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Mar 05 (1): A 5 months old baby boy is brought with the h/o progressive pallor for the last

3 months.
Mother narrates that infant is not thriving well and remains irritable. Mother also feels that baby has
started becoming inattentive to sounds. He was admitted previously at 4 weeks of age with seizures
which were documented to be due to hypocalcaemia. O/E baby is pale with petechial spots over the
body. His weight is 4 kg, length 59 cm, HC 45 cm, and there is marked hepatosplenomegaly.
Investigations reveal Hb 6.5, TLC 32000, P 55%, L 35%, myelocytes 3%, metamyelocytes 4%. There are
also normoblasts 8/100 RBCs, Platelets 65000.

A) What is the most likely diagnosis? Give reasons.


B) What 3 differential diagnoses will you consider?
C) What 3 further investigations would you perform?
D) How will you treat this baby?

Mar 05 (2): A 6 years old boy is brought in a comatose condition. Parents narrates that he has had two
such episodes previously which didn’t last long. He however is described to be lethargic and unwell for
the last one year with h/o weight loss. O/E he is a thin lean boy with reduced muscle mass. He is
dehydrated with RR of 38/min, systolic BP 40. There is no visceromegaly.
His investigations reveal: serum Na 129, K 5.5, blood glucose 42 mg, TLC 9000, P 52%, chest x-ray-
decreased cardiac shadow.

A) What is the likely diagnosis?


B) What are 3 likely etiologies?
C) What would be your immediate management?
D) What is the long term management?

Mar 05 (3): A 4 weeks old baby is noted to have increasing difficulties with feeding and cyanosis which
gets worse during crying and feeding. Chest x-ray shows cardiomegaly with oligaemic lungs. ECG
reveals an extreme left axis deviation. Arterial PO2 in air 35 mmHg. Arterial PO2 in 100% oxygen 55
mmHg.

A) What is the likely diagnosis?


B) What treatment would you advise?

Mar 05 (4): A 6 weeks old infant has h/o diarrhea since 5 days of life. He passes 20-25 stools a day.
Stools are watery and explosive. There is h/o polyhydramnios. Antenatal USG examination revealed
dilated intestinal loops. His ABGs reveal pH 7.49, PO2 102, PCO2 49.

A) What is the most likely diagnosis?


B) Give 2 differential diagnoses.
C) Give 3 relevant investigations.
D) How will you manage this condition.
Mar 05 (5): A 7 years old boy with grade IV T-cell Non-Hodgkin lymphoma has been started
chemotherapy. He develops edema, nausea and vomiting 24 hours after starting chemotherapy.
Investigations: Urea 68 mg, Ca 7.6 mg, PO4 9.8 mg, uric acid 9.8 mg.

A) What has led to the deterioration of this baby?


B) How would you manage this condition?

Mar 05 (6): What advice will you give in a neonate who was detected to have unilateral
hydronephrosis on antenatal USG examination at 20 weeks of gestational age.

Mar 05 (7): A 1500 gm male preterm infant was asphyxiated at birth. He underwent successful
resuscitation and subsequently had a number of apnoeic spells on the neonatal unit. On the third day
of life the infant began to vomit and developed abdominal distension, with passage of bloody stools.

A) Give your most likely diagnosis and differential diagnoses.


B) Give 5 relevant investigations and outline your management.

Mar 05 (8): A 41 days old male baby presents with vomiting and drowsiness for the last one day. O/E,
following findings were noted: weight 3.1 kg, length 50 cm, OFC 40 cm, pulse 92/min, RR 21, temp 98.6
F, GCS 6/15, fontanel full, pupils constricted, eyes sunken and skin turgor lost.

A) List 3 differential diagnoses with one line of reasoning with each.


B) List 4 investigations you will arrange for this child.
C) Mention 3 steps of initial management.

Mar 05 (9): A 3 year old boy has undergone surgery for inguinal hernia under general anesthesia. You
have been called to assess the child post operatively where he has been running high fever. Clinical
examination reveals a lethargic child with respiratory distress. Chest is clear on auscultation while the
temp is 105 F. There is rigidity of limbs. Investigations show blood pH 7.2, PCO 2 50, PO2 70, HCO3 11,
serum CK 20,000 u/l.

