronic malnutrition
a. HFA
48. Acute malnutrition
a. WFH
49. IMCI INCLUED diseases
50. ARI
a. Cyanosis means serious diseases
51. PT came in emergency with acute distress first choice
a. CXR

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 DR M AKHTAR VIRK DRAKHTARVIRK@YAHOO.COM

b. ABG
c. O2 inhalation
52. Paro virus B 19
a. Aplastic anemia

Paro virus B 19
Aplastic crises
( SICKLE H.S THALA PKD )
Arthropathy
Erythma infectiosum
Gloves and socks syndromes
Myocarditis
53. 3 y came with speech problem test for deafness
a. Brainstem auditory evoked response (BAER ) OR (ABR)
SRT Speech recognition threshold Non organic H.L
Malingers
ABR Auditory brainstem response Neonate

BOA Behavior observe audiometry <5m Non cooperative

VRA Visual reinforcement audiometry 6m -30m

PA Play audiometry 30m -5y

54. Development assessment is

a. Formal evaluation
55. Hypertrophic pyloric stenosis best test
a. USG ( TDL)
b. Barium study
c. Endoscopy
T 4cm
D 10cm
L 14cm
d.
56. DDH diagnostic test
a. USG below 6 m and X RAY after 6 m
57. SLE CRITERIA
a. SEIZURES
58. Rheumatic diseases first choice
a. NSAID
59. TOF Prophylaxis for dental extraction
a. Oral amoxicillin
60. PT came with URTI from 10 days now his pulses week hr 30 liver 5cm BCM
a. Diphtheria myocarditis
61. Febrile fits future prevention
62. SJS not feature correct
a. Steroids
63. Oligohydramnios and potter facies
a. B/L renal agenesis
64. CRF AND HTN choice

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 DR M AKHTAR VIRK DRAKHTARVIRK@YAHOO.COM

a. Thiazide
Thiazide >50 GFR
LOOP IV
ACE Proteinuria
Emergency CCB and BB

65. Bronchial asthma

a. PEFR for home management
66. FEVI 85%
a. Mild asthma
67. Hyperoxia test PO2 30-40
68. Post term
a. Cracked peeling skin
ERYTHMA TOXICUM PUSTULAR MELANOSIS
1-3 days Birth
1 week persist 2-3 days persist

Benign Benign
Contain EOSINOPHIL NEOTROPHIL

White papule Vesicular pustule

b.
69. Harlequin color changes
a. Normal physiology
Transient and harmless condition
Red and pale halves division
70. Meckel diverticulum
a. Recurrent painless bleed
71. 1Y OLD VIT A deficiency
a. 2 LAC
72. Post neonatal mortality
a. Diarrhea
73. Social factor of diarrhea
a. ↓breast feeding
74. Malnourished mother indicator of
a. LBW
75. Most consistent feature of hashimoto thyroiditis
a. GOITER
Most common cause of thyroid disease
Most common clinical manifestation is goiter and growth retardation
Most common cause of acquired hypothyroidism
76. Goiter surveillance least indicator
a. Short stature people
77. Most common shock in children
a. Hypovolemic
78. PT with G/E taking ORS and full fontanel test perform
a. S/ Na level
79. Infant inside of car door closed and mirror up , child is risk of
a. Sudden infant death
b. Hypoxia

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 DR M AKHTAR VIRK DRAKHTARVIRK@YAHOO.COM

c. Hyperthermia
80. Pertussis DOC
a. Erythromycin prophylaxis
<1m Azithromycin
1-2m Azo+Erythro+ Claritthro
>2 m A+E+C+ Septran
81. Child with normal WBC ↓IgG IgM IgE
a. X Linked agama
82. Child responsive to speech ,cries to pain , flexes to pain GCS IS
a. 11
b. 9
c. 10
VERBAL BICMoN
5 Babbles
4 Irritable

3 Cries to pain
2 Moaning
1 None

83. Heart rate 144 RR 38 CYANOSIS OF HAND ,APGAR SCORE

84. Indication of influenza vaccine
85. PT with bloody diarrhea ,abdominal distention and air fluid level
a. Intussusception
b. Bacillary dysentery
86. Normal CBC Parameters
87. Effect of Vinegar
a. Loss of consciousness
b. Burn in esophagus
c. Aspiration
d. Renal failure
e. Seizures
88. Mantoux test 5-9mm interpretation
89. HPS =ABG → ↓Cl , ↓K , Metabolic alkalosis
90. DKA =ABG → ↓Cl , ↓Na , ↓K , Meta Acidosis
91. CAH =ABG → ↓Na , ↑K Meta Acidosis
92. Na 120 , K 4 urine osmolality 500
a. SIADH
b. CAH
c. Addison
93. 2 month polyuria Na 138 ,K 2 , HCO3 34 , Cl 98
a. Barter
94. 7 days old female child with vaginal bleed , mild jaundice liver 2 cm
a. F-13 deficiency
b. HDN
c. ITP
d. WITHDRAWL BLEED

