LE 6 (Mas OLDER) Feeds

Question 1

24. A 2-day-old newborn presents with hypocalcemic seizures, cyanosis at birth, a cardiac murmur, and mild respiratory distress. A cleft palate is also noted. What is the most likely diagnosis?

A. Wiskott-Aldrich syndrome
B. Shwachman-Diamond syndrome
C. Chronic granulomatous disease
D. DiGeorge syndrome

Answer 1

D. DiGeorge syndrome
Rationale: DiGeorge syndrome presents with hypocalcemia (due to parathyroid hypoplasia), congenital heart defects, immune deficiency (due to thymic hypoplasia), and facial abnormalities.

Question 2

31. In which stage of acute nephritic syndrome does hypertensive encephalopathy usually occur?

A. Early convalescent
B. Diuretic
C. Oliguric
D. Latent

Answer 2

C. Oliguric
Rationale: Hypertensive encephalopathy is most likely to occur during the oliguric phase of acute nephritic syndrome due to fluid overload and severe hypertension.

Question 3

32. Complement C3 is a ß protein demonstrated by its deposition within or near the glomerular basement membrane. It is decreased in which of the following conditions?

A. APSGN
B. IgA nephropathy
C. Nephrotic syndrome
D. Rapidly progressive glomerulonephritis

Answer 3

A. APSGN
Rationale: Acute post-streptococcal glomerulonephritis (APSGN) is associated with decreased serum C3 due to complement activation via the alternative pathway.

Question 4

33. The common manifestations of UTI in older children are:

A. Fever, vomiting, diarrhea
B. Abdominal/flank pain, dysuria, malodorous urine
C. Asymptomatic
D. Oliguria, hypertension, edema

Answer 4

B. Abdominal/flank pain, dysuria, malodorous urine
Rationale: UTI symptoms in older children typically include dysuria, abdominal or flank pain, and foul-smelling urine. Younger children may present with fever, vomiting, and diarrhea.

Question 5

34. What is the definitive diagnostic test for acute pyelonephritis in children?

A. Intravenous pyelogram
B. Ultrasound
C. Vesicourethral cystogram
D. Renal scan

Answer 5

B. Ultrasound

Question 6

35. To diagnose UTI in children, urine culture should at least show how many colony-forming units (CFU)?

A. 1,000,000
B. 100,000
C. 10,000
D. None of these

Answer 6

B. 100,000
Rationale: A bacterial count of ≥100,000 CFU/mL in a clean-catch specimen is diagnostic of UTI. In symptomatic patients, ≥1,000 CFU/mL may also be considered significant.

Question 7

36. A 16-year-old boy notices a painless mass on the left side of his scrotum. What is the most likely diagnosis?

A. Torsion of the testes
B. Epididymitis
C. Varicocele
D. Hydrocele

Answer 7

C. Varicocele
Rationale: A varicocele is a collection of dilated veins in the spermatic cord, most commonly occurring on the left side due to venous drainage anatomy.

Question 8

37. A newborn delivered to a G1P1 mother with oligohydramnios has an abdominal finding of a single umbilical artery. This is associated with:

A. Polycystic kidney
B. Hydronephrosis
C. Renal agenesis
D. Renal hypoplasia

Answer 8

C. Renal agenesis
Rationale: A single umbilical artery is associated with congenital renal abnormalities, particularly renal agenesis, which may lead to oligohydramnios.

Question 9

38. At what age is corrective surgery recommended for a child with unilateral undescended testes?

A. Between 12 – 18 months
B. After puberty
C. Newborn period
D. Before puberty

Answer 9

A. Between 12 – 18 months
Rationale: Orchidopexy is ideally performed between 6 to 18 months to reduce the risk of infertility and malignancy.

Question 10

39. A child with APSGN has persistent low C3, RBC casts, BUN > 40 mg/dL, and creatinine > 2 mg/dL on follow-up at 4 months. What is the most appropriate next step?

A. VCUG
B. Renal biopsy
C. Renal scanning
D. Plain KUB

Answer 10

B. Renal biopsy
Rationale: Persistent low C3 and worsening renal function beyond 2 months suggest an alternative diagnosis like membranoproliferative glomerulonephritis or lupus nephritis, warranting a biopsy.

Question 11

40. A 2-year-old male develops a URI followed by generalized edema. BP is normal. UA shows 2-5 RBCs, 4+ proteinuria, BUN > 19 mg/dL, creatinine 6 mg/dL, cholesterol 402 mg/dL, ASO titer 1:160, and C3 892 mg/dL. What is the most likely diagnosis?

A. PSGN
B. IgA nephropathy
C. Henoch-Schönlein purpura nephritis
D. Minimal change disease

Answer 11

D. Minimal change disease
Rationale: Minimal change disease (MCD) is the most common cause of nephrotic syndrome in young children, characterized by massive proteinuria, hypoalbuminemia, hyperlipidemia, and normal complement levels.

Question 12

41. Which of the following statements about acute post-streptococcal glomerulonephritis (APSGN) in children is correct?

A. It is most common in children 15 years and above
B. It usually presents as acute renal failure
C. It follows the onset of streptococcal infection by 3-4 days
D. It can result from either streptococcal pharyngitis or streptococcal impetigo

Answer 12

D. It can result from either streptococcal pharyngitis or streptococcal impetigo
Rationale: APSGN occurs after Streptococcus pyogenes infections, including both pharyngitis and impetigo. The latency period is typically 1-2 weeks for pharyngitis and 3-6 weeks for impetigo.

Question 13

42. In the treatment of urinary tract infections (UTIs), the main goal is:

A. Prevent emergence of resistant strains
B. Prevent gram-negative sepsis
C. Prevent renal scarring
D. Preserve bladder function

Answer 13

C. Prevent renal scarring
Rationale: Renal scarring can lead to long-term complications such as hypertension and chronic kidney disease, making its prevention the primary goal in pediatric UTI management.

Question 14

43. Wilm’s tumor is the most frequent malignant tumor of the genitourinary tract. What is the most common presenting sign?

A. Hematuria
B. Abdominal pain
C. Loss of weight
D. Abdominal mass

Answer 14

D. Abdominal mass
Rationale: Wilm’s tumor often presents as a painless abdominal mass detected incidentally by caregivers, with hematuria and hypertension occurring in some cases.

Question 15

44. The most common form of primary idiopathic nephrotic syndrome is:

A. Focal segmental glomerulosclerosis
B. Membranoproliferative glomerulonephritis
C. Membranous glomerulopathy
D. Minimal change disease

Answer 15

D. Minimal change disease
Rationale: Minimal change disease is the leading cause of nephrotic syndrome in children, characterized by podocyte effacement on electron microscopy and steroid responsiveness.

Question 16

45. The initial signs one might expect in a 5-year-old boy presenting with dark brown urine and healing impetigo are:

A. Headache
B. Oliguria
C. Periorbital edema
D. Dyspnea

Answer 16

C. Periorbital edema
Rationale: APSGN commonly presents with periorbital edema, hematuria (cola-colored urine), hypertension, and oliguria due to immune complex deposition in the glomeruli.

Question 17

46. The most common cause of gross hematuria in the general pediatric setting is:

A. Acute pyelonephritis
B. Acute post-streptococcal glomerulonephritis
C. Benign familial hematuria
D. IgA nephropathy

Answer 17

D. IgA nephropathy

Question 18

47. Which of the following conditions is least commonly observed in APSGN?

A. Hematuria
B. Edema
C. Hypertension
D. Renal failure

Answer 18

D. Renal failure
Rationale: While APSGN can cause acute kidney injury, complete renal failure is uncommon. Most cases resolve spontaneously with supportive care.

Question 19

48. A 1-year-old child presents with recurrent UTIs and enlarged kidneys on ultrasound. What is the best next step for evaluation?

A. Renal tomography
B. Voiding cystourethrogram (VCUG)
C. Plain film KUB
D. MRI

Answer 19

B. Voiding cystourethrogram (VCUG)
Rationale: Recurrent UTIs with kidney enlargement raise suspicion for vesicoureteral reflux (VUR), best diagnosed with VCUG to assess for reflux of urine into the ureters and kidneys.

Question 20

49. A 3-year-old boy presents with an abdominal mass, hydronephrosis, and recurrent E. coli UTIs. What is the most likely cause?

A. Adrenal hemorrhage
B. Wilm’s tumor
C. Obstruction of the ureteropelvic junction
D. Obstruction of the vesicoureteral junction

Answer 20

C. Obstruction of the ureteropelvic junction
Rationale: UPJ obstruction is a common congenital cause of hydronephrosis, leading to recurrent UTIs and possible abdominal mass due to fluid accumulation.

Question 21

50. A 3-year-old boy had diarrhea a week ago and now presents with oliguria, edema, and petechial rash. Lab results: Hgb 5-9 g/dL, platelet count 50,000/mm³, protein +2, RBC 8-10/hpf. What is the most likely diagnosis?

A. Hemolytic uremic syndrome (HUS)
B. Post-streptococcal glomerulonephritis
C. Nephrotic syndrome
D. Systemic lupus erythematosus

Answer 21

A. Hemolytic uremic syndrome (HUS)
Rationale: HUS follows diarrheal illness (often E. coli O157:H7) and is characterized by microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury.

Question 22

51. Children with chronic renal failure may present with:

A. Mental retardation
B. Growth retardation
C. Hypotension
D. Hypokalemia

Answer 22

B. Growth retardation
Rationale: Chronic renal failure leads to growth retardation due to metabolic acidosis, poor nutrition, and disturbances in calcium-phosphate metabolism affecting bone growth.

Question 23

52. Which of the following statements about the management of nephrotic syndrome is correct?

A. Renal biopsy prior to giving immunosuppressive drugs
B. Steroid-responsive in minimal change lesions
C. Steroid-resistant if failure to respond despite 1 week of prednisone
D. Complete remission is possible if urinary protein is > 40 mg/m²/hr

Answer 23

B. Steroid-responsive in minimal change lesions

Rationale: Minimal change disease (MCD) is the most common cause of nephrotic syndrome in children and is highly responsive to corticosteroid therapy (prednisone). Over 90% of cases achieve remission with steroids.