A) What is the diagnosis?


B) Give your differential diagnoses.
C) What complications can occur?
D) How will you prevent this condition in other sibling?
Mar 05 (10): An 8 years old boy presented with a 3 day h/o headache and a brief episode of left sided
facial twitching which occurred within 24 hours of the onset of symptoms. He was seen by his GP who
started anticonvulsant therapy with phenytoin. The next day he had two further episodes of facial
twitching and was noted to have weakness on the left side of his face, drooling saliva, unable to
swallow, and to have slurred to speech. He was sent to hospital where on admission he had an episode
of left sided facial twitching and of his left arm lasting 5 minutes. Temp 38 C, drowsy but responding to
simple commands and not disoriented. Mild neck stiffness was present but no photophobia. Left sided
lower motor neuron type VII nerve palsy, depressed gag reflex, drooling saliva, slurred nasal speech,
left arm power reduced. Tendon jerks symmetrically reduced and plantars down going. No clinical
evidence of raised ICP, both fundi normal. CVS, respiratory system, abdomen and ENT examination,
otherwise unremarkable. Past medical history unremarkable, immunization full. Investigations: CBC
normal, urea and electrolytes, Ca, Mg, Glucose and Ammonia normal.
CSF: WBC 66, monocytes, protein0.29 g/l, glucose 72 mg, blood glucose 95. CSF, blood, urine culture
are negative.

A) Name 3 possible diagnoses.


B) What is the most likely?
C) What other investigations are necessary?
D) What would be your management?
July 05 (1): A 7 year old girl presented with generalized tonic clonic seizures. She was stated to be
previously well with out any significant complaint. O/E she had stable vital signs. Her growth
parameters were on the 10th percentile for age. There were few patches of alopecia over the scalp and
her nails were thick and deformed. Investigations revealed: Hb 11.8 g, creatinine 0.9 mg, Na 136, K 4.9,
Ca 6.8 mg, PO4 6.2 mg.

A) What is the most likely diagnosis?


B) What further investigations are required to reach the diagnosis?
C) Discuss management.

July 05 (2): A two months old male baby born to a primigravida, after an uneventful pregnancy and
delivery, is brought to you with FTT and recurrent episodes of vomiting. He weighs 2.9 kg where as the
birth weight was 3.0 kg. He has been exclusively breast fed with no feeding problems. There is no h/o
diarrhea or cough. O/E, the baby is emaciated with signs of dehydration. His RR is 52/min with clinically
clear chest and no visceromegaly. Other examination is unremarkable.
Investigations were: Na 130, K 3.1, HCO3 15, Cl 106.

A) What is the most likely diagnosis?


B) What further investigations are required?
C) Discuss management.

July 05 (3): A 5 year old girl is admitted for evaluation of chronic diarrhea. She has been having
treatment from GP with no significant relief. She was hospitalized at 18 months of age for acute
bacterial meningitis. She has two younger male siblings. O/E she is found to be a thin girl with a weight
of 14 kg and height of 99 cm. she has sparse hair with scars of old healed lesion on one side of face.
Anterior and posterior cervical lymph nodes are palpable with discharging right ear.
Investigations Hb 9 g, TLC 11400, N 80%, L 15%.

A) What are 3 differential diagnoses in order of priority?


B) How will you evaluate and manage this girl?

July 05 (4): A baby is born to a mother who was diagnosed to have SLE and had been on treatment
during pregnancy.

A) What are the 4 possible problems which you would anticipate in the newborn?
B) What could be the possible effects on the fetus because of maternal drug intake during pregnancy?
C) Mother is very keen to breast feed. What advise would you like to give her?
July 05 (5): A full term infant was born after uncomplicated pregnancy by uneventful vaginal delivery.
Physical examination of the infant showed short arms with normal hands and ptechiae all over the
body. Rest of the examination was normal.
Lab investigations showed Hb 15.5 g, TLC 12500, platelet count 5000.