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 DR M AKHTAR VIRK DRAKHTARVIRK@YAHOO.COM

95. Best test for hypothyroid

a. TSH
b. T3
c. T4
96. Screening for hypothyroid
a. Birth
b. 2-5 days
c. After 1 week
97. Effect of maternal myasthenia on baby
a. Transient
98. Treatment of erythematous red hot swelling in front of eyes
a. ABX
b. I&D
c. Warm compresses
99. Hereditary long QT interval DOC
a. BB
100.12 y old , systolic murmur at 4th ICS ,thrill + no cyanosis no clubbing , normal splitting of S2
a. PS
b. AS
c. ASD
101. 9Y old with fever , murmur spleen
a. I.E
102.5Y OLD rash, injected convective , lymphadenopathy ,
a. Aspirin
b. IVIG
c. Steroids
103.Measles epidemic 15 m old what to do
a. Vaccine
104.Child develop mumps , his younger brother does not develop rash , his br in witch phase is
a. Incubation period (12-25days)
105.Neonate with vomiting in 2nd week , Na 132, K 6.5
a. 17 OH Progesterone level
106.Neonate with vomiting and scrotal pigmentation
a. CAH
107.Difference in distal and proximal RTA
a. Nephrocalcinosis
108.Age of precocious puberty
a. F- 8Y AND MALE 9 Y
109.Infant presenting with afebrile seizures S/Ca 1.7 ,S/PO4 0.5
a. TETANY
110.Can speak 6 specific words in addition mama dada and follow command
a. 12m
b. 15m
111.Factors affecting learning

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 DR M AKHTAR VIRK DRAKHTARVIRK@YAHOO.COM

a. Parent divorce
b. ADHD
c. Autism
d. Epilepsy
112.Monthly monitoring is recommended for
a. 3y
b. 5y
c. Infant
d. Neonate
e. Toddler
113.Pediatric resident with TB
a. Opacity on lung
b. 3 sputum sample negative
c. Cough settles
114.6 week old FTT &throws milk has diffuse opacity upper RT lung with also wheeze
a. GERD
b. TB
c. Pn
115. 5 month old inconsable cry, retinal hemorrhage, large bruise on thigh investigation of choice
a. Skeletal survey ( child abuse)
116.Complication of Hypernatremic dehydration
a. Coma
117.Complication of treatment of Hypernatremic dehydration
a. Seizures
118.Interpretation of BCG scar
a. PT has developed immunity
b. PT IS immune compromised
c. PT is partially treated
d. PT has become vaccinated
e. No interpretation can be done
119. Fluid for hypovolemic shock
a. Osmolality of fluid
120. Features of bronchial breathing
a. High pitched blowing ( only tubular )
121.Difference B/W cow milk and mother milk regarding Vitamins
a. Vit K
122.RICH source of vit D
a. Cod Liver oil
123. Area of alopecia absence of hair follicle
a. Areatz
124.HBsAg + HBeAg + HBDNA+
a. Chronic HBV
125. 9 y old doing exercise become unconscious murmur going to left side and back
a. HOCM
126. 150/50 in RT limb , 160/90 in LT limb

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 DR M AKHTAR VIRK DRAKHTARVIRK@YAHOO.COM

a. COA
127.Baby born with bleed from umbilicus and rectal bleed first step bin treatment
a. FFP ( IF FRESH BLEED )
b. INJ VIT K
128. Infant contact with HBsAg+ mother chances of recurrence in infant
a. 90%
129.Parameter of acute malnutrition
130. 18 month TLC 21800, Mono 22%,Plt 78000, HbF 15, blast 4% café au lait spot
a. Fanconi anemia
131. Hypochromic microcytic anemia
132.Response of bone marrow retics to Rx at age
a. Days
133.Pt presented with hypochondriac mass RT side , S / level which is diagnostic and used for
monitoring of Rx
a. AFP
134.S / level in cystic fibrosis
a. ↑Na and ↑Cl in sweat
135. Vomiting headache MRI normal
a. Psudotumor cerebri
136. Infants with zoster , isolation from school how many days
a. When scalp forms
137. 8 y old male child e hematuria for 6 month after URTI C3 level normal protein 580 in urine
a. AGN
b. ATYPICAL N.S
138. TYPE OF HBV induced GN
a. Membranous GN
139.GSD pt. presented e seizures first action
a. Correct hypoglycemia
140.Neonatal meningitis
a. GBS
b. HIB
c. N.M
d. STREPTO
e. MENINGOCOCAL
141.ANAPHYLAXIS which is not given
a. Adrenaline infusion
b. Fluid
c. Antihistamine
d. Isoproterenol infusion
142.Complex partially seizures
a. Conscious level affected last 1-2 min proceeded by aura
143.Hyperkalemia definite Rx
a. Dialysis
b. Insulin
c. Ca gluconate
144.Spasmodic cruop
a. Evening or night ( episodic, viral allergic psychological ,1-3 y )
145. Tall T wave K 7.8