Question 24

53. Hypocomplementemia and hematuria are seen in:

A. APSGN
B. Acute pyelonephritis
C. Nephrotic syndrome
D. Renal tuberculosis

Answer 24

A. APSGN
Rationale: APSGN is characterized by low serum complement (C3) levels due to immune complex deposition and hematuria due to glomerular inflammation.

Question 25

54. The most frequent cause of graft loss in pediatric renal transplant patients is: A. Trauma to the graft B. Technical difficulties C. Rejection reactions D. Infection

Answer 25

C. Rejection reactions Rationale: Acute and chronic rejection remain the most common causes of graft failure, necessitating lifelong immunosuppressive therapy.

Question 26

55. A 4-year-old boy had an URTI 2 weeks earlier and now presents with generalized edema. BP: 90/50 mmHg, Urinalysis: RBC 2-5/hpf, Protein +4, BUN 19 mg/dL, Cr 1.0 mg/dL, Cholesterol 402 mg/dL, ASO titer 150, C3 900 g/dL. What is the most likely diagnosis? A. Focal segmental glomerulosclerosis B. Minimal change nephrotic syndrome C. Post-streptococcal glomerulonephritis D. Membranous glomerulonephritis

Answer 26

B. Minimal change nephrotic syndrome Rationale: Minimal change disease is the most common nephrotic syndrome in children, presenting with edema, heavy proteinuria, normal C3 levels, and hypoalbuminemia.

Question 27

56. True statement about vesicoureteral reflux (VUR): A. It is non-hereditary B. It predisposes to episodes of pyelonephritis C. It always needs surgical correction D. Only boys are affected

Answer 27

B. It predisposes to episodes of pyelonephritis Rationale: VUR allows urine to reflux into the ureters, increasing the risk of recurrent UTIs and pyelonephritis, which may lead to renal scarring.

Question 28

57. Among the following, the last finding to resolve in a child with APSGN is usually: A. Elevated BUN B. Hypertension C. Edema D. Microscopic hematuria

Answer 28

D. Microscopic hematuria Rationale: While edema and hypertension resolve within weeks, microscopic hematuria can persist for several months to a year.

Question 29

58. Which of the following statements about undescended testes is true? A. It is histologically normal at birth B. It is usually located in the inguinal canal C. Testicular descent occurs early in gestation D. It descends spontaneously 6 months after birth

Answer 29

A. It is histologically normal at birth Rationale: An undescended testis (cryptorchidism) is histologically normal at birth, but over time, it may undergo degenerative changes, leading to impaired spermatogenesis and an increased risk of infertility and malignancy.

Question 30

59. A hydrocele that completely reduces when compressed is most likely due to: A. Epididymitis B. Spermatocele C. Testicular tumor D. Inguinal hernia

Answer 30

D. Inguinal hernia Rationale: A communicating hydrocele, associated with an inguinal hernia, reduces completely when compressed due to an open processus vaginalis.

Question 31

60. Hyperlipidemia in nephrotic syndrome is possibly secondary to: A. Overproduction of lipoproteins B. Lower levels of lipoprotein lipase C. Both A and B are correct D. Neither A nor B are correct

Answer 31

C. Both A and B are correct Rationale: Hyperlipidemia in nephrotic syndrome results from increased hepatic lipoprotein production (due to low oncotic pressure) and decreased lipoprotein clearance.

Question 32

61. Clinically apparent edema usually is not seen until serum albumin levels drop below: A. 5.0 gm/dL B. 4.0 gm/dL C. 3.0 gm/dL D. 2.0 gm/dL

Answer 32

D. 2.0 gm/dL Rationale: Generalized edema in nephrotic syndrome typically develops once serum albumin falls below 2.0 g/dL due to reduced oncotic pressure leading to fluid leakage into the interstitial space.

Question 33

62. Indications for renal biopsy in a patient with nephrotic syndrome include: A. Continued proteinuria after a week of prednisone treatment B. A patient with a history of systemic lupus erythematosus C. Cholesterol level greater than 400 gm/dL D. Relapse 1 year after initial therapy

Answer 33

B. A patient who has a history of systemic lupus erythematosus Rationale: Renal biopsy is indicated in nephrotic syndrome when secondary causes, such as lupus nephritis, are suspected. Patients with systemic lupus erythematosus (SLE) are at risk for lupus nephritis, which requires biopsy to determine the type and severity of kidney involvement.

Question 34

63. The most common cause of mortality in primary idiopathic nephrotic syndrome is: A. Bacterial infection B. Congestive heart failure C. Seizures D. Acute renal failure

Answer 34

A. Bacterial infection Rationale: Nephrotic syndrome is associated with increased susceptibility to infections, particularly bacterial sepsis, peritonitis, pneumonia, and cellulitis due to loss of immunoglobulins in the urine.

Question 35

64. In 25% of children under 10 years old, recurrent UTIs are usually associated with: A. Renal stones B. Chronic glomerulonephritis C. Vesicoureteral reflux (VUR) D. Renal tumors

Answer 35

C. Vesicoureteral reflux (VUR) Rationale: VUR is found in 25-30% of children with recurrent UTIs. Primary VUR can resolve spontaneously, while secondary VUR requires intervention.

Question 36

65. The best treatment for generalized edema in nephrotic syndrome is: A. Antibiotics B. Diuretics C. 5% albumin D. Prednisone

Answer 36

D. Prednisone Rationale: Corticosteroids (e.g., prednisone) are the first-line treatment for nephrotic syndrome, addressing the underlying glomerular pathology and reducing proteinuria, which in turn resolves edema.

Question 37

66. A 12-year-old presents with severe arthritis of the hips and sacroiliac joints. Labs reveal HLA-B27 positivity. What is the most likely diagnosis? A. Juvenile idiopathic arthritis B. Systemic lupus erythematosus C. Henoch-Schönlein purpura D. Reactive arthritis

Answer 37

A. Juvenile idiopathic arthritis Rationale: Juvenile idiopathic arthritis (JIA), specifically the enthesitis-related subtype, is strongly associated with HLA-B27 and commonly affects the axial skeleton and sacroiliac joints.

Question 38

88. A child presents with ear discharge for almost 3 weeks but has no pain or fever. What is the appropriate management? A. Refer immediately to a hospital B. Start oral antibiotics for 5 days C. Dry by ear wicking D. Give paracetamol oral

Answer 38

C. Dry by ear wicking ✅ Correct Rationale: Chronic ear infection (≥14 days of discharge) is managed with ear wicking and topical quinolone eardrops for 14 days, with a follow-up in 5 days​ .

Question 39

89. A child with stridor during sleep was brought to you. The child has been coughing for 2 weeks and had fever for a week. Which of the following is NOT suitable management based on IMCI before referral? A. Give Vitamin A B. Prevent low blood sugar C. Give the first dose of antibiotics D. Request a chest X-ray

Answer 39

D. Request a chest X-ray ✅ Correct Rationale: IMCI guidelines prioritize giving the first dose of antibiotics, preventing hypoglycemia, and providing Vitamin A before urgent referral. Ordering a chest X-ray is not an immediate step in the emergency management of stridor​

Question 40

90. A child with fever was brought to the health center. Which of the following danger signs would indicate an immediate referral to a hospital? A. The child is irritably crying B. The child does not like to drink C. The child just had convulsions D. The child is very sleepy but easily aroused

Answer 40

C. The child just had convulsions ✅ Correct Rationale: Any history of convulsions in a febrile child is a danger sign that requires urgent hospital referral, as it may indicate severe febrile disease such as meningitis or sepsis​ .

Question 41

91. A 3-year-old girl comes in for consultation due to cough. How will you assess and classify the cough? A. Look for signs of chest deformity B. Note for stridor when the child is not crying C. Ask what time of the day the child coughs D. Count the breaths; 30 breaths/min means fast breathing

Answer 41

B. Note for stridor when the child is not crying **Rationale:** - The IMCI chart states that when assessing a child with **cough or difficult breathing**, you should: - **Count the breaths in one minute** - **Look for chest indrawing** - **Look and listen for stridor** - **Look and listen for wheezing** - **Stridor in a calm child** (i.e., not crying) is a sign of **severe pneumonia or very severe disease** and requires **urgent referral**. **Why the other options are incorrect?** - **A. Look for signs of chest deformity** ❌ → **Not an immediate classification criterion** for pneumonia under IMCI. - **C. Ask what time of the day the child coughs** ❌ → **Not part of IMCI assessment** for classifying pneumonia. - **D. Count the breaths; 30 breaths/min means fast breathing** ❌ → **Incorrect threshold**. The correct IMCI fast breathing criteria are: - **≥50 breaths/min for 2 months up to 12 months** - **≥40 breaths/min for 12 months up to 5 years**

Question 42

92. You diagnose a child with pneumonia. What is the appropriate action? A. Relieve the cough with a cough suppressant B. Give appropriate antibiotics for 5 days C. Ask the mother to follow up after 7 days D. Refer to a hospital

Answer 42

B. Give appropriate antibiotics for 5 days Rationale: Pneumonia in children is treated with empiric antibiotics, typically amoxicillin or cotrimoxazole, for at least 5 days.

Question 43

93. In assessing and classifying a child with diarrhea, which of the following is NOT included? A. Are there signs of dehydration? B. Ask if there is blood in the stools C. Ask for the duration of diarrhea D. Ask for the presence of vomiting

Answer 43

D. Ask for the presence of vomiting ❌ Incorrect Correct Answer: Vomiting is considered in dehydration assessment. However, it is not the main criterion for classifying diarrhea itself. The correct answer should be none of the above, as all listed factors are part of the diarrhea assessment​

Question 44

94. A 5-year-old boy was brought in due to a 3-day history of fever, cough, and colds. How should you assess the patient? A. Look for rashes and conjunctivitis B. Treat the child with oral antimalarial C. Do a thick and thin smear D. Do a CBC

Answer 44

A. Look for rashes and conjunctivitis Rationale: Fever with cough and coryza suggests viral illnesses like measles, which presents with rash and conjunctivitis.

Question 45

95. Regarding severe malnutrition, which of the following statements is NOT correct? A. Give iron supplementation as initial management B. Give Vitamin A as initial management C. Presence of edema in both feet D. Presence of severe wasting

Answer 45

A. Give iron supplementation as initial management Rationale: Iron should be given after acute complications resolve, as it may worsen infections in malnourished children.

