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OMSB Pediatrics (OEPEDS) study materials
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OMSB Pediatrics (OEPEDS) practice questions

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Question 1General Pediatrics

A 3-day-old term newborn is noted to have a bluish discoloration of the hands and feet with pink central mucous membranes. He is vigorous, feeding well, and pre-ductal and post-ductal oxygen saturations are both 98%. What is the most appropriate management?

  1. Immediate prostaglandin E1 infusion
  2. Urgent echocardiography and cardiology referral
  3. Chest radiograph and blood gas analysis
  4. Reassurance and routine newborn care Correct answer.

Explanation

Acrocyanosis is a benign physiological finding in the first days of life caused by peripheral vasoconstriction and immature circulation; it resolves spontaneously and central mucosae remain pink with normal saturations. Because this infant is well, has normal pre- and post-ductal saturations, and shows no central cyanosis, no investigation or treatment is required.

Question 2General Pediatrics

Which of the following is the most common cause of neonatal conjunctivitis presenting within the first 24–48 hours of life?

  1. Staphylococcus aureus
  2. Chlamydia trachomatis
  3. Chemical irritation from prophylaxis Correct answer.
  4. Neisseria gonorrhoeae

Explanation

Chemical conjunctivitis from silver nitrate or other prophylactic agents classically presents within the first 24–48 hours after birth and resolves spontaneously. Gonococcal disease typically appears at 2–5 days, chlamydial at 5–14 days, and staphylococcal infection later still.

Question 3General Pediatrics

A 6-month-old infant is brought with a 2-day history of profuse watery diarrhoea and vomiting. He is lethargic, has sunken eyes, a capillary refill of 4 seconds, and no tears. According to WHO/IMCI classification, which category best describes his dehydration?

  1. No dehydration
  2. Hypernatraemic dehydration
  3. Some dehydration
  4. Severe dehydration Correct answer.

Explanation

The combination of lethargy, sunken eyes, delayed capillary refill, and absence of tears meets WHO criteria for severe dehydration, which mandates immediate intravenous or intraosseous fluid resuscitation with Ringer's lactate. Two or more of these signs in the severe category confirm the classification.

Question 4General Pediatrics

At what age does a normally developing infant typically achieve independent sitting without support?

  1. 10–12 months
  2. 4–5 months
  3. 6–8 months Correct answer.
  4. 2–3 months

Explanation

Independent sitting without support is a gross motor milestone usually achieved between 6 and 8 months of age, following head control and rolling. Persistence of inability to sit unsupported beyond about 9 months warrants developmental assessment.

Question 5General Pediatrics

A 4-year-old child presents with a barking cough, hoarse voice, and inspiratory stridor that worsens at night. He is afebrile and has a steeple sign on neck radiograph. What is the most likely diagnosis?

  1. Epiglottitis
  2. Bacterial tracheitis
  3. Croup (laryngotracheobronchitis) Correct answer.
  4. Foreign body aspiration

Explanation

Croup typically affects children aged 6 months to 5 years with a barking cough, hoarseness, and inspiratory stridor, often worse at night, and the steeple sign reflects subglottic narrowing. It is usually viral, most commonly parainfluenza, and responds to dexamethasone with nebulised adrenaline in moderate cases.

Question 6General Pediatrics

Which of the following is the recommended first-line treatment for a child with newly diagnosed uncomplicated type 1 diabetes mellitus presenting in diabetic ketoacidosis?

  1. Isotonic fluid resuscitation followed by a low-dose insulin infusion Correct answer.
  2. Intravenous insulin bolus followed by infusion
  3. Subcutaneous insulin analogue with oral rehydration
  4. Rapid intravenous bolus of 0.9% sodium chloride at 20 mL/kg

Explanation

Management of paediatric diabetic ketoacidosis begins with careful isotonic fluid resuscitation over 1–2 hours, followed by a continuous low-dose insulin infusion (usually 0.05–0.1 units/kg/hour) once circulation is restored. Insulin boluses are avoided because they increase the risk of cerebral oedema.

Question 7General Pediatrics

A 2-year-old child has a generalised tonic-clonic seizure lasting 3 minutes in the emergency department. Which is the most appropriate first-line medication?