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 DR M AKHTAR VIRK DRAKHTARVIRK@YAHOO.COM

a. Ca gluconate
b. Insulin
c. Nebulization e Ventolin
146. Ejection systolic murmur at RT side of sternum carotid thrill
a. AS
b. PS
c. PDA
d. TOF
e. ASD
147.PORT wine on face
a. MRI/CT
b. Eye examination
c. USG BRAIN
d. EEG
148. 1 m sepsis at birth treated with gentamycin ,ceftriaxone and pheno, still taking pheno
,immediate test
a. EEG
b. MRI
c. DRUG LEVEL
149. Karosin oil aspiration indication shows
a. Pn sign
b. >1ml/kg
c. >30ml /kg
150. K/C OF VSD Going for Dental surgery , prophylactic ABX
a. Amoxicillin
b. Oxacillin
c. Erythromycin
151. Long QT synd
a. Atropine
b. Lidocaine
c. digoxin
d. propranolol
e. phenylephrine
152. salbutamol sos inhaler but symptoms not improving
a. low dose ICS
b. LABA
c. Cromoline
d. Nidocromoline
153. <5 y stunting
a. WT FOR HT
b. HT FOR AGE ( chronic mal)
c. Mid arm circumferences
154. <5y WASTED
a. Skin fold thickness
b. WT FOR AGE
c. WT FOR HT (acute mal )
155. Anthropometric measure
a. Malnutrition categorize

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 DR M AKHTAR VIRK DRAKHTARVIRK@YAHOO.COM

b. Non invasive
156. Ambiguous genital most imp step
a. Assign of sex
b. Hormonal evaluation
c. Chromosomal analysis
d. Family counseling
157. Hypotonia wide fontanel open
a. Hypothyroidism
158. Hypothyroid followed by
a. T4
b. TSH
c. HT
d. XRAY
159. WEANIG
a. Cow milk 24OZ/day and no soda
160. Skin fold thickness
a. Index for fat
161. Upgiong planter + LMNS +ataxia
a. Fredrick ataxia
b. Ataxia telangiectasia
c. Abetalipoproteinemia
162. Fondoscopy papilledema first sign
a. Blurring of margins
163. Bulging of tympanic membrane (TM)
a. Mastoiditis
b. Effusion
c. Adenoids
d. Atelectasis of tympanic membrane
e.
164. TM Perforated retracted, bulging , immobile
a. Otitis media
165. TM bulging , immobile ,air fluid level behind the tympanic membrane
a. Middle ear effusion (MEE)
166. 12 Y presented with tingling numbness and muscle cramps
a. PTH
b. Ca
c. BSR
d. ABG
e. EMG
f. NCS
167. PT presented e Bladder distention, back pain flaccid paralysis ,planter equivocal , investigation
choice
a. EMG
b. NCS
c. MRI
d. CSF
168. PT presented with sore throat, proteinuria, hypoalbuminemia, cholesterol increased. after
steroids pt. improved but latter went into relapse

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 DR M AKHTAR VIRK DRAKHTARVIRK@YAHOO.COM

a. MCD
b. RPGN
c. AGN
d. FSG
169.PRE RENAL failure changes
a. Fe Na > 1%
b. Urine Na <20
c. Osmolality <400
d. Specific gravity
170.Immediate workup of pt.
a. 14y-----BP—130/85
b. 14m---BP—95/60
c. 12Y----BP—100/70
171.PARASITE enter by skin
a. Tenia solium
b. E. Vermicularous
c. Strangoloids
172.Schistosomiasis, strongyloids , cutaneous larva migrans , hookworm
a. All penetrate by skin
173.Rubella
a. AV canal defect
b. Hydrocephalus
c. Conductive deafness
d. After 6 week not affected
174.Pt presented e cyanosis left axis tall p wave
a. Ebstein anomaly
b. TGA
c. TAPVC
d. PS
175. HUS
a. Burr cell
b. Shistocytes
c. Spherocytes
176. Max K loss in diarrhea
a. Cholera
b. Shigella
c. Salmonella
d. Campylobacter
177. HCV + ON treatment what to do check
a. HCV DNA
b. ALT rising
c. Hepatic fibrosis
178. Pt on NSIAD therapy BRUFAN causing gastric ulcer
a. PG inhibiters
b. Arteriolar
179. 25 KG how many calories require
a. 1800
b. 1600