Question 46

96. Which of the following is NOT a clinical sign of a possible bacterial infection? A. Fever B. Lethargy C. Red umbilicus D. Fast breathing

Answer 46

D. Fast breathing Rationale: While fast breathing suggests pneumonia, it is not a direct sign of bacterial sepsis. Fever, lethargy, and red umbilicus are more specific.

Question 47

97. Which of the following is a sign of a local bacterial infection? A. Less than normal movement B. Nasal flaring C. Bulging fontanelle D. Umbilicus draining pus

Answer 47

D. Umbilicus draining pus Rationale: Local bacterial infections include omphalitis (umbilical infection), while bulging fontanelle suggests meningitis.

Question 48

98. You are teaching mothers about Vitamin A supplementation. Which of the following is NOT true? A. The first dose is at 6 months or above B. Infants 6 months old should receive 100,000 IU Vitamin A C. Subsequent doses are given every 6 months until 59 weeks of age D. 200,000 IU Vitamin A is given to children 12 months to 59 months every 6 months

Answer 48

C. Subsequent doses are given every 6 months until 59 weeks of age Rationale: Vitamin A supplementation continues until 59 months (5 years old), not 59 weeks.

Question 49

99. A 5-month-old boy presents with febrile convulsions, maculopapular rash, cough, conjunctivitis, and corneal clouding. What is the appropriate action in the health center? A. Give 200,000 IU of Vitamin A B. Ask to follow up in 2 days C. Apply gentian violet to the eyes D. Refer urgently to the hospital

Answer 49

D. Refer urgently to the hospital Rationale: Corneal clouding suggests severe Vitamin A deficiency, requiring urgent hospitalization to prevent blindness.

Question 50

100. An infant has a feeding problem if he is: A. Well attached to the breast when feeding B. Suckling effectively C. Does not receive any other foods or drinks D. Low weight for age

Answer 50

D. Low weight for age Rationale: Low weight for age indicates poor nutrition, often due to ineffective feeding, malabsorption, or underlying illness.

Question 51

1. A previously healthy 5-year-old child has a 5-minute generalized tonic-clonic seizure associated with fever (39°C). Past history reveals a febrile seizure at 8 months old. PE shows ear discharge with a perforated tympanic membrane but no nuchal rigidity or altered mental status. Family history is positive for maternal febrile seizures. Which statement is TRUE about the patient’s condition? A. The initial drug of choice is a benzodiazepine. B. An EEG must be done prior to discharge. C. The risk of recurrence increases to 20%. D. CSF analysis should be done.

Answer 51

C. The risk of recurrence increases to 20%. Rationale: Febrile seizures are common in young children, and a history of a previous febrile seizure increases the recurrence risk to about 30-50%, not just 20%. However, this is the best choice as it acknowledges an increased recurrence risk. EEG is not necessary for simple febrile seizures, CSF analysis is only needed if signs of meningitis are present, and benzodiazepines are used only if seizures persist beyond 5 minutes.

Question 52

2. A 3-month-old female presents with a generalized seizure lasting 25 minutes, refractory to rectal diazepam and IV lorazepam. Temperature is 37.5°C, with no trauma. What is the best next intervention? A. Get glucose level and correct hypoglycemia. B. Support the airway. C. Start IV phenobarbital. D. Start hypertonic saline for suspected hyponatremia.

Answer 52

B. Support the airway. Rationale: The immediate priority in a status epilepticus case refractory to first-line benzodiazepines is airway support and preventing hypoxia, which is the primary cause of mortality. Glucose should be checked but is not the next immediate step. Phenobarbital can be considered after airway management if seizures persist.

Question 53

3. A 12-month-old child with epileptic spasms upon arousal is admitted. History reveals only limited motor milestones (can turn from supine to prone). EEG shows a high-voltage, slow, and chaotic background with multifocal spikes. What is the diagnosis? A. West syndrome B. Dravet syndrome C. Ohtahara syndrome D. Doose syndrome

Answer 53

A. West syndrome Rationale: West syndrome presents with epileptic spasms, developmental delay, and a characteristic EEG pattern known as hypsarrhythmia (high-voltage, chaotic background with multifocal spikes). Dravet syndrome typically presents with febrile seizures early in infancy, Ohtahara syndrome manifests in neonates with burst-suppression EEG, and Doose syndrome is characterized by myoclonic-astatic seizures.

Question 54

4. A child with Lennox-Gastaut syndrome presents to the ER due to drop attacks. After stabilization, you plan to start an anticonvulsant. Which drug should be your least priority due to potential toxicity? A. Topiramate B. Felbamate C. Lamotrigine D. Rufinamide

Answer 54

B. Felbamate Rationale: Felbamate is associated with severe adverse effects, including aplastic anemia and hepatotoxicity, making it a last-resort option for Lennox-Gastaut syndrome. Topiramate, Lamotrigine, and Rufinamide are safer and commonly used for seizure control in this syndrome.

Question 55

5. A 10-year-old with controlled seizures presents with gingival hyperplasia. Which anticonvulsant is most likely responsible? A. Valproic acid B. Carbamazepine C. Levetiracetam D. Phenytoin

Answer 55

D. Phenytoin Rationale: Phenytoin is well known for causing gingival hyperplasia as a side effect. Valproic acid is associated with weight gain and hepatotoxicity, carbamazepine with agranulocytosis, and levetiracetam with mood changes.

Question 56

6. A 6-year-old with tetralogy of Fallot (TOF) has a first episode of febrile seizures. Postictally, there is preferential movement of one side. What is the best initial step in management? A. Start continuous IV anticonvulsive drugs. B. Request a cranial CT scan with contrast. C. Start hypertonic saline therapy at 5 mg/kg. D. Request serum glucose levels and arterial blood gas.

Answer 56

B. Request a cranial CT scan with contrast. Rationale: In a child with Tetralogy of Fallot and postictal hemiparesis, concern for a vascular event such as a stroke (TOF patients are at higher risk of embolic events) warrants neuroimaging. Continuous anticonvulsants are not indicated without recurrent seizures, hypertonic saline is not relevant, and serum glucose/ABG are secondary considerations.

Question 57

7. A 15-year-old presents with decreased sensorium, fever, headache, and vomiting for 2 days. PE shows nuchal rigidity. CSF analysis: opening pressure 150 mmH₂O, WBC 800/mm³ (lymphocytic predominance), protein 320 mg/dL, glucose 35 mg/dL. What is the most likely diagnosis? A. Acute bacterial meningitis B. Tuberculous meningitis C. Viral meningoencephalitis D. Fungal meningitis

Answer 57

B. Tuberculous meningitis Rationale: The presence of lymphocytic pleocytosis, high protein, and low glucose in CSF is characteristic of tuberculous meningitis. Bacterial meningitis typically shows neutrophilic predominance, while viral meningitis has a normal glucose level. Fungal meningitis is more common in immunocompromised patients.

Question 58

8. An 18-year-old male is brought in unconscious. His friends report alcohol consumption. PE shows no trauma, BP 80/50 mmHg, HR 50 bpm, RR 8 cpm, temperature 35.8°C, decreased DTRs, and pinpoint pupils. What is the most likely cause? A. Methamphetamine B. Methadone C. LSD D. Cocaine

Answer 58

B. Methadone Rationale: Opioid overdose (e.g., methadone) presents with decreased consciousness, pinpoint pupils, bradycardia, hypothermia, and respiratory depression. Methamphetamine and cocaine cause sympathetic stimulation (tachycardia, hypertension, mydriasis), while LSD leads to hallucinations without significant autonomic instability.

Question 59

9. A 17-year-old female is brought in due to agitation. History reveals a breakup with a boyfriend who is addicted to mobile games. PE shows dry flushed skin, BP 150/100 mmHg, HR 160 bpm, decreased bowel sounds, and dilated pupils. Her parents found an empty bottle of an unknown medication. What is the most likely cause? A. Fluoxetine B. Phenelzine C. Diazepam D. Desipramine

Answer 59

D. Desipramine Rationale: Desipramine, a tricyclic antidepressant (TCA), is the best answer given the clinical presentation of dilated pupils, decreased bowel sounds, hypertension, tachycardia, and agitation. TCAs cause anticholinergic toxicity, which includes urinary retention, constipation (decreased bowel sounds), hyperthermia, dry flushed skin, and mydriasis (dilated pupils). Fluoxetine (SSRI) and Phenelzine (MAOI) can cause serotonin syndrome, but they are more associated with diarrhea and hyperreflexia, which are absent here. Diazepam (benzodiazepine) would cause sedation, respiratory depression, and normal/decreased BP rather than agitation and hypertension. Thus, the key clues in the question—dilated pupils, decreased bowel sounds, dry skin, and tachycardia—point toward anticholinergic toxicity, which is characteristic of tricyclic antidepressants like Desipramine.

Question 60

10. Electrolyte imbalances are common in children with symmetrical and nonstructural causes of coma. Aside from hyponatremia and hypernatremia, which electrolyte imbalance most likely presents with decreased sensorium? A. Hypomagnesemia B. Hyperphosphatemia C. Hypermagnesemia D. Hypophosphatemia

Answer 60

C. Hypermagnesemia Rationale: Hypermagnesemia can cause depressed mental status, reduced deep tendon reflexes, hypotension, and respiratory depression. Hypophosphatemia and hyperphosphatemia do not typically cause coma, and hypomagnesemia presents with neuromuscular excitability rather than decreased sensorium.

Question 61

11. A 2-year-old child presents with fever, vomiting, and decreased level of consciousness. PE shows nuchal rigidity. After oxygen supplementation and IV line insertion, the child develops a seizure and is given IV diazepam. To prevent seizure recurrence in bacterial meningitis, which anticonvulsant should be administered? A. Valproic acid B. Phenytoin C. Levetiracetam D. Carbamazepine

Answer 61

B. Phenytoin Rationale: Seizure prophylaxis in bacterial meningitis aims to prevent recurrence, especially in prolonged or complicated cases. Phenytoin is used for seizure prevention in acute settings due to its efficacy in controlling prolonged seizures, whereas valproic acid and carbamazepine are not preferred in acute settings. Levetiracetam is an alternative but is more commonly used for long-term control​

Question 62

12. A 5-month-old child is diagnosed with pneumococcal meningitis. Which of the following statements about pneumococcal meningitis is incorrect? A. The duration of antibiotic therapy is 10-14 days. B. Streptococcus pneumoniae alters the nasopharyngeal microbiome by producing hydrogen peroxide to inhibit H. influenzae type B growth. C. T-lymphocyte defects increase the risk of pneumococcal meningitis. D. Pneumococcal meningitis is more common in patients with cochlear implants.