  1. Rectal or intravenous diazepam Correct answer.
  2. Intravenous levetiracetam
  3. Intravenous phenytoin
  4. Intravenous phenobarbitone

Explanation

For a convulsive seizure lasting more than 5 minutes, a benzodiazepine such as diazepam (rectal or intravenous) or midazolam (buccal or intramuscular) is first-line. Second-line agents such as phenytoin, levetiracetam, or phenobarbitone are used if seizures persist after benzodiazepines.

Question 8General Pediatrics

Which of the following statements about the routine measles-mumps-rubella (MMR) vaccine is correct?

  1. It is contraindicated in all children with egg allergy
  2. It should not be given to children with a mild febrile illness
  3. It is an inactivated vaccine given at 6 and 12 months
  4. It is a live attenuated vaccine given at 12 and 18 months in most schedules Correct answer.

Explanation

MMR is a live attenuated vaccine typically scheduled at 12 and 18 months in most national immunisation programmes, providing two doses for optimal seroconversion. Mild febrile illness is not a contraindication, and egg allergy is not a barrier to MMR administration.

Question 9General Pediatrics

A 7-year-old boy is brought with a 3-week history of periorbital oedema, frothy urine, and weight gain. Urinalysis shows 3+ protein but no haematuria, and serum albumin is 18 g/L. What is the most likely diagnosis?

  1. Acute post-streptococcal glomerulonephritis
  2. IgA nephropathy
  3. Urinary tract infection
  4. Minimal change nephrotic syndrome Correct answer.

Explanation

The combination of heavy proteinuria, hypoalbuminaemia, oedema, and absence of haematuria in a child aged 2–10 years is typical of minimal change nephrotic syndrome, which responds well to corticosteroids. Post-streptococcal glomerulonephritis would show haematuria, hypertension, and only mild proteinuria.

Question 10General Pediatrics

A 5-year-old child presents with a 4-day history of fever, bilateral conjunctivitis, strawberry tongue, cracked lips, and a polymorphous rash. Which of the following is the most important complication to screen for?

  1. Coronary artery aneurysm Correct answer.
  2. Hepatic failure
  3. Renal vein thrombosis
  4. Pulmonary fibrosis

Explanation

The clinical picture is Kawasaki disease, and the most serious complication is coronary artery aneurysm, which occurs in up to 25% of untreated cases. Early treatment with intravenous immunoglobulin and aspirin within 10 days of fever onset reduces this risk.

Question 11General Pediatrics

A 10-year-old child is brought with a 2-week history of fatigue, pallor, and jaundice. Blood film shows spherocytes, reticulocytosis, and a positive direct antiglobulin test. What is the most likely diagnosis?

  1. Glucose-6-phosphate dehydrogenase deficiency
  2. Thalassaemia major
  3. Hereditary spherocytosis
  4. Autoimmune haemolytic anaemia Correct answer.

Explanation

A positive direct antiglobulin test (Coombs test) indicates immune-mediated destruction, so spherocytes with reticulocytosis and jaundice in this context indicate autoimmune haemolytic anaemia. Hereditary spherocytosis has a negative Coombs test because the defect is intrinsic to the red cell membrane.

Question 12General Pediatrics

A 6-week-old infant presents with projectile non-bilious vomiting after feeds and a palpable olive-shaped mass in the right upper quadrant. Which electrolyte abnormality is most characteristic?

  1. Hypernatraemia and metabolic acidosis
  2. Normal electrolytes with respiratory alkalosis
  3. Hypochloraemic hypokalaemic metabolic alkalosis Correct answer.
  4. Hyperkalaemic metabolic acidosis

Explanation

Hypertrophic pyloric stenosis causes repeated loss of gastric hydrochloric acid and potassium, producing a hypochloraemic hypokalaemic metabolic alkalosis with paradoxical aciduria. Correction of the electrolyte disturbance precedes surgical pyloromyotomy.

Question 13General Pediatrics

A 3-year-old child with a known ventricular septal defect develops fever, poor feeding, and a new murmur. Blood cultures are drawn. What is the most appropriate next step in management?

  1. Await culture results before starting antibiotics
  2. Start empirical intravenous antibiotics after cultures and obtain echocardiography Correct answer.
  3. Reassure as this represents a viral illness
  4. Start oral amoxicillin as an outpatient

Explanation

Infective endocarditis should be suspected in a child with congenital heart disease who develops unexplained fever and a new murmur; blood cultures should be drawn and empirical intravenous antibiotics started promptly, with echocardiography to identify vegetations. Delay in treatment increases the risk of embolic and valvular complications.