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 DR M AKHTAR VIRK DRAKHTARVIRK@YAHOO.COM

c. 2500
180. I month old presented e fits and retinal hemorrhage, on mother feed, was home delivery. on
enquiring history they told baby felt from sisters laps
a. HDN
b. Head trauma
c. Child abuse
181.Pt presented e loose motion dehydration. Mother giving home fluid and cow milk .Na 170 , after
treatment fits started
a. SSST
b. Fits due to rapid correction
c. Pyomeningitis
182.Hyper natremic complication
a. Cerebral edema
b. Thrombosis
c. Seizures
183. Pt presented e pamper wet and black
a. AGN
b. G6PD
c. Myoglobinuria
d. Alkaptonuria
184. Cost effective management of diphtheria in asia
a. Immunization under 5 years
b. Early detection and treatment
c. Trace contact and treat
185. Pt presented e fits and drowsy , lower limb rash other symptoms normal
a. ITP E BLEED
b. MENINGOCOCCEMIA
c. SEPSIS
186.PT presented e fever LN+ gum bleed , HSM
a. ALL
b. Lymphoma
c. TB
d. Scurvy
187.Pt taking chemotherapy suffered from chickenpox
a. Stop chemo
b. IVIG
c. VZIG
d. Immunocompromised
e. Acyclovir
188.6 week noisy breathing since birth
a. Laryngomalacia
b. Asthma
c. Bronchiolitis
d. TEF
189. 6 month old e vomiting and RT upper lobe consolidation
a. GERD
b. H TYPE
c. HPS

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 DR M AKHTAR VIRK DRAKHTARVIRK@YAHOO.COM

190. 4 weeks old e vomiting bile stained and constipation

a. Volvulus
b. Duodenal atresia
c. HD
191.10 m old e chronic constipation rectal examination gush of stool
a. HD
b. Functional
c. Hypothyroidism
d. Anal atresia
192.Complication of hyponatremia
a. Seizures
b. Cerebral edema
c.
193. 12 y old e decrease school performance and fall during walking
a. Wilson
b. Psycho
194.Pt e gum bleed , epistaxis BT 12, PT/APTT PLAT normal
a. Platelet aggregation study
b. BMB
c. Fibrinogen
195. Pt e fracture compartment synd , ist sign check
a. Pulse absent
b. Perfusion poor
c. Pain prick
d. Loss of movement
196.Pt is K/C Of ALL his playmate develop varicella
a. Acyclovir
b. Vaccine
c. VZIG
d. Stop chemo
197.B/L HIP displacement investigation of choice
a. USG
b. X RAY
c. CT
d. MRI
198.Pt presented e hip pain , no internal rotation and abduction
a. Perthes
b. Slipped femoral
199.APGAR SCORE 2/10
a. Adrenaline
b. Ambubag
c. Chest compression
d. Intubation &resuscitation
200. Baby e lie presentation try to deliver by SVD but not successful then forceps applied still not
delivered then C/S DONE ,suffered ERB paralysis , respiratory distress and cyanosis due to
a. Congenital Pn
b. Sepsis
c. Pneumothorax

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 DR M AKHTAR VIRK DRAKHTARVIRK@YAHOO.COM

d. Diaphragmatic paralysis
201. On CXR air Broncho gram and ground glass appearance
a. RDS
b. TTN
c. Congenital Pn
202. 5 days old neonate presented e persisting hypoglycemia still not improving by 15% D/W S/
insulin > 15 next step
a. Glucagon
b. 25%D/W
c. Octreotide
d. Partially pancreatectomy
203. Neonate e ecchymosis valorous circumvallate nodular lesion on face
a. Hematoma
b. Cellulitis
c. Abscess
d. Fat necrosis
e. Hemangioma
204.Neonate e pustule lesion otherwise well baby
a. Neonatal acne
b. Erythma toxicum
c. Streptococcal
d. Postural melanosis
205.Pt presented e URTI ,on exam basal crept, liver 4cm BCM tachycardia , poor perfusion
a. Myocarditis
206. 7 y old female presented e body aches ,difficulty walking and eye lid rash
a. Dermatomyositis
b. SLE
c. DMD
207.Pt presented e hip pain ,elbow .stool e blood
a. HSP
b. Ankylosing spondylitis
c. Septic arthritis
d. Rheumatic fever
e. Reactive arthritis
208.Ist sign of IRON toxicity
a. Vomiting &bloody stool
b. Convulsion
209. Pt came e B/L knee pain ibufren taking improved and next elbow joint , ESR 60 fever 103F
a. RF
b. Septic arthritis
c. JRA
210.Preterm e bradycardia hypothermia
a. Apnea of prematurity
211. H/O of 10 days fever vomiting headache, drowsy convulsion CSF TLC 300 L 80% protein 800
sugar 20 BSR 80
a. TBM
b. Partially treated TB
c. Meningitis

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 DR M AKHTAR VIRK DRAKHTARVIRK@YAHOO.COM