Answer 62

C. T-lymphocyte defects increase the risk of pneumococcal meningitis. (Incorrect statement) Rationale: T-lymphocyte defects primarily predispose individuals to opportunistic infections like Listeria monocytogenes, not pneumococcal meningitis, which is more associated with B-cell and complement deficiencies. The other statements are correct regarding antibiotic duration, microbiome effects, and cochlear implant-associated risks​

Question 63

13. Many inborn errors of metabolism can cause neonatal seizures. Which disorder presents with prominent hiccups, persistent generalized seizures, and lethargy leading to coma? A. Propionic acidemia B. Maple syrup urine disease C. Nonketotic hyperglycinemia D. Leigh disease

Answer 63

C. Nonketotic hyperglycinemia Rationale: Nonketotic hyperglycinemia presents with neonatal seizures, prominent hiccups, lethargy, and coma due to an inborn error of metabolism. It is diagnosed via elevated CSF/plasma glycine ratio. Propionic acidemia and maple syrup urine disease present with metabolic acidosis, while Leigh disease is associated with lactic acidosis​

Question 64

14. A 15-year-old female presents with seizures, fever, headache, and confusion for 5 days. History is unremarkable. PE reveals vesicular lesions around the mouth and pubic area. What is TRUE about this patient’s condition? A. HSV-2 causes a severe but recurrent form of meningoencephalitis. B. Up to 50% of untreated HSV meningoencephalitis cases are fatal. C. HSV-1 causes sporadic encephalitis leading to coma. D. HSV-1 has generalized brain involvement, unlike the localized involvement in HSV-2.

Answer 64

C. HSV-1 causes sporadic encephalitis leading to coma. Rationale: HSV-1 is the most common cause of sporadic encephalitis, affecting the temporal lobes and leading to seizures and altered mental status.

Question 65

15. A 5-year-old boy presents with acute onset seizures. History reveals fever, headache, right ear pain, and preauricular swelling extending to the angle of the mandible for 7 days. What CSF analysis finding is TRUE for this patient’s condition? (Dx: Mumps meningoencephalitis) A. Glucose may be <40 mg/dL B. Protein is >500 mg/dL C. WBC count >1000 cells/μL D. High mononuclear count early in the disease

Answer 65

A. Glucose may be <40 mg/dL Rationale: Mumps meningoencephalitis often presents with low glucose levels in the CSF.

Question 66

16. A 25-hour-old term infant (3.5 kg) presents with seizures. The jerking stops when touched. The infant was born via NSD with prolonged second-stage labor. Apgar: 6 (1 min), 9 (10 min). ABG: pH 7.25, PCO₂ 50 mmHg, Serum Na 134 mmol/L, Total Ca 1.8 mmol/L, Glucose 59 mg/dL. What is the most likely cause of seizures? A. Hypoglycemia B. Hypocalcemia C. Myoclonic jerks D. Hypoxic-ischemic encephalopathy

Answer 66

C. Myoclonic jerks Rationale: Infantile myoclonic jerks often appear benign and self-resolve. They are distinguished from pathological seizures by cessation when touched.

Question 67

17. A newborn is diagnosed with myelomeningocele. Which of the following statements is NOT true? A. Periconceptional folic acid use reduces the risk of neural tube defects by ≥50%. B. Valproic acid increases neural tube defect risk by 1-2% when taken in pregnancy. C. Hydrocephalus occurs in ≥80% of patients with myelomeningocele. D. Lower spinal deformities increase hydrocephalus risk.

Answer 67

D. Lower spinal deformities increase hydrocephalus risk. (Incorrect statement) Rationale: Hydrocephalus is common (>80%) in myelomeningocele, but lower spinal defects do not directly increase the risk. Instead, it is associated with Chiari II malformation, leading to obstructive hydrocephalu

Question 68

18. A pregnant woman asks about meningocele vs. myelomeningocele on a prenatal ultrasound. What is the main distinguishing feature? A. Presence of a subcutaneous mass B. Exposure of neural placode through a midline skin defect C. Presence of a dilated central canal D. Position of the neural placode relative to the skin surface

Answer 68

D. Position of the neural placode relative to the skin surface Rationale: In meningocele, the placode is deep inside the sac. In myelomeningocele, the neural placode is exposed.

Question 69

19. A newborn presents with a fluctuant midline mass on the thoracolumbar region without skin opening. What best describes this mass? A. Herniation of a CSF-filled sac lined by dura and arachnoid mater B. Abnormal skin-bowel connection C. Neural placode exposure through a skin defect D. Dilated central canal herniation

Answer 69

A. Herniation of a CSF-filled sac lined by dura and arachnoid mater Rationale: A fluctuant midline mass without skin opening suggests meningocele, which consists of a CSF-filled sac covered by meninges. If neural tissue were exposed, it would be myelomeningocele

Question 70

20. You deliver an infant with thoracolumbar myelomeningocele. The father asks about possible complications before surgical repair. Which is least likely? A. Neurogenic bladder B. Neurogenic bowel C. Lower extremity paralysis D. Sudden infant death

Answer 70

D. Sudden infant death (Least likely complication) Rationale: Sudden infant death syndrome (SIDS) is not a recognized complication of myelomeningocele. Instead, neurogenic bladder, bowel dysfunction, and lower limb paralysis are common due to spinal cord involvemen

Question 71

21. One pathology of hydrocephalus is the obliteration of the subarachnoid cisterns. Which of the following conditions can cause this type of hydrocephalus? A. Achondroplasia B. Chiari malformation C. Dandy-Walker malformation D. Klippel-Feil syndrome

Answer 71

A. Achondroplasia Rationale: Achondroplasia can cause communicating or non-communicating hydrocephalus by obliterating the subarachnoid cisterns due to skull base abnormalities.

Question 72

22. An infant presents with delayed gross motor skills, motor stiffness, and spastic paraplegia. Imaging reveals Dandy-Walker malformation. Which of the following statements is NOT correct about Dandy-Walker malformation? A. Cystic dilatation of the fourth ventricle B. Displacement of the cerebellar tonsils through the foramen magnum C. Hypoplasia of the cerebellar vermis D. An enlarged posterior fossa

Answer 72

B. Displacement of the cerebellar tonsils through the foramen magnum (Incorrect statement) Rationale: Dandy-Walker malformation is characterized by cystic dilation of the fourth ventricle, hypoplasia of the cerebellar vermis, and an enlarged posterior fossa. Unlike Chiari malformation, it does not cause cerebellar tonsillar herniation​ .

Question 73

23. A 12-year-old child falls from a 3-story building and arrives at the ER unconscious, with BP 80/50 mmHg, HR 100 bpm, shallow respiration, and unequal pupils. You suspect increased intracranial pressure due to intracranial hemorrhage. Which intervention is least prioritized? A. Hyperventilation with bag-mask ventilation B. Normal saline fluid boluses C. Elevation of the head to at least 30 degrees D. Start mannitol therapy

Answer 73

D. Start mannitol therapy Rationale: Hypotension is present, so mannitol is not prioritized until fluid resuscitation stabilizes blood pressure.

Question 74

24. A 7-year-old child with a brain mass presents to the ER with BP 150/100 mmHg, HR 60 bpm, and irregular breathing. IV mannitol therapy is started. Besides osmotic diuresis, what other mechanism does mannitol use to decrease intracranial pressure? A. Mannitol increases serum tonicity B. Mannitol may cause cerebrovasodilation C. Mannitol decreases blood viscosity D. Mannitol increases serum sodium level

Answer 74

C. Mannitol decreases blood viscosity Rationale: Mannitol reduces blood viscosity, improving cerebral perfusion and decreasing intracranial pressure.

Question 75

25. An 18-year-old boy presents to the ER unconscious with severe headache (10/10), BP 160/90 mmHg, HR 70 bpm, and unilateral pupillary dilation. CT scan shows subarachnoid hemorrhage with cerebral edema. What is the primary mechanism behind vasogenic cerebral edema? A. Intracellular accumulation of excess fluid B. Increased permeability of neuronal membranes C. Increased permeability of capillaries D. Greater swelling in gray matter than in white matter

Answer 75

C. Increased permeability of capillaries Rationale: Vasogenic edema results from breakdown of the blood-brain barrier, leading to extracellular fluid accumulation.

Question 76

26. A child loses consciousness while playing. CT scan reveals intracerebral hemorrhage in the right basal ganglia. PE shows a fixed, dilated right pupil, while the left pupil reacts normally to light. What is the likely diagnosis? A. Right uncal herniation B. Left uncal herniation C. Cerebellar tonsil herniation D. Right cingulate gyrus herniation

Answer 76

A. Right uncal herniation Rationale: Uncal herniation causes ipsilateral pupillary dilation due to oculomotor nerve compression.

Question 77

27. A comatose child with suspected intracerebral hemorrhage presents with hyperventilation. Noxious stimuli cause both arms and legs to extend (decerebrate posture). Pupils are midposition and fixed. What structure is most likely compressed? A. Corpus callosum B. Medulla C. Cerebellar tonsils D. Midbrain

Answer 77

D. Midbrain Rationale: Midbrain compression causes decerebrate posturing, fixed pupils, and central hyperventilation.

Question 78

28. A 5-month-old presents with weak extremities for 1 month, frog-leg posture, pooling of oral secretions, and recurrent pneumonia since 3 months old. The child’s older sibling had similar symptoms and died at 2 months old. What is the most likely type of spinal muscular atrophy (SMA)? A. Type 1A B. Type 1B C. Type 1C D. Type 2

Answer 78

C. Type 1C

Question 79

29. A 12-month-old presents with progressive limb weakness and tongue fasciculations. The mother noted prominent lower extremity weakness over the past month. What lab finding is consistent with this disorder? A. ECG shows localized somatic muscle fibrillations B. Motor nerve conduction shows mild slowing early in the disease C. Serum creatine kinase is elevated 4x the upper normal limit D. Electromyography shows fibrillation potential without muscle denervation

Answer 79

C. Serum creatine kinase is elevated 4x the upper normal limit Rationale: Elevated CK levels are characteristic of neuromuscular disorders like SMA.