Question 14General Pediatrics

A 12-year-old girl presents with weight loss, palpitations, heat intolerance, and a diffuse goitre. Laboratory tests show suppressed TSH with elevated free T4. Which is the most likely diagnosis?

  1. Hashimoto thyroiditis
  2. Thyroid carcinoma
  3. Subacute thyroiditis
  4. Graves disease Correct answer.

Explanation

A suppressed TSH with elevated free T4 in an adolescent girl with a diffuse goitre and symptoms of thyrotoxicosis is characteristic of Graves disease, caused by TSH-receptor stimulating antibodies. Hashimoto thyroiditis usually causes hypothyroidism with elevated TSH.

Question 15General Pediatrics

A 4-year-old boy is brought with a 2-day history of fever, sore throat, and drooling. He is sitting forward and refuses to lie down. What is the most appropriate immediate action?

  1. Give oral amoxicillin and discharge with follow-up
  2. Inspect the throat with a tongue depressor
  3. Perform a throat swab and await results
  4. Prepare for emergency airway management and start intravenous antibiotics Correct answer.

Explanation

The presentation suggests epiglottitis, an airway emergency; the child should be kept calm in a position of comfort while preparations are made for controlled airway securing in theatre, with intravenous antibiotics started. Throat inspection with a tongue depressor may precipitate complete airway obstruction and must be avoided.

Question 16General Pediatrics

A 9-year-old child with known sickle cell disease presents with fever of 39°C, tachypnoea, and chest pain. Chest radiograph shows a new infiltrate. What is the most appropriate initial management?

  1. Blood transfusion alone
  2. Simple analgesia and observation
  3. Intravenous broad-spectrum antibiotics, oxygen, hydration, and analgesia Correct answer.
  4. Oral antibiotics and outpatient follow-up

Explanation

Acute chest syndrome is a leading cause of death in sickle cell disease and requires prompt intravenous broad-spectrum antibiotics covering atypical organisms, oxygen, careful hydration, analgesia, and often transfusion. Fever with a new pulmonary infiltrate in this population should be treated as acute chest syndrome until proven otherwise.

Question 17General Pediatrics

Which of the following is the most common congenital heart defect overall?

  1. Patent ductus arteriosus
  2. Ventricular septal defect Correct answer.
  3. Tetralogy of Fallot
  4. Atrial septal defect

Explanation

Ventricular septal defect is the most frequently occurring congenital cardiac anomaly, accounting for roughly a quarter of all cases. Many small defects close spontaneously, while larger ones may cause heart failure and require intervention.

Question 18General Pediatrics

A 2-year-old child presents with a 3-day history of fever, irritability, and pulling at the right ear. Otoscopy shows a bulging, erythematous tympanic membrane. What is the most appropriate first-line antibiotic?

  1. Intravenous ceftriaxone
  2. Amoxicillin Correct answer.
  3. Ciprofloxacin
  4. Azithromycin

Explanation

High-dose amoxicillin is first-line for uncomplicated acute otitis media because it covers the common pathogens Streptococcus pneumoniae and Haemophilus influenzae. Macrolides and fluoroquinolones are reserved for penicillin allergy or treatment failure, and intravenous therapy is not indicated here.

Question 19General Pediatrics

A 10-year-old child with asthma presents with acute exacerbation and is not responding to repeated inhaled salbutamol. Which of the following is the most appropriate next step?

  1. Start oral antibiotics
  2. Add systemic corticosteroids and consider ipratropium bromide Correct answer.
  3. Reduce salbutamol frequency
  4. Start long-term montelukast alone

Explanation

For moderate-to-severe asthma exacerbations not responding to inhaled bronchodilators, systemic corticosteroids reduce airway inflammation and should be added promptly, along with nebulised ipratropium in severe cases. Antibiotics are only indicated when bacterial infection is suspected.

Question 20General Pediatrics

A 15-year-old girl presents with a 2-month history of amenorrhoea, weight loss, and body image distortion. Her BMI is 15. Which cardiac complication is most concerning?

  1. Hepatic encephalopathy
  2. Coronary artery aneurysm
  3. Ventricular arrhythmia and sudden death Correct answer.
  4. Pulmonary fibrosis

Explanation

Anorexia nervosa causes electrolyte disturbance, bradycardia, QT prolongation, and ventricular arrhythmias, and sudden cardiac death is a well-recognised cause of mortality. Careful monitoring of electrolytes and cardiac rhythm is essential during refeeding.