212. Virus causes low sugar in CSF

a. Varicella
b. Herpes
c. Mumps
d. Measles
213.Hyperchloremic metabolic alkalosis
a. Barter
b.
214. 2 y old his mother died , living e grandfather , play full alert WT LOSS 1kg/2m
a. Child neglect
b. Malnutrition
c. Celiac disease
d. Child abuse
215. 2y old e loose motion alternate e constipation vitamin A deficiency albumin 1.2 ferritin < 5 Hb 7
a. Celiac disease
216. Versus injectable polio why oral preferred
a. Herd immunity
b. Easily given
217. Infant mortality rate social cause
a. Breast feed
b. Age of mother
c. Sex
d. Bad sanitation
218. Acute infectivity marker of HBV
a. HBsAg
b. HBeAg
219.Vaccinated
a. Anti HBsAg
220.12 y old e decrease school performance unconscious , hypertonia
a. MRI
b. EEG
c. 24H urine Cu
221. Abnormal movement and mood liability
a. Chorea
222. Child presented e vomiting FTT feed intolerance , hyperpigmentation
a. 17 OH progesterone
223. 3 y old unilateral breast enlargement
a. FSH&LH
b. GnRH
c. Pelvic USG
224. Growth hormone deficiency
a. Basal growth H low
b. 3 consecutive days
c. After exercise
d. Growth hormone level e oral glucose
e. Insulin stress test
225.Pt presented metabolic acidosis HCO3 10 , INC Anion GAP URINE PH 5.5 ,urine osmolality 500
a. RTA1

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b. RTA2
c. Organic academia
d. Galactosemia
226.Pt presented e vomiting fits lethargic hypotonia NH4 120
a. Urea cycle defect
227.SIADH
a. Fluid restriction
b. 3% N/S
c. 0.9% N/S
228.6y old become unconscious after exercise 3/6 ESM left upper border
a. A.S
b. QT prolong
c. P.S
229.HR 280 , QRS 0.07 sec P wave absent
a. SVT
b. VT
c. HEART BLOCK
d. VF
230. K/C OF HOCM came e SVT drug of choice
a. Propranolol
b. Quinidine
c. Digoxin
d. Procainamide
231. Neonate came with respiratory distress and scaphoid abdomen
a. Diaphragmatic hernia
b.
232.On ventilation PO2↓and PCO2 ↑ causes
a. PIP↓ and RR↓
b. PIP↓ AND RR ↑
233. 16 days old e persisting jaundice Hb 15 BILLI 16 (1.5)
a. Crigler
b. Rh incompatibility
c. G6PD
d. H.S
e. Enclosed hemorrhage
234. 8 weeks old jaundice persist investigation
a. Liver biopsy
b. Hida scan
c. USG
d. GGT
235. 3 y old was playing develop sudden respiratory distress ,RT side wheeze, RT side
hyperinflation , no crept
a. Bronchoscopy
b. Chest tube
c. Nebulization
236. Knuckle rigidity and dysphagia
a. MRI
b. CXR

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 DR M AKHTAR VIRK DRAKHTARVIRK@YAHOO.COM

c. X RAY NECK LAT VIEW

d. CSF
237.Diagnosed as pertussis , indication of erythromycin for other family members
a. All regardless of age & immunization
b. <7Y
c. Immunized no need
238. At 9 month of age was vaccinated , now 15 month old and measles epidemic
a. Vaccine and life long
b. IST dose then 5 y
c. No need
239.Rectal prolapse parasite
a. Entrobius vermicularis
240. Most common cause of hypothyroid
a. Thyroid agenesis
b. Endemic goiter
241.VIT D intoxication
a. Diarrhea
b. Gum hyperplasia
c. Hypocalcemia
d. Hypomagnesemia
242.Pt came with cheilosis dermatitis nape rash , perioral rash
a. Zn
b. Cu
c. Iron
243. 3 y old e malnutrition thigh swelling , limp afebrile
a. Scurvy
b. Osteomyelitis
c. Cellulitis
d. Reactive arthritis
e. Fracture
244. Development age , crawling alone walking , drink e cup
a. 12m
b. 14m
c. 18
d. 24
245. Stand on one leg for sec and downstairs on alternate step
a. 4y
b. 5y
246. No eye contact , school performance low
a. Autism
b. ADHD
c. Deaf
247. Child presented wheeze and R/D first therapy
a. O 2
248. Child play in ground develop sudden R/D XRAY hyperinflation in one lobe first step in
management
a. Bronchoscopy
249. First sign iron poisoning 30-60 min of poison

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a. Bloody diarrhea and vomiting