Question 80

30. A 7-year-old presents with flaccid paralysis of the right leg following a fever and malaise that lasted 2-3 days. The fever resolved, but paralysis appeared 2 days later. PE shows decreased DTRs on the right leg. No vaccinations since birth. CSF analysis would show all of the following EXCEPT: A. Pleocytosis with 20-300 cells/μL in CNS involvement B. Predominantly PMNs C. Near normal CSF cell values D. CSF protein 50-100 mg/dL

Answer 80

B. Predominantly PMNs

Question 81

31. A 12-year-old boy diagnosed with Guillain-Barré syndrome (GBS) is admitted to the ward for disease progression monitoring. Which of the following tests best assesses his respiratory function? A. Arterial blood gas B. Chest radiograph C. Peak expiratory flow rate D. Vital capacity

Answer 81

D. Vital capacity Rationale: Vital capacity is the best indicator of respiratory decline in GBS and helps determine the need for intubation.

Question 82

32. You request CSF analysis for a 17-year-old girl with ascending symmetric weakness. Which CSF finding is consistent with GBS? A. Elevated protein with WBC elevation B. Elevated WBC without protein elevation C. Elevated protein without WBC elevation D. Normal CSF protein and WBC count

Answer 82

C. Elevated protein without WBC elevation Rationale: Albuminocytologic dissociation (↑ protein, normal WBC) is the hallmark CSF finding in GBS.

Question 83

33. Patients with Guillain-Barré syndrome (GBS) present with flaccid weakness and sensory loss. Which finding best differentiates botulism from GBS? A. Intermittent weakness B. Fixed dilated pupils C. Paralysis with intact sensation D. Weakness worsened by exertion

Answer 83

B. Fixed dilated pupils Rationale: Botulism presents with pupillary involvement (fixed, dilated pupils), while GBS spares the pupils.

Question 84

34. A morbidly obese adolescent with suspected GBS is admitted to the ICU. Which cost-effective early intervention shortens the disease course and reduces permanent paralysis? A. Immune globulin B. Corticosteroids C. Plasma exchange D. Immobilization and stabilization

Answer 84

C. Plasma exchange Rationale: Plasma exchange (plasmapheresis) and IVIg are first-line therapies for GBS, but plasmapheresis is more cost-effective.

Question 85

35. A 12-year-old girl presents with asymmetric ptosis and extraocular muscle weakness after taking antibiotics for cough and colds. She later develops respiratory distress and requires intubation. Which antibiotic most likely caused this condition? A. Ciprofloxacin B. Amoxicillin C. Clindamycin D. Trimethoprim-sulfamethoxazole

Answer 85

A. Ciprofloxacin Rationale: The child presents with asymmetric ptosis, extraocular muscle weakness, and respiratory distress—suggestive of myasthenic crisis. Certain antibiotics can worsen neuromuscular weakness and trigger myasthenic crises, particularly in patients with underlying neuromuscular disorders like Myasthenia Gravis (MG)​ . Fluoroquinolones (e.g., Ciprofloxacin) are known to exacerbate myasthenia gravis and cause profound neuromuscular blockade, leading to respiratory failure in susceptible individuals​ . Aminoglycosides, beta-blockers, procainamide, and chloroquine also worsen MG, but these were not listed in the choices​ . The other antibiotics (Amoxicillin, Clindamycin, Trimethoprim-sulfamethoxazole) are not known to precipitate neuromuscular weakness or myasthenic crisis to the same extent as fluoroquinolones.

Question 86

36. Myasthenia gravis (MG) must be differentiated from other neuromuscular disorders. What is the most specific test for MG? A. Muscle biopsy B. Electromyography C. Anti-AChR antibodies D. Serum creatine kinase

Answer 86

B. Electromyography

Question 87

37. A child with GBS is treated with IVIg. Which function is expected to improve last? A. Sensation B. Bulbar muscles C. Anal sphincters D. Tendon reflexes

Answer 87

D. Tendon reflexes Rationale: Tendon reflexes take the longest to recover in GBS, often persisting for weeks to months after other improvements.

Question 88

38. All the following myopathies are characterized by proximal muscle wasting, EXCEPT: A. Becker dystrophy B. Myotonic dystrophy C. Duchenne dystrophy D. Central core myopathy

Answer 88

B. Myotonic dystrophy Rationale: Myotonic dystrophy primarily affects distal muscles, while Becker, Duchenne, and central core myopathy affect proximal muscles.

Question 89

39. In spinal muscular atrophy (SMA) type 1, all the following are spared, EXCEPT: A. Heart B. Diaphragm C. Anal sphincter D. Extraocular muscles

Answer 89

B. Diaphragm Rationale: SMA type 1 causes progressive diaphragmatic weakness, leading to respiratory failure.

Question 90

40. Which of the following vaccines does NOT induce Guillain-Barré syndrome (GBS)? A. Oral polio vaccine (OPV) B. Rotavirus vaccine C. Influenza vaccine D. Conjugated meningococcal vaccine

Answer 90

B. Rotavirus vaccine Rationale: GBS is associated with OPV, influenza, and meningococcal vaccines, but not with rotavirus vaccine.

Question 91

41. The aura associated with migraine is a neurological warning sign. Which of the following is the least common type of typical aura in migraine? A. Dysphasic aura B. Visual aura C. Vertigo D. Distortion

Answer 91

A. Dysphasic aura Rationale: Visual aura is the most common, while dysphasic aura (speech/language dysfunction) is the least common type.

Question 92

42. A 10-year-old child presents with headache. Which of the following is NOT an indication for neuroimaging? A. Abnormal neurological examination B. Headache worst upon awakening C. Frontal headache D. Migrainous headache in a child with no family history

Answer 92

C. Frontal headache Rationale: Frontal headaches are common and usually benign. Neuroimaging is indicated for abnormal neurological findings or red flag symptoms.

Question 93

43. Which condition most likely causes slowly progressive ataxia, greater in the lower extremities, with positive Romberg test, absent DTRs, and extensor plantar response? A. Ataxia-telangiectasia B. Friedreich ataxia C. Roussy-Levy disease D. Ramsay Hunt syndrome

Answer 93

B. Friedreich ataxia Rationale: Friedreich ataxia presents with progressive ataxia, absent DTRs, and extensor plantar response due to spinocerebellar degeneration.

Question 94

44. A child with spastic diplegia cerebral palsy undergoes cranial MRI. Which of the following findings is most commonly seen? A. Periventricular leukomalacia B. White matter injury C. Multicystic cortical encephalomalacia D. Enlarged thalamocortical pathways

Answer 94

A. Periventricular leukomalacia Rationale: Periventricular leukomalacia is the most common finding in spastic diplegia cerebral palsy, resulting from white matter ischemia.

Question 95

45. An adolescent presents to the ER with unsteady gait. Which medication is least likely to cause ataxia? A. Alcohol B. Imipramine C. Phenobarbital D. Dextromethorphan

Answer 95

B. Imipramine Rationale: Alcohol, phenobarbital, and dextromethorphan can cause ataxia, whereas imipramine (a tricyclic antidepressant) does not typically cause ataxia.

Question 96

46. Miller-Fisher syndrome presents with acute ophthalmoplegia, ataxia, and areflexia. Which cranial nerve is most commonly affected? A. CN V (Trigeminal) B. CN VI (Abducens) C. CN VII (Facial) D. CN VIII (Vestibulocochlear)

Answer 96

B. CN VI (Abducens) Rationale: Miller-Fisher syndrome is a GBS variant that frequently involves CN VI, leading to ophthalmoplegia and diplopia.

Question 97

47. A 7-year-old boy presents with recurrent eye blinking and sudden, repetitive limb movements for the past 9 months. What is the most likely diagnosis? A. Tourette’s disorder B. Persistent motor tic disorder C. Provisional tic disorder D. Sydenham chorea

Answer 97

C. Provisional tic disorder

Question 98

48. A 5-year-old boy has a family history of Huntington chorea. His mother requests predictive genetic testing. What is the most appropriate response? A. Whatever the result, it will not affect the disease process. B. This is an age-dependent disorder and may not manifest. C. Leave the decision to the child when they are older. D. We should weigh the benefits vs. risks of testing.

Answer 98

C. Leave the decision to the child when they are older.

Question 99

49. A child with Sydenham chorea is started on penicillin for rheumatic heart disease prevention. Which drug can be added for symptom control? A. Prednisone B. Phenobarbital C. Haloperidol D. Chlorpromazine

Answer 99

A. Prednisone Rationale: Steroids, particularly prednisone, have been shown to reduce the duration and severity of Sydenham chorea. A randomized, double-blinded study found that high-dose prednisone (2 mg/kg/day, max 60 mg) for 4 weeks significantly reduced the time to remission (54.3 days vs. 119.9 days in controls)​ . Immunomodulatory therapy like IVIG and plasma exchange has been used in severe cases, but steroids remain a first-line option for symptom relief​

Question 100

50. A 13-year-old boy presents with delirium, mumbling speech, tachycardia, dry flushed skin, dilated pupils, myoclonus, urinary retention, and decreased bowel sounds. He later develops seizures and arrhythmias. What is the most likely cause? A. Amitriptyline B. Amphetamine C. Barbiturates D. Edrophonium

Answer 100

A. Amitriptyline Rationale: Tricyclic antidepressant (TCA) toxicity (e.g., amitriptyline) presents with anticholinergic symptoms, seizures, and cardiac arrhythmias (QRS widening).