Question 21General Pediatrics

A 3-year-old child is brought with a 24-hour history of colicky abdominal pain, vomiting, and passage of redcurrant jelly stool. Examination reveals a sausage-shaped mass in the right upper quadrant. What is the most likely diagnosis?

  1. Meckel diverticulum
  2. Appendicitis
  3. Hirschsprung disease
  4. Intussusception Correct answer.

Explanation

The combination of colicky pain, vomiting, a sausage-shaped abdominal mass, and redcurrant jelly stool is classic for ileocolic intussusception in a toddler. Air or contrast enema is both diagnostic and therapeutic in most cases.

Question 22General Pediatrics

A 12-year-old boy with a known peanut allergy develops generalised urticaria, wheeze, and hypotension 10 minutes after accidental ingestion. What is the first drug to administer?

  1. Nebulised salbutamol
  2. Intravenous hydrocortisone
  3. Oral antihistamine
  4. Intramuscular adrenaline Correct answer.

Explanation

Intramuscular adrenaline into the anterolateral thigh is the first-line treatment for anaphylaxis because it reverses airway oedema and hypotension rapidly. Antihistamines and corticosteroids are adjuncts and do not treat airway or circulatory compromise.

Question 23General Pediatrics

A 5-year-old child presents with a purpuric rash on the buttocks and lower limbs, abdominal pain, and painful swollen knees. Platelet count is normal. What is the most likely diagnosis?

  1. Haemophilia A
  2. Meningococcal sepsis
  3. Immune thrombocytopenia
  4. Henoch-Schönlein purpura (IgA vasculitis) Correct answer.

Explanation

IgA vasculitis (Henoch-Schönlein purpura) classically presents with a palpable purpuric rash over the buttocks and extensor surfaces, abdominal pain, arthritis, and sometimes renal involvement, with a normal platelet count. It reflects small-vessel leukocytoclastic vasculitis.

Question 24General Pediatrics

A term newborn develops jaundice at 6 hours of life with a bilirubin of 240 µmol/L. Which is the most important immediate consideration?

  1. Pathological jaundice requiring urgent investigation and phototherapy Correct answer.
  2. Physiological jaundice requiring no action
  3. Breastfeeding jaundice with continued observation
  4. Jaundice of prematurity requiring delayed intervention

Explanation

Jaundice appearing within the first 24 hours of life is always pathological and may indicate haemolytic disease, sepsis, or metabolic disease; urgent measurement of bilirubin, blood group, direct Coombs test, and full blood count with prompt phototherapy is required to prevent kernicterus.

Question 25General Pediatrics

A 14-year-old presents with polyuria, polydipsia, and weight loss. Blood glucose is 22 mmol/L, pH 7.15, bicarbonate 10 mmol/L, and ketones are positive. Which of the following is the most important complication to monitor for during treatment?

  1. Pulmonary oedema
  2. Hyperkalaemia during insulin infusion
  3. Hypoglycaemia from overhydration
  4. Cerebral oedema Correct answer.

Explanation

Cerebral oedema is the most serious complication of paediatric diabetic ketoacidosis and is associated with rapid fluid administration, early insulin boluses, and overly rapid correction of osmolality. Careful fluid and insulin protocols with frequent neurological monitoring are essential.

Question 26General Pediatrics

A 4-year-old child is brought to the clinic with a 2-day history of low-grade fever, runny nose, and a rash that began on the face and spread to the trunk and limbs. On examination, there are small white spots on the buccal mucosa and a maculopapular rash. Which of the following is the most likely diagnosis?

  1. Scarlet fever
  2. Measles Correct answer.
  3. Roseola infantum
  4. Rubella

Explanation

Measles classically presents with a prodrome of fever, coryza, and conjunctivitis, followed by Koplik spots on the buccal mucosa and a maculopapular rash that starts on the face and spreads downwards. Rubella typically has a milder prodrome and posterior auricular lymphadenopathy, without Koplik spots. Roseola infantum causes high fever followed by a rash that appears after defervescence, and scarlet fever has a sandpaper-like rash with a strawberry tongue.

Question 27General Pediatrics

A 2-year-old child is brought to the emergency department with a 1-day history of fever and refusal to bear weight on the right leg. On examination, the child is irritable but has no obvious swelling or erythema over the joint. Which of the following is the most appropriate next step in management?