250. Cause of death mostly in paracetamol poisoning
a. ,
251. First sign of paracetamol poisoning
a. Hyperventilation
252. Most reliable test for hypothyroidism in newborn
a. After 3-5 days
253. After loose motion taken medicine from Hakeem develop pinpoint pupil.
a. Naloxone
254. Delivered by C/S develop R/D cyanosis and bradycardia , first investigation
a. ABG
b. CXR
c. ECHO
d. ECG
255. Extra intestinal manifestation of celiac
a. Short stature
256. Screening of Wilson diseses
a. S/ ceruloplasmin level
257. Presentation of Wilson before 7 years
a. CLD
258. ABG in gastric outlet obstruction
a. Hypochloremic metabolic alkalosis
259. Distal and proximal RTA can be differentiated by
a. Hypophosphatemia in proximal
260. Sign that need for further evaluation in newborn at 2nd day of life
a. Pallor / jaundice
261. Road traffic accident presented in hypovolemic shock fluid choice
262. Acholic stool in 8 week old baby
a. Biliary atresia
263. Pain RT inguinal region e vomiting
a. Incarcerated hernia
264. BCG scar shows
a. definitely vaccinated
265. Negative Mantoux show
a. No result can be drawn
266. Bitot spot need to be positive in how many population to declare vit A deficiency
a. 1%
b. 2%
c. 3%
d. 4%
e. 5%
267. Development screening is done mostly to
a. Detect the child e learning difficult
b. Develop the child e mental retardation
c. Detect child when need formal evaluation
268. Influenza vaccine is given
a. To all healthy children
269. Child in encephalopathy drug

DR M AKHTAR VIRK CH&ICH LAHORE

 DR M AKHTAR VIRK DRAKHTARVIRK@YAHOO.COM

a. ??
270. Phenomena in which morphogenesis is impaired result in impaired organ
a. Dysmorphology
b. ??
271. Baby born to HBsAg + mother
a. Vaccine & immunoglobulin
272. Dexamethasone is given in TBM
a. To prevent adhesion formation
b. ??
273. Baby presented e Hb 9 MCV 98 next plan
a. Add VIT B12 in diet
274. Night blindness xerosis which VIT deficient
a. VIT A
275. Child saying amma aba plus 2 words age
a. 14 m
276. At age of one years , child is most likely
a. First real word
277. Child had exercise intolerance and sudden loss of consciousness o/e 3/6 murmur lest supra
sternal border
a. A.S
b. COA
278. Child presented e cyanosis R/D murmur at left upper sternal border
a. TGA e VSD
279. Child presented e repeated loose motion and FTT and chest infection
a. Cystic fibrosis
280. Jaundice in child is dangerous
a. Rise of bilirubin > 5 mg / dl / day
281. Mother Rh- baby Rh + , determination of severity
a. Rate of rise of bilirubin
282. Child e ASOC 7 days cerebral hemorrhage , test
a. BT
b. Clotting profile
c. CBC
d. PLATELET
283. AT birth normal HT & WT
a. 50cm &3.2 kg
284. Kerosene oil intake
a. Pulmonary hemorrhage
b. Atelectasis
285. Muscle aches and rash on hands and legs
a. Dermatomyositis
286. Baby e R/D and distance heart sound
a. Myocarditis
287. Baby e hyponatremia & hyperkalemia
a. CAH
288. Suspicion of CAH , most reliable test
a. 17 0h progesterone
289. F.U case of ALL , most common site of relapse

DR M AKHTAR VIRK CH&ICH LAHORE

 DR M AKHTAR VIRK DRAKHTARVIRK@YAHOO.COM

a. Brain
290. Course facial features , protruding tongue short stature
a. Hypothyroidism
291. Unilateral enlargement of ureters on USG of abdomen next investigation
a. IVU
292. Idiopathic nephrotic syndrome
a. Proteinuria +++
293. Chrioretinitis most commonly associated e
a. Toxoplasmosis
294. Bloody diarrhea organism e EOISINO 3%
a. E COLI
295. Rotavirus infection mostly likely
a. Stool contain leukocyte
b. Curative e nitro furantoin
c. Recurrent dehydration
296. Trans illumination swelling on front of neck
a. Thyroglossal cyst
b. Brachial cyst
c. Thymoma
d. Thyroid
297. Cleft lip & cleft palate mostly associated
a. Pnenobarbitone
b. Phyntoin
298. Recurrent chest infection e prominent perihilar e RT upper lobe
a. GERD
b. TEF H TYPE
299. Persisting hypoglycemia
a. Subtotal pancreatectomy
300. Antenatal screening is best recommended
a. TORCH
b. ???
301. 6 Y old e abdominal pain referred from surgery for opinion, advised
a. CXR for Pneumonia
302. IMCI included which disease
a. ARTI,Diarrhea , measles malnutrition
303. H/O of fever fits SOMI + rash over body ( meningococcemia )
a. CT BRAIN
304. Diagnosis of alpha thalassemia made by
a. Determination of Hb A2
305. Screening of GBS , ascending paralysis , labs
a. CSF
306. Most reliable features of pyloric stenosis is
a. Mass in RT hypochondrium &visible peristalsis
307. PR done , gush of feces
a. HD
308. 4 day baby presented with bleeding PR
a. HDN
309. Hypernatremic dehydration , ORS given , then fits started