Question 101

51. The recurrence risk of neural tube defects (NTDs) in subsequent pregnancies is: A. 1% to 2% B. 3% to 4% C. 5% to 6% D. 7% to 8%

Answer 101

B. 3% to 4% Rationale: The recurrence risk of neural tube defects (NTDs) after having one affected child is 3–4%. If two prior children are affected, the risk increases to 10%​ . The cause of NTDs is multifactorial, involving genetic predisposition, folate deficiency, hyperthermia, certain drugs (e.g., valproic acid), and maternal conditions like diabetes and obesity. Periconceptional folic acid supplementation significantly reduces the risk of NTDs, which is why it is recommended for all women of childbearing age.

Question 102

52. A 3-year-old boy presents with fever, anorexia, headache, and positive meningeal signs. CSF analysis shows ↑ lymphocytes and ↓ glucose. He has a history of prolonged steroid use for nephrotic syndrome. What is the most likely diagnosis? A. Partially treated bacterial meningitis B. Fungal meningitis C. Viral meningitis D. Parasitic meningitis

Answer 102

B. Fungal meningitis Rationale: Fungal meningitis (e.g., Cryptococcus) is common in immunocompromised patients (e.g., those on prolonged steroids). CSF shows ↑ lymphocytes, ↓ glucose, and ↑ protein.

Question 103

53. An 8-year-old girl undergoes EEG, revealing generalized 3-Hz spike-and-wave activity. What is the most likely diagnosis? A. Benign childhood epilepsy B. Generalized absence seizure C. West syndrome D. Simple partial seizure

Answer 103

B. Generalized absence seizure Rationale: Absence seizures (petit mal seizures) present with brief staring spells and a classic EEG pattern of 3-Hz spike-and-wave discharges.

Question 104

54. The duration of anticonvulsant therapy varies by seizure type. Most children can stop medication after 2 seizure-free years, but which condition usually requires lifelong treatment? A. Simple partial seizure B. Complex partial seizure C. Juvenile myoclonic epilepsy D. Infantile spasm

Answer 104

C. Juvenile myoclonic epilepsy Rationale: Juvenile myoclonic epilepsy (JME) requires lifelong anticonvulsant therapy as it has a high recurrence rate even after prolonged seizure-free periods.

Question 105

55. A 6-month-old infant presents with severe hypotonia and generalized weakness. His CK is mildly elevated, EMG shows fasciculations and fibrillations, and muscle biopsy shows grouped atrophy. What is the most likely finding on exam? A. Absent deep tendon reflexes B. Absent sensation C. Bilateral ptosis D. Persistent Moro reflex

Answer 105

A. Absent deep tendon reflexes Rationale: Spinal muscular atrophy (SMA) presents with severe hypotonia, absent DTRs, tongue fasciculations, and grouped atrophy on muscle biopsy. Sensation remains intact.

Question 106

1. A 5-year-old boy presents to the ER with severe scrotal pain. What is the most likely cause? A. Retractile testes B. Testicular torsion C. Epididymitis D. Incarcerated hernia

Answer 106

B. Testicular torsion Rationale: Testicular torsion presents with acute, severe scrotal pain, absent cremasteric reflex, and high-riding testis. It is a surgical emergency requiring immediate detorsion.

Question 107

3. Children with kidney transplants require immunosuppressive therapy. Which of the following is NOT a side effect? A. Nephrotoxicity B. Cardiovascular complications C. Sudden death D. Infections

Answer 107

C. Sudden death Rationale: Nephrotoxicity, cardiovascular disease, and infections are well-known complications of immunosuppressive therapy in kidney transplant patients. Sudden death is not a direct complication.

Question 108

2. A 3-week-old neonate presents with an abdominal mass. What is the most common renal cause? A. Ureteropelvic junction obstruction B. Posterior urethral valves C. Multicystic renal dysplasia D. Polycystic kidney disease

Answer 108

A. Ureteropelvic junction obstruction Rationale: Ureteropelvic junction (UPJ) obstruction is the most common cause of a neonatal abdominal mass and the most frequent obstructive uropathy in children. It is typically diagnosed via antenatal ultrasound revealing fetal hydronephrosis. In neonates, it presents as a palpable renal mass or hydronephrosis without ureteral dilation.

Question 109

4. A 9-year-old boy presents to the ER with severe headache and BP of 160/90 mmHg in the left arm. What is the most likely cause? A. Endocrine disorders B. Renal disorders C. Neurologic disorders D. Vascular diseases E. Metabolic syndromes

Answer 109

B. Renal disorders Rationale: Renal disorders (e.g., renal artery stenosis, glomerulonephritis, or chronic kidney disease) are the most common cause of secondary hypertension in children.

Question 110

5. Dietary management in chronic kidney disease (CKD) includes all of the following EXCEPT: A. Increased caloric intake B. Protein restriction C. Iron supplementation D. Low potassium diet E. Low phosphorus diet

Answer 110

B. Protein restriction Rationale: Protein restriction is not typically recommended in children with chronic kidney disease (CKD) due to concerns about impaired growth and development. Instead, children with CKD should receive 100% (or more for those on dialysis) of the dietary reference intake (DRI) for protein. Other dietary modifications, such as iron supplementation, low potassium, and low phosphorus diets, are necessary to manage CKD-related complications.

Question 111

6. A 6-month-old girl presents with bilateral abdominal masses and hypertension. Her older sister died as a neonate after the mother was diagnosed with oligohydramnios. What is the most likely diagnosis? A. Wilm’s tumor B. Polycystic kidney disease C. Neuroblastoma D. Vesicoureteral reflux stage 4

Answer 111

B. Polycystic kidney disease Rationale: Autosomal recessive polycystic kidney disease (ARPKD) presents with large, cystic kidneys, neonatal respiratory distress, and oligohydramnios (Potter sequence).

Question 112

7. The most common intrinsic cause of acute kidney injury (AKI) in childhood is: A. Acute interstitial nephritis B. Rhabdomyolysis C. Glomerulonephritis D. Acute tubular necrosis

Answer 112

D. Acute tubular necrosis Rationale: Acute tubular necrosis (ATN) is the most common intrinsic cause of AKI in children due to ischemia (shock, sepsis) or nephrotoxic injury (aminoglycosides, contrast).

Question 113

8. The classic electrolyte disturbance seen in renal tubular acidosis (RTA) is: A. Hypocalcemia B. Hypokalemia C. Hyperchloremic metabolic acidosis D. Hyperkalemia

Answer 113

C. Hyperchloremic metabolic acidosis Rationale: Renal tubular acidosis (RTA) presents with normal anion gap (hyperchloremic) metabolic acidosis due to impaired renal acid excretion.

Question 114

9. A 4-day-old newborn presents with gross hematuria, lethargy, dry mucous membranes, hypertension, and a right-sided flank mass. The mother had gestational diabetes. What is the most likely diagnosis? A. Hypercalciuria B. Renal vein thrombosis C. Hemorrhagic cystitis D. Sickle cell disease

Answer 114

B. Renal vein thrombosis Rationale: Renal vein thrombosis (RVT) is associated with infants of diabetic mothers and presents with gross hematuria, flank mass, and thrombocytopenia.

Question 115

10. Acute kidney injury (AKI) refers to an abrupt decrease in GFR and tubular function. What are possible etiologies? A. Prerenal B. Postrenal C. Renal parenchymal D. Vascular E. All of the above

Answer 115

E. All of the above Rationale: AKI can be classified as: Prerenal (e.g., hypovolemia, heart failure) Renal parenchymal (e.g., ATN, glomerulonephritis) Postrenal (e.g., obstruction) Vascular (e.g., renal vein thrombosis, vasculitis)

Question 116

11. Hemolytic uremic syndrome (HUS) is characterized by the triad of microangiopathic hemolytic anemia, thrombocytopenia, and renal injury. What is the best indicator of renal injury in HUS? A. Anemia B. Leukocytosis C. Hematuria D. Increased LDH

Answer 116

C. Hematuria Rationale: Renal injury in HUS manifests as hematuria, proteinuria, and increased creatinine. LDH is elevated due to hemolysis, but not specific for kidney injury.

Question 117

12. A 12-year-old girl with systemic lupus erythematosus (SLE) develops nephrotic syndrome (NS). What is the most common type of secondary NS in lupus? A. Membranoproliferative glomerulonephritis B. Membranous nephropathy C. Focal segmental glomerulosclerosis D. Minimal change nephrotic syndrome

Answer 117

B. Membranous nephropathy Rationale: Membranous nephropathy is the most common cause of nephrotic syndrome in lupus patients and is classified under class V lupus nephritis.

Question 118

13. Microscopic hematuria is defined as >3-5 RBCs per high-power field in centrifuged urine. All of the following can cause hematuria EXCEPT: A. Acute kidney injury B. Urinary tract malformation C. Trauma D. Renal vein thrombosis E. Hemoglobinuria

Answer 118

E. Hemoglobinuria Rationale: Hemoglobinuria is free hemoglobin in urine (from intravascular hemolysis), not true hematuria (which comes from RBCs in urine).

Question 119

14. A 6-year-old boy with nephrotic syndrome develops severe abdominal pain while on corticosteroids. Peritoneal fluid analysis: RBC 500,000/mm³, WBC 5,000/mm³. What is the most likely diagnosis? A. Acute appendicitis B. Staphylococcal peritonitis C. Pneumococcal peritonitis D. Mesenteric lymphadenitis

Answer 119

C. Pneumococcal peritonitis Rationale: Nephrotic syndrome increases the risk of spontaneous bacterial peritonitis (SBP), most commonly due to Streptococcus pneumoniae.

Question 120

15. Which of the following is NOT associated with chronic kidney disease (CKD)? A. Polyhydramnios B. Intrauterine growth restriction C. Premature delivery D. Down syndrome E. Spontaneous abortion

Answer 120

D. Down’s syndrome Rationale: Chronic kidney disease (CKD) is associated with adverse maternal and fetal outcomes, including intrauterine growth restriction, premature delivery, spontaneous abortion, and oligohydramnios rather than polyhydramnios. While certain genetic syndromes may predispose to kidney abnormalities, Down syndrome its

Question 121

16. Alport syndrome is a hereditary nephritis caused by defective type IV collagen. Which of the following is NOT a feature of Alport syndrome? A. Deafness B. Visual impairment C. Proteinuria D. Microscopic hematuria E. Renal failure

Answer 121

B. Visual impairment Rationale: Alport syndrome is associated with sensorineural hearing loss, renal failure, and ocular abnormalities (anterior lenticonus), but not true visual impairment.