  1. Perform arthrocentesis immediately
  2. Obtain blood cultures and start intravenous antibiotics Correct answer.
  3. Order a plain radiograph of the leg
  4. Prescribe oral amoxicillin and discharge home

Explanation

In a young child with fever and refusal to bear weight, septic arthritis or osteomyelitis must be excluded urgently. Blood cultures should be obtained and empirical intravenous antibiotics started promptly, after joint aspiration if septic arthritis is suspected. Plain radiographs are often normal early in osteomyelitis and should not delay treatment. Discharging home on oral antibiotics is unsafe.

Question 28General Pediatrics

A 6-month-old infant is brought for a routine check-up. The parents report that the infant has been having episodes of stiffening and brief loss of consciousness when startled by loud noises. Which of the following is the most likely diagnosis?

  1. Infantile spasms Correct answer.
  2. Startle epilepsy
  3. Breath-holding spells
  4. Febrile seizure

Explanation

Infantile spasms (West syndrome) typically present in infancy with clusters of brief, symmetric contractions that may be triggered by startle or arousal. They are associated with an EEG pattern of hypsarrhythmia and require urgent evaluation and treatment to prevent developmental regression. Febrile seizures occur with fever, breath-holding spells are provoked by crying or frustration, and startle epilepsy is rare and not the typical presentation in this age group.

Question 29General Pediatrics

A 10-year-old boy is brought with a 3-day history of sore throat and fever. On examination, there is a greyish-white membrane adherent to the tonsils that bleeds when swabbed. Which of the following is the most appropriate initial management?

  1. Immediate intubation and intensive care admission
  2. Urgent administration of diphtheria antitoxin and antibiotics Correct answer.
  3. Oral penicillin and discharge home
  4. Reassurance and symptomatic treatment

Explanation

The presentation is suggestive of diphtheria, which requires urgent administration of diphtheria antitoxin and antibiotics (erythromycin or penicillin) to prevent systemic toxicity and transmission. The membrane is characteristically adherent and bleeds when removed. Discharging home or giving only symptomatic treatment would be dangerous, and intubation is reserved for airway compromise.

Question 30General Pediatrics

A 3-year-old child is brought with a 2-day history of fever, cough, and rapid breathing. On examination, there are crackles and reduced breath sounds over the right lower lobe. Which of the following is the most likely causative organism?

  1. Mycoplasma pneumoniae
  2. Staphylococcus aureus
  3. Streptococcus pneumoniae Correct answer.
  4. Respiratory syncytial virus

Explanation

Streptococcus pneumoniae is the most common cause of community-acquired pneumonia in children beyond the neonatal period, typically presenting with fever, cough, and focal signs such as crackles. Staphylococcus aureus often causes more severe, necrotising pneumonia with empyema. Mycoplasma is more common in older children, and RSV typically causes bronchiolitis in infants.

Question 31General Pediatrics

A 5-year-old child is brought with a 1-day history of colicky abdominal pain, vomiting, and passage of bloody stools. On examination, there is a sausage-shaped mass in the right upper quadrant. Which of the following is the most appropriate initial investigation?

  1. Plain abdominal radiograph
  2. Barium enema
  3. Abdominal ultrasound Correct answer.
  4. Abdominal CT scan

Explanation

The presentation is classic for intussusception, and abdominal ultrasound is the preferred initial investigation, showing a target or doughnut sign. It is non-invasive and highly sensitive. Barium enema is therapeutic as well as diagnostic but is not the first-line investigation in many centres. CT involves radiation and is not first-line, and plain radiographs are nonspecific.

Question 32General Pediatrics

A 12-year-old girl is brought with a 2-week history of fatigue, pallor, and a sore tongue. Laboratory tests show a macrocytic anaemia with a low vitamin B12 level. Which of the following is the most likely underlying cause?

  1. Lead poisoning
  2. Iron deficiency
  3. Pernicious anaemia Correct answer.
  4. Thalassaemia trait

Explanation

Pernicious anaemia is an autoimmune condition causing vitamin B12 deficiency due to intrinsic factor deficiency, leading to macrocytic anaemia and neurological symptoms. Iron deficiency causes microcytic anaemia, thalassaemia trait causes microcytic anaemia with a normal or high red cell count, and lead poisoning causes microcytic anaemia with basophilic stippling.