DR M AKHTAR VIRK CH&ICH LAHORE

 DR M AKHTAR VIRK DRAKHTARVIRK@YAHOO.COM

a. Rapid correction e cerebral edema

310. Urinary PH 5.5 which type of RTA
a. RTA1
b. RTA2
311. Baby born , Apgar score 2/10 poor pulses
a. Ambubag
312. Baby born e bradycardia & poor pulses
a. Chest compression and Ambubag
313. Antihypertensive in CKD
a. BB
b. CCB
c. ACE
314. Investigation for pyloric stenosis
a. USG
315.

DR M AKHTAR VIRK CH&ICH LAHORE

 MCQ’
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ase
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elevelofFSH,
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tost
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malkar
yot
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……………. .
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VITY

9. Femalehavingambi
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tl
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ionandi
ncr
eas
elevelof11
deox
yc or
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ciency

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ehavi
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irmat
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..

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11.Babybor
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Vmot
her
……….
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acc
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eas
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12.Babybornt
omotherhavi
ngac
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uber
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tat
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ng havcynot
icspel
lswatinvesti
gati
on?
coor
dinat
edsucki
ngsois
smainmotherfeedker
waij
askhtihai  
14.Mot
herwi
thunc
ont
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edepi
leps
y……….
.asmot
herhav
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leps
yasc
hance S.
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mg 
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33.Ekcer
ebel
lars
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27.Achi
ldhascont
inuousmur
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ntens
ityofwhi
chi
ncr
eas
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tht
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eft 34.Eks
hor
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35.Ekr
etts
yndr
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venoushamp
37.pati
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et50%,
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ates15% f
ats10%
28.14year
sol
dmal
eas
ymmet
ricbr
eas
tenl
argementmi
ldt
enderwasi
nves
tigat
ed 
2inj
/day
Karyotype  l
owf i
berdi
et
xraychest 
Serum estr
ogenl
evel
38.Atallnthinchil
dwithlongar
msnt hi
nfi
nger
s,whohassomement alr
etar
dati
onals
o,has
Reas
sur
anc
e developedchestpai
n,coughndys
pnea.Whatist
hebesti
nves
tigat
iontoassessc
auseof
hi
ss ymptoms :

29.Cal
cif
icat
ionwal
a………………….
.neur
obl
ast
oma
Chestxray
Heli
calspir
alctches
t
Coagulat
iontests
30.ASD,hypopl
ast
ict
humb…….
Hol
tor
am s
yndr
ome

39.A12yrol
dgi
rli
suncons
cious
,hasi
ncr
eas
eds
ali
vat
ionandpi
npoi
nt:
31.Ekmyocar
dit
iskat
a

Or
ganophos
phat
epoi
soni
ng

32.Chi
ldhavi
nghear
trat
e240/
minandnowhavi
ngr
espi
rat
orydi
str
ess
,whatt
reat
ment
? 40.Typi
calr
adi
ologi
calf
indi
ngi
nachondr
opl
asi
a

Fl
atacet
abul
ars
hadows

Adenos
ine Antbeaki
ngofver
etebr
ae

Ox
ygen I
ncr
eas
eint
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caldi
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d

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lowver
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41.Regar
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: pr
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Vacci
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seffecti
vewi t
hin5days
I
mmunglobulineffecti
vewithin5days
I
mmunoglobulineffect
ivewithi
n1week 47. 
Ment
all
yret
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nges
tedcont
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cur
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momet
er,whatwoul
dbt
he
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ivewithi
n2week pr
esent
ings
ympt
oms
Abdomi
nalpai
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I.s
ympt
oms
Dys
art
her
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42.Afterf
irs
tdos
eofmeas
lesvacci
neat9mont
hsofagehowmuchpr
otec
tioni
sachi
eved?
Or
alul
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60%
70% Bl
eedi
ngf
rom mout
h
80% 48.Apat
enthasns
tagmasi
ntent
iont
remori
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vingr
ightar
mles
ionwi
llbe 
90%
100%
Bas
algangl
ia 
Ri
ghtcer
ebel
um 
Lef
tcer
ebel
lum
43.A16yrol
dgi
rlhasdevel
opeds
ever
echi
ckenpox
,shehasdev
elopedpneumoni
a,s
hehasa
5yrol
dsi
bwhoi
sons
ter
oidsduet
onephr
oti
csy
ndr
ome,whati
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or
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hem 49.40daysneonat
edevol
ops
trept
ococalmeni
git
ssens
iti
vet
ocef
otax
imeont
rpr
esent
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wi
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hfi
tscts
howeds
ubdur
alhemat
omabi
lt
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Vz
igf
or16y
rol
d
Acycl
ovi
rfor16y
rol
d adddex
a 