A) Give 3 differential diagnoses.


B) What further investigations would you carry out?
C) What management steps would you undertake and give prognosis?

July 05 (6): A 3 hours old full term neonate is admitted in the neonatal unit with h/o delayed cry at
birth , followed by progressive cyanosis and associated respiratory distress. O/E, he is inactive and
listless having marked cyanosis all over the body, tachypnea, tachycardia and chest in drawing.
Abdomen is soft with no visceromegaly.
Investigations revealed: Hb 19 g, echocardiography shows no structural heart defect but shunting of
blood from right to left at foramen ovale.

A) Give 3 most likely diagnoses.


B) What further investigations will be required?
C) Describe the management.

July 05 (7): A 12 month old boy was brought for recurrent convulsions for the last 4 days. There was no
h/o head injury, fever and rash. He was born at home by normal vaginal delivery. He was breast fed
only for one month after which he was he was fed on artificial feeding. The water used for preparation
of feed was stored in a painted container. Motor mile stones were normal. O/E, his weight was 8 kg,
length 73 cm, OFC 46 cm, pallor ++, temp 99 F. Vital signs were stable. He was drowsy with boggy
anterior fontanel. His CSF examination was normal. Blood picture revealed Hb 5 g, MCV 55 fl.
Peripheral smear shows microcytic hypochromic anemia.

A) What is the most likely diagnosis and justify?


B) How would you confirm your diagnosis?

July 05 (8): An 8 months old child is seen because of vomiting for 24 hours. The child passed one soft
stool at the onset and has had no bowel movements since. The infant has had recurrent episodes of
agitation since the onset of vomiting. O/E child is listless and apathetic with soft and non tender
abdomen. A mass is palpable in right upper quadrant. Rectal examination is unremarkable. He has
severe dehydration.

A) What tests should be performed promptly?


B) What would be the management of this patient?
C) What is the most likely diagnosis?
July 05 (9): You are asked to see a 3 years old boy with speech delay. O/E he is a withdrawn child,
playing alone, who got agitated whenever his attention was sought, other wise he is a well oriented
boy with normal motor functions and hearing.

A) What 3 other features would you look for?


B) How would you manage him?
C) What is the prognosis?

July 05 (10): A 5 years old girl is brought to hospital with two days h/o hematuria. She had been well
previously except that she developed few pustules 3 weeks back which healed after local application of
antiseptic lotion. There is no h/o sore throat, medications, oliguria or dysuria. Her mother developed
high grade fever one week back, which was diagnosed as malaria. O/E the child was conscious, alert,
active and afebrile, rest of the systemic examination was normal. Urine report showed numerous RBCs
and proteinuria.

A) What is the most likely diagnosis?


B) What further investigations you would like to perform to arrive at the diagnosis?
C) What is the management of this condition?
Nov 05 (1): A 2 year old presents with four days of rectal bleeding. The mother noticed reddish colored
stools 2 days prior to arrival and has since changed several diapers with just blood. The child is afebrile,
alert and playful and is eating well without any vomiting. He is slight tachycardic with normal
abdominal examination.

A) What is the most likely diagnosis?


B) How would you investigate this child?
C) What treatment would you advise?
D) What are the complications of this condition?

Nov 05 (2): A 9 months old girl presented with three days h/o increasing breathlessness. O/E, she
looked pale with RR of 55/min with marked intercostals recession. Her pulse is 155/min with normal
heart sounds and 3/6 pansystolic murmur at lower left sternal border. There was no hepatomegaly.
Investigations: Hb 7.5 g, TLC 8000. Chest X-ray: cardiomegaly with plethoric lung fields.
Echocardiogram: perimembranous VSD. Pulmonary: systemic blood flow 1.4:1.

A) What is the cause of this child’s symptoms?


B) How would you manage the case?

Nov 05 (3): A10 year old boy has been having recurrent abdominal pain mostly confined to the left
flank for the past 2 years. Investigations show: urine RBCs 50/hpf, WBC 10-12/hpf, hexagonal crystals
present, albumin+, glucose-ve, urine metabolic screen reveals a positive cyanide nitroprusside test.