Question 33General Pediatrics

A 7-year-old boy is brought with a 3-week history of fatigue, polyuria, and weight loss. Blood glucose is 18 mmol/L and urine ketones are positive. Which of the following is the most appropriate initial fluid management?

  1. Rapid intravenous bolus of 0.9% saline
  2. Oral rehydration solution
  3. Intravenous 5% dextrose
  4. Slow intravenous infusion of 0.9% saline Correct answer.

Explanation

In diabetic ketoacidosis, rapid fluid boluses can precipitate cerebral oedema, so fluid should be replaced slowly with isotonic saline after the initial resuscitation. Oral rehydration is inadequate in moderate to severe DKA, and dextrose-containing fluids are used later when glucose falls, not as initial therapy.

Question 34General Pediatrics

A 2-year-old child is brought with a 2-day history of fever, irritability, and vomiting. On examination, there is neck stiffness and a petechial rash. Which of the following is the most appropriate immediate action?

  1. Prescribe oral amoxicillin and review in 24 hours
  2. Administer intravenous ceftriaxone and admit Correct answer.
  3. Perform a lumbar puncture before antibiotics
  4. Obtain a CT head before any treatment

Explanation

The presentation suggests bacterial meningitis with meningococcal sepsis, requiring immediate intravenous antibiotics (e.g., ceftriaxone) without delay. Lumbar puncture should be deferred if there are signs of raised intracranial pressure or if it would delay antibiotics. Oral antibiotics and waiting for CT would be dangerous.

Question 35General Pediatrics

A 4-year-old child is brought with a 3-day history of fever, cough, and a rash that started on the face and spread to the trunk. The child has not been vaccinated. Which of the following complications is most likely to occur?

  1. Subacute sclerosing panencephalitis
  2. Encephalitis
  3. Bronchiolitis
  4. Otitis media Correct answer.

Explanation

Otitis media is a common complication of measles, occurring in up to 10% of cases. Encephalitis is rarer but more serious, and subacute sclerosing panencephalitis is a late complication occurring years after infection. Bronchiolitis is typically caused by RSV, not measles.

Question 36General Pediatrics

A 9-year-old boy is brought with a 2-week history of fatigue and dark urine. On examination, he has hypertension and periorbital oedema. Urinalysis shows red cell casts and proteinuria. Which of the following is the most likely diagnosis?

  1. Minimal change disease
  2. Hemolytic uremic syndrome
  3. Acute post-streptococcal glomerulonephritis Correct answer.
  4. IgA nephropathy

Explanation

Acute post-streptococcal glomerulonephritis typically presents 1-2 weeks after a streptococcal infection with haematuria, hypertension, and oedema. Red cell casts indicate glomerular bleeding. Minimal change disease presents with nephrotic syndrome without red cell casts. IgA nephropathy often presents with recurrent haematuria after upper respiratory infections, and HUS presents with anaemia, thrombocytopenia, and renal failure.

Question 37General Pediatrics

A 6-year-old child is brought with a 1-day history of fever, sore throat, and a sandpaper-like rash. On examination, there is a strawberry tongue and circumoral pallor. Which of the following is the most appropriate treatment?

  1. Oral amoxicillin-clavulanate
  2. Topical corticosteroids
  3. Oral penicillin V Correct answer.
  4. Antihistamines

Explanation

The presentation is consistent with scarlet fever caused by group A streptococcus. Penicillin V is the treatment of choice. Amoxicillin-clavulanate is broader than necessary, and topical corticosteroids or antihistamines do not treat the bacterial infection.

Question 38General Pediatrics

A 3-year-old child is brought with a 2-day history of fever, cough, and rapid breathing. On examination, there is subcostal recession and nasal flaring. Which of the following is the most appropriate initial management?

  1. Prescribe oral amoxicillin and discharge
  2. Perform a chest radiograph before any treatment
  3. Start nebulised salbutamol
  4. Administer oxygen and start intravenous antibiotics Correct answer.

Explanation

The child has severe pneumonia with signs of respiratory distress, requiring hospital admission, oxygen, and intravenous antibiotics. Oral antibiotics and discharge are inappropriate for severe disease. A chest radiograph should not delay treatment, and salbutamol is not indicated for pneumonia.

Question 39General Pediatrics

A 10-year-old girl is brought with a 3-month history of recurrent abdominal pain, bloating, and diarrhoea. She has been growing poorly. Serology for coeliac disease is positive. Which of the following is the most appropriate next step?