Vz
igf
or5yrol
dnacycl
ovi
rfor16yrol
d s
ubdur
alt
ap 

Vz
igf
or15y
rol
dnac
ycl
ovi
rfor6yrol
d s
endcul
tur
e 
changeant
biot
ic
50.Babybor
ntomot
herhavi
ngHBs
Ag+ve?
44.Chi
ldcomeswi
thcompl
aintofdi
ffi
cul
tyi
nfl
exi
onandabduct
ionofhi
p
SCFE
Per
thedi
seas
e HepBVacci
ne

Os
teonec
ros
is HepBvacci
ne+HepBI
mmunogl
o
45.Chi
ldcomeswi
thcompl
aintofpai
nfull
impi
nggai
tandonx
rays
howi
ngi
rregul
ari
tyof HepBi
mmune
f
emor
alhead?
CheckHBs
Ag
SCFE
Per
thedi
seas
e
51.5Year
soldfemalehavi
ngast
hmaonBet aAgonis
tandus e4t
imes/
dayi
nthi
swkandno
Os
teonec
ros
is
ni
ghtsympt
oms ,nowhaveexer
cis
eint
olr
ence,whichdr
ugyouuse?

46.Pat
ienthavi
ng46x
y,andonex
ami
nat
ionhavi
ngnopal
pabl
egonadesi
nsc
rot
um,andon
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tras
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rusB19)

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57.pati
enthavingoffandonabdomi
nalpai
nandhavi
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crocyt
ichypochr
omi
c
anemia,
organis
m?

52.10yearsoldgirlhavi
nglowermot orneurontypeofweaknessoflowerl
imbsandi
npas
t ankyl
ost
omadudenal
e
pati
enthavings uch2epis
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ohavehistor
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agnos i
s? entrobi
ousver
micul
ari
s
ascari
asi
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coi
ds

GBS
58.
Heal
thwor
kerhasdi
agnos
ed6mont
hol
dinf
antasmal
ari
adr
ugofchoi
ce 
Fami
li
aldys
aut
onomi
a

Por
phyr
ia ar
temet
hr 

Per
iodi
cpar
alys
is qui
nine

s
ulpham pyr
idox
ine
53.Aneonatewi
thper
sis
tenthypogl
cemi
a,notcor
ect
edwi
thgl
ucos
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usi
ons
..
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t
apr
opri
atel
ongter
mt reat
ment Chl
oroqui
ne

Cef
exi
me
diaz
oxide
octr
eotide 59.Pat
ienthavi
ngbi
li
ousvomi
ti
ngandcons
tipat
ion,andonxr
aygr
oundgl
ass
subtot
alpancr
eat
ect
omy appear
ancewi
thmi
crocol
on?

54.Babybor
nAPGARs
cor
e..
.
...
.
...
.
..
..
..
..
.nor
malbodymovement
,nor
mals
neez
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s chprungDi seas
e
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ipher
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nk? Miconi um i
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Volvolus
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on
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ntes ti
nalobs t
ructi
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awalFunct
ionalmegacol
onkat
a
7
55.Pat
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our
,ands
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oles
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ienthavi
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yur
iaandpol
ydys
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emi
awi
thal
kal
osi
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a?

Bar
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ome
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ori
asi
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ient
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56.chi
ldwithher
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orys
phr
ocyt
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esent
swi
thf
everandr
ash.
.
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VT 75.Mot herhavingmyast
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aandbabybornhavi
nghypot
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aandputonvent
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ator
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AF outcome?
Babyr ecoveraf
ter4monthsandhavi
ngnodis
eas
e
63.AkLei
ghs
yndr
omekat
a
Babyhavi
ngcongeni
talmyas
theni
a
64.Akur
eacyc
ledef
ectka
Babhyhavi
ngpt
osi
s

65.Pat
ienthavi
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ing,havi
nghyper
ammonemi
a,r
espi
rat
orydi
str
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ing
metabol
icaci
dosi
s?
76.AkSar
cidos
iskat
a
Ureacycl
edefect
Organicaci
ddefect
Tyros
enemia
77.Abnor
malat18mont
hs?
66.akgl
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67.aki
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79.akJ
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a
Trumatotest
is
Testi
cul
artor
sion
Epidydi
mit
is
80.AkMeas
leskat
a

69.Recur
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..
..
..
.
...
..
.
choi
ceofs
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VCUG
81.Akwheez
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ionyaadnaihanab
I
VP
Uri
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70.4Yearmi
les
tones
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a

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73.AkBez
oarkat
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74.AkCr
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