A) What is the diagnosis?


B) What further investigations are needed?
C) What treatment would you advise?

Nov 05 (4): A 12 year old boy has been admitted with coma in the ED. O/E, he has tachypnea with GCS
of 6/15. ABGs reveal the following results: pH 7.25, PCO2 25 mmHg, base excess -14, PO2 70 mmHg.
Urine examination shows: glucose is negative on glucostix. The lab result shows a positive Benedict’s
test.

A) What is the diagnosis?


B) How will you confirm the diagnosis?
C) What is the management?
Nov 05 (5): A 2 year old boy has been having recurrent respiratory infections for the past one year and
is failing to thrive. Clinical examination reveals eczematous lesions over limbs and face and few
scattered rhonchi in the chest. Investigations reveal Hb 12 g, TLC 4700, N 88%, L 10%, and M 2%.
Serum IgE levels 600 iu/l (normal upto 220).

A) What is the diagnosis?


B) What further investigations would you advise?
C) What is the management?

Nov 05 (6): A 4 year old girl has been brought with vaginal bleeding and bilateral breast enlargement.
Clinical examination reveals her height > 97th centile. Rectal examination reveals a palpable mass to the
left of the uterus. Investigations reveal bone age 7 years, normal skull x-ray and serum oestradiol 160
p.mol/l (normal < 50).

A) What is the likely diagnosis?


B) What further investigations are needed?
C) What is the treatment?

Nov 05 (7): A 2 day old term female infant presents with fever, tachypnea, apnea, drowsiness and a
generalized seizure. She has been born by SVD with no h/o birth asphyxia or prolonged rupture of
membranes. Examination revealed a hypotonic obtunded infant weighing 3.6 kg with profuse serous
lacrimation. Investigations showed: Hb 15.1g, WBC 14500, platelets 360,000, glucose 90 mg, Ca 2.1
mmol, Mg 1.5 mg, Na 138, K 4.0, urea 16 mg, creatinine 0.9 mg. ABGs: pH 7.3, PCO2 45, PO2 60,
bicarbonate 20, base deficit 6.0, arterial lactate 5.3 mmol (normal), serum ammonia 20 mcg/dl (raised),
head CT diffuse cerebral edema.

A) What is the most likely diagnosis?


B) Give two differential diagnoses.
C) What treatment would you institute?
D) How would you further investigate this neonate?

Nov 05 (8): A baby girl was brought from home by her parents for passing black colored stools on 3 rd
day of life. She was born to primigravida mother at home uneventfully and started on mother’s milk
after 24 hours of plain water and ghutti. She was active, pink, jaundiced mildly and had no other
bleeding site.

A) Name 5 relevant investigations and justify each according to cause.


B) What is the most likely cause of bleeding?
C) What is the appropriate treatment?
Nov 05 (9): A 10 year old boy was admitted with h/o high grade fever for 2 months. He received many
courses of anti malarial and antibiotics without any improvement. O/E he was febrile (temp 41 C), pale
with hepatosplenomegaly but no jaundice, skin rash or lymphadenopathy. His Hb was 5.2 g, TLC 2250
with lymphocytes 750 and platelets 55,000. Peripheral blood smear normocytic normochromic anemia,
slide for MP negative, blood and urine cultures negative, widal and brucella negative, LFTs and urea
electrolytes normal.

A) What is your diagnosis?


B) Give 4 differential diagnoses.
C) What further investigations would you like to do?
D) How will you manage this case?

Nov 05 (10): Two brothers 3 years and 5 years old presented to ED with h/o high grade fever and
persistent vomiting for 5 days, h/o epistaxis and hematemesis for one hour. O/E children were drowsy
with mild jaundice and hepatomegaly of 5 cm below costal margin and clinical ascites. There is h/o
contact with cattle and goats 14 days ago at Eid-ul-azha.

A) What differential diagnoses would you consider?


B) Give 5 relevant investigations with justification in reaching at diagnosis.
C) Give management plan.

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