  1. Duodenal biopsy Correct answer.
  2. Repeat serology in 6 months
  3. Perform a colonoscopy
  4. Start a gluten-free diet

Explanation

In children, the diagnosis of coeliac disease is confirmed by duodenal biopsy showing villous atrophy and crypt hyperplasia while on a gluten-containing diet. Starting a gluten-free diet before confirmation can make diagnosis difficult. Repeat serology is not diagnostic, and colonoscopy evaluates the large bowel, not the small intestine.

Question 40General Pediatrics

A 2-year-old child is brought with a 1-day history of fever, irritability, and vomiting. On examination, the child is lethargic and has a bulging fontanelle. Which of the following is the most appropriate immediate investigation?

  1. Lumbar puncture
  2. CT head
  3. Blood cultures Correct answer.
  4. Urine culture

Explanation

In a child with suspected meningitis and signs of raised intracranial pressure (bulging fontanelle, lethargy), lumbar puncture should be deferred, and blood cultures should be obtained before starting antibiotics. CT head may be considered but should not delay antibiotics. Urine culture is not the priority.

Question 41Neonatology

A term newborn is noted at 6 hours of age to have a respiratory rate of 80/min, nasal flaring, and grunting. Which single finding on examination most strongly suggests that the respiratory distress is caused by a cardiac rather than a pulmonary problem?

  1. Subcostal recessions with each breath
  2. Fine inspiratory crackles at both bases
  3. A continuous machinery murmur at the left infraclavicular area Correct answer.
  4. Expiratory grunting that improves with nasal CPAP

Explanation

A continuous machinery murmur suggests a patent ductus arteriosus with left-to-right shunting, a cardiac cause of neonatal respiratory distress that can mimic respiratory disease in the first days of life. Pulmonary causes such as respiratory distress syndrome or transient tachypnoea of the newborn produce recessions, crackles, and grunting that typically improve with CPAP rather than a continuous murmur. Any newborn with distress out of proportion to the chest radiograph should be assessed for congenital heart disease.

Question 42Neonatology

A well-appearing 3-day-old exclusively breastfed newborn has a total serum bilirubin of 15 mg/dL with a direct fraction of 0.4 mg/dL. The baby is feeding well and passing stools. According to the hour-specific bilirubin nomogram, which action is most appropriate?

  1. Arrange an exchange transfusion within 6 hours
  2. Reassure the parents and continue breastfeeding with follow-up bilirubin in 24 hours Correct answer.
  3. Start intensive phototherapy immediately
  4. Repeat the bilirubin after 24 hours of formula feeding

Explanation

A total bilirubin of 15 mg/dL at 72 hours in a well, feeding baby usually falls below the phototherapy threshold on the hour-specific nomogram, so continued breastfeeding with close follow-up is appropriate. Breastfeeding should not be interrupted because intake and stool output reduce enterohepatic circulation of bilirubin. Phototherapy is reserved for values above the age- and risk-specific treatment line.

Question 43Neonatology

Which infant is at highest risk of developing necrotising enterocolitis?

  1. A preterm infant of 28 weeks' gestation fed breast milk from day 1
  2. A term infant with physiological jaundice at 48 hours
  3. A preterm infant of 27 weeks' gestation receiving formula feeds and indomethacin Correct answer.
  4. A term infant born by elective caesarean section at 39 weeks

Explanation

Prematurity is the strongest risk factor for necrotising enterocolitis, and formula feeding plus indomethacin (which reduces mesenteric perfusion) add further risk. Human milk feeding is protective, and term infants without other risk factors rarely develop the disease.

Question 44Neonatology

A newborn is delivered at term after an uncomplicated pregnancy. On examination the anterior fontanelle is small, and the mid-posterior parietal region of the skull is soft and depressed but the skin over it is intact. What is the most likely diagnosis?

  1. Caput succedaneum
  2. Cephalohaematoma
  3. Moulding of the skull with a depressed skull fracture Correct answer.
  4. Subgaleal haemorrhage

Explanation

A localised soft depression of the parietal bone with intact overlying skin represents moulding with a depressed skull fracture (ping-pong fracture), which usually requires imaging and neurosurgical review. Caput succedaneum and cephalohaematoma are fluid collections and present as swellings, not depressions.