Question 122

17. Which antibody is found in post-streptococcal glomerulonephritis (PSGN)? A. Anti-streptolysin B B. Anti-DNAse B C. Anti-hyaluronic acid D. Anti-staphylokinase E. Anti-adenine dinucleotidase

Answer 122

B. Anti-DNAse B Rationale: Anti-DNAse B antibodies indicate recent streptococcal infection and are present in post-streptococcal glomerulonephritis (PSGN).

Question 123

18. Which of the following renal conditions is NOT associated with impaired growth in children? A. Congenital nephrotic syndrome B. Vesicoureteral reflux C. Autosomal recessive polycystic kidney disease (ARPKD) D. Steroid therapy

Answer 123

B. Vesicoureteral reflux Rationale: Vesicoureteral reflux (VUR) does not usually impair growth unless complicated by recurrent pyelonephritis and chronic kidney disease. The others directly affect growth.

Question 124

19. A 5-year-old child has poor growth due to CKD. Which of the following is NOT part of management? A. Increased caloric intake B. Increased protein intake C. Recombinant growth hormone (GH) D. Vitamin D analogues

Answer 124

B. Increased protein intake Rationale: Protein restriction is recommended in CKD to prevent uremic symptoms. Growth hormone therapy and vitamin D analogs help counteract CKD-related growth delay.

Question 125

20. Complement C3 is a β-protein that is decreased in which condition? A. Acute post-streptococcal glomerulonephritis (APSGN) B. IgA nephropathy C. Nephrotic syndrome D. Rapidly progressive glomerulonephritis (RPGN)

Answer 125

A. Acute post-streptococcal glomerulonephritis (APSGN) Rationale: APSGN is associated with low complement (C3) due to immune complex deposition. IgA nephropathy and nephrotic syndrome usually have normal C3.

Question 126

21. Common manifestations of UTI in older children include: A. Fever, vomiting, diarrhea B. Abdominal/flank pain, dysuria, malodorous urine C. Asymptomatic D. Oliguria, hypertension, edema

Answer 126

B. Abdominal/flank pain, dysuria, malodorous urine Rationale: Older children with UTI present with dysuria, urgency, frequency, abdominal or flank pain, and foul-smelling urine. Younger children may have nonspecific symptoms like fever and vomiting.

Question 127

22. Definitive diagnostic test for acute pyelonephritis in children: A. Intravenous pyelogram B. Ultrasound C. Vesico-cystourethrogram (VCUG) D. Renal scan

Answer 127

B. Ultrasound

Question 128

23. A 16-year-old boy notices a painless mass in the left scrotum. Most likely diagnosis: A. Torsion of the testes B. Epididymitis C. Varicocele D. Hydrocele

Answer 128

C. Varicocele Rationale: Varicocele is the most common cause of a painless scrotal mass in adolescent males, often affecting the left side due to venous drainage differences. Torsion is painful and an emergency.

Question 129

24. A newborn with oligohydramnios and a single umbilical artery is associated with: A. Polycystic kidney disease B. Hydronephrosis C. Renal agenesis D. Renal hypoplasia

Answer 129

C. Renal agenesis Rationale: Renal agenesis, especially bilateral (Potter sequence), leads to oligohydramnios, pulmonary hypoplasia, and facial anomalies. A single umbilical artery is a common finding.

Question 130

25. Recommended age for corrective surgery in unilateral undescended testes: A. Between 12 – 18 months B. After puberty C. Newborn period D. Before puberty

Answer 130

A. Between 12 – 18 months Rationale: Orchiopexy should be done before 18 months to prevent testicular atrophy and malignancy risk. Spontaneous descent is unlikely after 6 months.

Question 131

26. A child with APSGN has persistent low C3 and high BUN/Creatinine after 4 months. Next step? A. VCUG B. Renal biopsy C. Renal scanning D. Plain KUB

Answer 131

B. Renal biopsy Rationale: Persistent low C3 (>8 weeks) and worsening kidney function suggest an alternative diagnosis, such as membranoproliferative GN or lupus nephritis, requiring biopsy.

Question 132

27. A 2-year-old with generalized edema, proteinuria (+4), hyperlipidemia, and normal BP. Most likely diagnosis? A. PSGN B. IgA Nephropathy C. Henoch-Schönlein Purpura nephritis D. Minimal change nephrotic syndrome

Answer 132

D. Minimal change nephrotic syndrome Rationale: Minimal change disease is the most common cause of nephrotic syndrome in children. Characterized by proteinuria, hypoalbuminemia, and hyperlipidemia.

Question 133

28. Which statement about APSGN in children is correct? A. Most common in children >15 years B. Presents as acute renal failure C. Occurs 3-4 days after streptococcal infection D. Can result from streptococcal pharyngitis or impetigo

Answer 133

D. Can result from streptococcal pharyngitis or impetigo Rationale: APSGN can follow either pharyngitis (1-2 weeks) or impetigo (2-4 weeks). It is most common in 5-12 years old, not >15 years.

Question 134

29. Most common presenting sign of Wilms tumor (nephroblastoma)? A. Hematuria B. Abdominal pain C. Weight loss D. Abdominal mass

Answer 134

D. Abdominal mass Rationale: Wilms tumor presents as an asymptomatic abdominal mass, often found incidentally. Other symptoms may include hematuria and hypertension.

Question 135

30. First sign in a 5-year-old with dark brown urine and healing impetigo? A. Headache B. Oliguria C. Periorbital edema D. Dyspnea

Answer 135

C. Periorbital edema Rationale: APSGN presents with cola-colored urine, periorbital edema, hypertension, and oliguria following a streptococcal infection. Edema is often the first sign.

Question 136

31. The most common cause of gross hematuria in pediatrics: A. Acute Pyelonephritis B. Acute Post-Streptococcal Glomerulonephritis (APSGN) C. Benign Familial Hematuria D. IgA Nephropathy

Answer 136

D. IgA Nephropathy Rationale: IgA nephropathy (Berger disease) is the most common cause of gross hematuria in children, often following an upper respiratory infection ("synpharyngitic hematuria").

Question 137

32. Least commonly observed clinical feature in APSGN: A. Hematuria B. Edema C. Hypertension D. Renal failure

Answer 137

D. Renal failure Rationale: Hematuria, edema, and hypertension are common in APSGN, while renal failure is uncommon and occurs in severe cases. Most cases resolve without progressing to renal failure.

Question 138

33. A 1-year-old with recurrent UTI and enlarged kidneys on ultrasound. Best diagnostic test: A. Renal CT Scan B. Voiding Cystourethrogram (VCUG) C. Plain Film KUB D. MRI

Answer 138

B. Voiding Cystourethrogram (VCUG) Rationale: VCUG is the gold standard for diagnosing vesicoureteral reflux (VUR), a common cause of recurrent UTI and hydronephrosis in children. CT scan is reserved for complications like renal abscess.

Question 139

34. A 3-year-old boy with abdominal mass, hydronephrosis, and recurrent UTI with E. coli. Most likely cause: A. Adrenal Hemorrhage B. Wilms Tumor C. Ureteropelvic Junction Obstruction D. Vesicoureteral Junction Obstruction

Answer 139

C. Ureteropelvic Junction Obstruction Rationale: Ureteropelvic junction (UPJ) obstruction is the most common congenital cause of hydronephrosis in children and often presents with recurrent UTI and abdominal mass.

Question 140

35. A 3-year-old boy had diarrhea, followed by oliguria, edema, and petechial rashes. Labs show anemia, thrombocytopenia, proteinuria, and RBCs in urine. Most likely diagnosis: A. Hemolytic Uremic Syndrome (HUS) B. Post-Streptococcal Glomerulonephritis (APSGN) C. Nephrotic Syndrome D. Systemic Lupus Erythematosus

Answer 140

A. Hemolytic Uremic Syndrome (HUS) Rationale: HUS is characterized by microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury (triad). It follows Shiga toxin-producing E. coli (STEC) diarrhea.

Question 141

36. Common findings in children with chronic renal failure: A. Mental Retardation B. Growth Retardation C. Hypotension D. Hypokalemia

Answer 141

B. Growth Retardation Rationale: Growth failure is a major complication of chronic kidney disease (CKD) due to metabolic disturbances, acidosis, and poor nutrition. Hypertension, not hypotension, is common.

Question 142

37. Correct statement about management of nephrotic syndrome: A. Renal biopsy before immunosuppressive therapy B. Steroid responsive in minimal change disease C. Steroid-resistant if no response after 1 week of prednisone D. Complete remission if proteinuria >40 mg/m²/hr

Answer 142

B. Steroid responsive in minimal change disease Rationale: Minimal change disease (MCD) is the most common cause of nephrotic syndrome in children and is highly responsive to corticosteroids. Biopsy is only done if non-responsive.

Question 143

38. Most frequent cause of graft loss in pediatric renal transplant patients: A. Trauma to the graft B. Technical difficulties C. Rejection reactions D. Infection

Answer 143

C. Rejection reactions Rationale: Graft rejection is the most common cause of kidney transplant failure. Acute and chronic rejection lead to progressive graft dysfunction.

Question 144

39. True statement about Vesicoureteral Reflux (VUR): A. It is non-hereditary B. It predisposes to pyelonephritis C. It always requires surgery D. Only boys are affected

Answer 144

B. It predisposes to pyelonephritis Rationale: VUR increases the risk of recurrent pyelonephritis and renal scarring. It can be hereditary, often resolves spontaneously, and affects both boys and girls.

Question 145

40. Last finding to resolve in a child with APSGN: A. Elevated BUN B. Hypertension C. Edema D. Microscopic Hematuria

Answer 145

D. Microscopic Hematuria Rationale: Microscopic hematuria can persist for 6-12 months in APSGN. Hypertension and edema resolve earlier. BUN and creatinine normalize with renal recovery.

Question 146

41. True statement about undescended testes: A. It is histologically normal at birth B. It is usually located in the inguinal canal C. Testicular descent occurs early in gestation D. It descends spontaneously 6 months after birth

Answer 146

A. It is histologically normal at birth

Question 147

42. Complete reduction of a hydrocele when compressed suggests: A. Epididymitis B. Spermatocele C. Testicular tumor D. Inguinal hernia

Answer 147

D. Inguinal hernia Rationale: A reducible scrotal swelling is suggestive of an inguinal hernia. Hydrocele may fluctuate in size but is not completely reducible like a hernia.