Question 45Neonatology

A 2-day-old term infant born to a mother with group B streptococcal colonisation develops temperature instability, grunting, and apnoea. Which initial investigation and management combination is most appropriate?

  1. Chest radiograph alone, then oral amoxicillin
  2. Lumbar puncture alone, then observation without antibiotics
  3. Full blood count, blood culture, and empirical intravenous ampicillin plus gentamicin Correct answer.
  4. Repeat maternal rectovaginal swab, then await the result before treating

Explanation

Early-onset group B streptococcal sepsis in a neonate requires prompt full blood count, blood culture, and empirical intravenous ampicillin plus gentamicin while awaiting results. Delay in starting antibiotics increases mortality and morbidity, and oral therapy is inadequate for neonatal sepsis.

Question 46Neonatology

A preterm infant of 26 weeks' gestation is being ventilated. Which intervention has the strongest evidence for reducing the incidence of severe intraventricular haemorrhage?

  1. Nursing the infant flat with the head midline and avoiding sudden changes in cerebral blood flow
  2. Antenatal maternal corticosteroids given before delivery Correct answer.
  3. Early routine indomethacin for all preterm infants
  4. Aggressive volume expansion in the first hour

Explanation

Antenatal corticosteroids given to mothers before preterm delivery reduce the incidence and severity of intraventricular haemorrhage as well as respiratory distress syndrome and mortality. Careful nursing with head midline and avoidance of rapid volume or pressure changes is supportive but is not the primary intervention with the strongest evidence.

Question 47Neonatology

A 36-week infant is noted to have a sacral dimple 4 mm in diameter, 20 mm above the anal verge, with a small tuft of hair but no visible tract. What is the most appropriate next step?

  1. Arrange immediate surgical referral for closure
  2. Start prophylactic antibiotics
  3. Request ultrasound of the spine Correct answer.
  4. Reassure the parents and review at the 6-week check

Explanation

Sacral dimples more than 5 mm from the anal verge, larger than 5 mm, or associated with hair tufts, tracts, or other cutaneous markers warrant spinal imaging to exclude occult spinal dysraphism. Ultrasound is the first-line investigation in neonates before ossification limits the view. Simple dimples within 2.5 cm of the anus without other features can be observed.

Question 48Neonatology

Which finding is most characteristic of a newborn with congenital hypothyroidism detected on screening?

  1. Prolonged physiological jaundice, constipation, and a large anterior fontanelle Correct answer.
  2. Polyuria, weight loss, and dehydration
  3. Generalised oedema with a normal thyroid-stimulating hormone level
  4. Hypertonia, jitteriness, and a high-pitched cry

Explanation

Congenital hypothyroidism typically causes prolonged jaundice, constipation, hypotonia, macroglossia, and delayed closure of the fontanelles. Many affected infants appear normal at birth, which is why newborn screening is essential.

Question 49Neonatology

A newborn of a mother with poorly controlled diabetes has a blood glucose of 1.8 mmol/L at 1 hour of age. The infant is symptomatic with jitteriness. What is the most appropriate immediate management?

  1. Subcutaneous glucagon
  2. Oral glucose gel and immediate breastfeeding
  3. Intravenous 10% dextrose bolus of 2 mL/kg followed by a continuous infusion Correct answer.
  4. Observation with repeat glucose in 4 hours

Explanation

Symptomatic neonatal hypoglycaemia is treated with an intravenous 10% dextrose bolus of 2 mL/kg followed by a continuous infusion and frequent monitoring. Oral glucose gel is used for asymptomatic or mild hypoglycaemia in some protocols, but symptomatic infants require intravenous therapy.

Question 50Neonatology

A term infant born by emergency caesarean section for fetal bradycardia has an Apgar score of 3 at 1 minute. After initial steps of drying and stimulation, the infant remains apnoeic with a heart rate of 70/min. What is the correct next action?

  1. Insert a laryngeal mask airway before any ventilation attempt
  2. Start positive pressure ventilation with a self-inflating bag and mask Correct answer.
  3. Begin chest compressions at a ratio of 3:1
  4. Give intravenous adrenaline 0.1 mL/kg of 1:10,000

Explanation

In the neonatal resuscitation algorithm, apnoea with a heart rate below 100/min after initial steps requires positive pressure ventilation with a mask and bag. Chest compressions are started only if the heart rate remains below 60/min despite effective ventilation.