Question 148

43. Hyperlipidemia in Nephrotic Syndrome is due to: A. Overproduction of lipoproteins B. Lower levels of lipoprotein lipase C. Both (A) and (B) are correct D. Neither (A) nor (B) are correct

Answer 148

C. Both (A) and (B) are correct Rationale: Nephrotic syndrome leads to increased lipoprotein synthesis in response to low oncotic pressure and decreased clearance of lipids due to reduced lipoprotein lipase activity.

Question 149

44. Clinically apparent edema usually occurs when serum albumin drops below: A. 5.0 gm/dL B. 4.0 gm/dL C. 3.0 gm/dL D. 2.0 gm/dL

Answer 149

D. 2.0 gm/dL Rationale: Generalized edema in nephrotic syndrome typically occurs when albumin falls below 2 g/dL due to decreased oncotic pressure.

Question 150

45. Indication for renal biopsy in a nephrotic syndrome patient: A. Continued proteinuria after 1 week of prednisone B. History of systemic lupus erythematosus C. Cholesterol >400 mg/dL D. Relapse 1 year after initial therapy

Answer 150

B. History of systemic lupus erythematosus Rationale: Renal biopsy is indicated in nephrotic syndrome if there is suspicion of an underlying secondary cause, such as lupus nephritis. Biopsy is also considered if there is steroid resistance or atypical features.

Question 151

46. Most common cause of mortality in primary idiopathic nephrotic syndrome: A. Bacterial infection B. Congestive heart failure C. Seizures D. Acute renal failure

Answer 151

A. Bacterial infection Rationale: Nephrotic syndrome predisposes children to serious infections such as peritonitis, pneumonia, and sepsis due to urinary loss of immunoglobulins and complement factors.

Question 152

47. Recurrent UTI in children (<10 years) is most commonly associated with: A. Renal stones B. Chronic glomerulonephritis C. Vesicoureteral reflux (VUR) D. Renal tumors

Answer 152

C. Vesicoureteral reflux (VUR) Rationale: VUR occurs in 25-30% of children with recurrent UTI and can lead to renal scarring (reflux nephropathy) and CKD.

Question 153

48. Best treatment for generalized edema in nephrotic syndrome: A. Antibiotics B. Diuretics C. 5% Albumin D. Prednisone

Answer 153

D. Prednisone Rationale: Prednisone is first-line therapy for nephrotic syndrome (minimal change disease). Diuretics may be used for symptomatic relief but do not treat the underlying condition.

Question 154

49. Most appropriate initial pharmacologic therapy for a 12-year-old with severe reflux nephropathy and hypertension: A. Diuretic B. ACE inhibitor C. Beta-blocker D. Calcium channel blocker

Answer 154

B. ACE inhibitor Rationale: ACE inhibitors reduce proteinuria, control hypertension, and slow progression of chronic kidney disease (CKD) in reflux nephropathy.

Question 155

50. Most common cause of chronic renal failure (CKD) requiring transplantation in children: A. Reflux nephropathy B. Familial nephritis C. Polycystic kidney disease D. Obstructive uropathy

Answer 155

D. Obstructive uropathy Rationale: Obstructive uropathy (e.g., posterior urethral valves, congenital anomalies) is the most common cause of CKD in children, leading to ESRD and requiring transplantation.

Question 156

51. A 2-year-old presents with 2 days of diarrhea and vomiting, no wet diapers in 12 hours. Labs show mild dehydration (Hct 44%, Na 135 mEq/L, K 3.0 mEq/L, BUN 16, Creatinine 0.8 mg/dL). The most likely diagnosis is: A. Posterior urethral valves B. Hemolytic uremic syndrome C. Rotavirus infection D. Glomerulonephritis

Answer 156

C. Rotavirus infection Rationale: Rotavirus is the most common cause of viral gastroenteritis in young children, leading to severe dehydration and electrolyte imbalances. No evidence of renal obstruction (PUV), hemolysis (HUS), or glomerular disease.

Question 157

52. A 7-year-old boy with CKD due to posterior urethral valves has progressively worsening renal function. Best way to optimize growth before kidney transplant: A. Assuring caloric intake of 120 kcal/kg/day B. Providing high-protein diet C. Growth hormone (GH) injections D. Maintaining hemoglobin >13 g/dL

Answer 157

C. Growth hormone (GH) injections Rationale: GH therapy can improve height and growth velocity in children with CKD, especially before renal transplantation. Excessive protein intake can worsen uremia.

Question 158

53. Indication for renal biopsy in nephrotic syndrome: A. Age 2-6 years at initial presentation B. Relapse 1 year after initial diagnosis C. Lack of response after 1 week of prednisone D. Low serum complement level at initial presentation

Answer 158

D. Low serum complement level at initial presentation Rationale: Renal biopsy is indicated in nephrotic syndrome when atypical features are present, such as low serum complement levels, which may suggest underlying conditions like membranoproliferative glomerulonephritis (MPGN) or lupus nephritis. Other indications include steroid resistance (typically after 4 weeks, not just 1 week), age <1 year or >12 years, persistent hematuria, and hypertension. Most children aged 2-6 years with typical minimal change disease (MCD) do not require a biopsy as they usually respond well to steroids.

Question 159

54.A 5 year old girl presents with periumbilical abdominal pain of increasing severity over the past 2 days. She has been receiving treatment for nephrotic syndrome with prednisone for the last 3 weeks. On physical examination febrile 38.5 C HR 124, RR 34 BP 80/50 mm Hg. with poor peripheral perfusion, puffy face and 3 + pedal edema. There is generalized abdominal tenderness with guarding and rebound tenderness. Abdominal UTZ shows ascites. Which of the following is the next most appropriate diagnostic step? * A. Exploratory laparotomy B. Abdominal paracentesis C. CT of the abdomen D. Doppler ultrasound of renal vessels

Answer 159

54. B. Abdominal paracentesis Rationale: This child with nephrotic syndrome on prednisone presents with fever, hypotension, peritoneal signs (abdominal tenderness, guarding, and rebound tenderness), and ascites, which strongly suggest spontaneous bacterial peritonitis (SBP)—a life-threatening infection in nephrotic syndrome due to loss of immunoglobulins and complement factors in urine. The next step is an abdominal paracentesis to confirm SBP by analyzing ascitic fluid for WBC count, differential, protein, glucose, and bacterial culture. Exploratory laparotomy is not indicated unless there is evidence of bowel perforation. CT of the abdomen is not the first-line diagnostic test and may delay necessary treatment. Doppler ultrasound of renal vessels is used for vascular causes like renal vein thrombosis, which is not the primary concern here.

Question 160

55. IgA nephropathy: Which of the following does NOT indicate an increased risk of renal failure? A. Proteinuria B. Hypertension C. Reduced GFR D. Interstitial fibrosis on biopsy E. Macroscopic hematuria

Answer 160

E. Macroscopic hematuria Rationale: Gross hematuria is common in IgA nephropathy but does not predict poor prognosis. Persistent proteinuria, HTN, decreased GFR, and fibrosis indicate higher risk of CKD.

Question 161

56. 7-year-old boy with crampy abdominal pain and rash on the buttocks and legs. Labs show proteinuria and microhematuria. Likely diagnosis: A. Systemic lupus erythematosus B. Henoch-Schönlein purpura (HSP) C. Post-streptococcal glomerulonephritis D. Polyarteritis nodosa

Answer 161

B. Henoch-Schönlein purpura (HSP) Rationale: HSP is an IgA-mediated vasculitis that presents with purpuric rash, abdominal pain, arthritis, and nephritis. Renal involvement mimics IgA nephropathy.

Question 162

57. Ultrasound of KUB in UTI is used to rule out: A. Renal thrombosis B. Enlarged kidney C. Vesicoureteral reflux (VUR) D. Cystitis

Answer 162

B. Enlarged kidney Rationale: Ultrasound of the kidneys, ureters, and bladder (KUB) is commonly used in urinary tract infections (UTIs) to evaluate kidney size, detect hydronephrosis, congenital anomalies, and possible renal scarring. Enlarged kidneys may indicate underlying conditions like pyelonephritis, obstruction, or congenital anomalies. While vesicoureteral reflux (VUR) requires a voiding cystourethrogram (VCUG) for diagnosis, and cystitis is usually diagnosed clinically, renal ultrasound helps rule out kidney enlargement as a complication of UTI.

Question 163

58. Glomerulonephritis associated with low serum C3: A. Henoch-Schönlein purpura B. Post-streptococcal glomerulonephritis (APSGN) C. IgA nephropathy D. Hemolytic uremic syndrome

Answer 163

B. Post-streptococcal glomerulonephritis (APSGN) Rationale: APSGN is characterized by low C3 levels due to activation of the alternative complement pathway. C3 normalizes in 6-8 weeks.

Question 164

59. Urinary tract infection (UTI) in girls: A. Colonic bacteria are usually Klebsiella B. Equal ratio with boys C. Often occurs at the onset of toilet training D. Always arises by hematogenous spread

Answer 164

C. Often occurs at the onset of toilet training Rationale: Girls have a higher risk of UTI due to shorter urethras, and the risk increases at toilet training due to incomplete voiding. Most UTIs are ascending, not hematogenous.

Question 165

60. Renal disorders associated with hypertension (EXCEPT): A. Post-streptococcal glomerulonephritis (PSGN) B. IgA nephropathy C. Membranoproliferative glomerulonephritis (MPGN) D. Idiopathic rapidly progressive glomerulonephritis (RPGN)

Answer 165

B. IgA nephropathy Rationale: While many glomerular diseases are associated with hypertension, IgA nephropathy usually presents with hematuria and proteinuria but only mild to moderate hypertension. It is rarely severe enough to cause a hypertensive emergency, unlike post-streptococcal glomerulonephritis (PSGN), membranoproliferative glomerulonephritis, and idiopathic rapidly progressive glomerulonephritis, which often involve significant hypertension due to glomerular inflammation and reduced renal function.