CC SILVA - RATIONALIZATION

2022

PEDIATRICS

# Question Rationale

1 Most common cause of brain abscess: Answer: D. Streptococcus viridans

A. Haemophilus influenzae Rationale:
B. Neiserria meningitides ● The predominant organisms causing brain abscesses in children are
C. Staphylococcus aureus aerobic and anaerobic streptococci (60-70% of the cases) with
D. Streptococcus viridans Streptococcus milleri gp (Streptococcus anginosus, Streptococcus
constellatus, and Streptococcus intermedius) being increasingly
isolated from surgically drained brain abscesses. Streptococcus
viridans is also a common cause of brain abscess, especially in
intraoral sources of infections

Sources:
● Ruderman, Brandon, Traci Thoureen, and Joshua Broder. "Viridans
streptococci Intracranial Abscess Masquerading as Metastatic
Disease." Journal of Education and Teaching in Emergency Medicine
3.1 (2018).
● Nelson’s textbook of pediatrics 20th edition. Page 2949

2 Growth spurt in adolescent begins with: Answer: D. Enlargement of hands and feet
A. lengthening of arms and legs Rationale:
B. lengthening of the trunk ● Linear growth acceleration begins in early adolescence. The growth
C. enlargement of the chest spurt begins distally, with enlargement of the hands and feet,
D. enlargement of hands and feet followed by the arms and legs, and finally, the trunk and chest.
● NTK. Bone growth precedes increases in bone mineralization and
bone density, which may increase the adolescent’s risk of fracture
during times of rapid growth. Since skeletal growth precedes muscle
growth, sprains and strains may be more common during this time
as well.

Source: Nelson’s textbook of pediatrics 20th edition. Page 2949

3 Which of the following statements about Answer: C. Approval of participation of children in nontherapeutic research
participation of children in research is least can be secured easier than therapeutic research
accurate? Rationale:
A. The balance of anticipated benefit ● United States federal regulations allow participation of children in
to the risk when a child participates greater than minimal risk research with no potential for direct benefit
in research should be as favorable under narrowly defined circumstances. This type of research is
or better than the available controversial, as it runs contrary to the best interest standard, on
alternative which we base most decisions made on behalf of children. I argue
B. Children are considered as that such research is ethically defensible if a fully informed,
vulnerable population therefore risk scrupulous, and virtuous parent would choose to enroll his or her
levels acceptable to adults may not child in the study.
be applicable
C. Approval of participation of Source: Pediatric Participation in Non-Therapeutic Research by Maryn C.
children in nontherapeutic research Morris
can be secured easier than
therapeutic research
D. Screening test, such as the
Newborn Screening test, ideally
should be highly sensitive and
highly specific

4 Which is a minor risk factor for children to Answer: C. Inhalant allergy sensitization
develop persistent asthma? Rationale:
 A. Eczema ● The most common risk factors for developing asthma are:
B. Parental asthma ○ Having a parent with asthma
C. Inhalant allergy sensitization ○ Having a severe respiratory infection as a child
D. Allergic rhinitis ○ Having an allergic condition
○ Being exposed to certain chemical irritants or industrial
dust in the workplace.

5 What age does an infant begin to orient to Answer: D. 2-3 months

the source of sound? Rationale:
A. 5-6 months ● An infant starts to smile in response to face, voice at 1.5 months.
B. 4-5 months ● Closest answer among the choices is 2-3 months.
C. 3-4 months
D. 2-3 months

6 Which of the following organisms is the Answer: B. Staphylococcus aureus

least likely etiology of perinatally acquired Rationale:
neonatal pneumonia? ● Etiology of Neonatal Pneumonia:
A. Escherichia coli ○ 0 – 28 days:
B. Staphylococcus aureus ■ GBS
C. Group B Streptococus ■ E. coli
D. Chlamydia ■ Listeria
■ S. pneumoniae
○ 3 wks – 3 mos:
■ RSV
■ Parainfluenza
■ Chlamydia
■ Mycoplasma
■ S. pneumoniae

7 Infection of the bones of the foot is almost Answer: C. Staphylococcus aureus

exclusively due to: Rationale:
A. Kingella kingae ● Hematogenous osteomyelitis is primarily monomicrobial, while
B. Bartonella henselae osteomyelitis due to contiguous spread or direct inoculation is usually
C. Staphylococcus aureus polymicrobial or monomicrobial.
D. Pseudomonas aeruginosa ● The most common pathogens in osteomyelitis depend on the
patient's age.
● Staphylococcus aureus is the most common cause of acute and
chronic hematogenous osteomyelitis in adults and children.

8 Which is true about transitioning to adult Answer: D. Transition to adult care is a crucial aspect of the health of all
care? adolescents.
A. The transition is not so important Rationale: Choices A, B, C are false
for those young people with
chronic medical conditions.
B. Children with complex medical
conditions cannot benefit the
transitioning process.
C. There is no such delayed transition
or transfer to inappropriate adult
health.
D. Transition to adult care is a crucial
aspect of the health of all
adolescents.

9 True of Orthostatic or Postural Proteinuria: Answer: C. Absence of proteinuria in the first morning urine
 A. Occurs in <10% of children with Rationale:
persistent proteinuria ● Occurs in up to 60% of children with persistent proteinuria
B. It is associated with ● Usually asymptomatic, detected only during routine urinalysis
hypoalbuminemia and edema ● Assessed by collection of first morning urine sample
C. Absence of proteinuria in the first ○ Child must empty bladder before going to bed → collect
morning urine first voided urine sample immediately upon arising
D. Steroid therapy should be initiated ○ Absence of proteinuria in the first morning urine on 3
upon diagnosis consecutive days confirms diagnosis
● Absence of proteinuria
○ Dipstick negative or trace for protein
○ Urinary protein to urinary creatinine ratio < 0.2
● Studies suggest that it is a benign process
● No further evaluation nor treatment is needed

Source: Orthostatic Proteinuria - Nelson Pediatrics 2st1 Ed, Page 2750

10 Type of mucopolysaccharidoses with an Answer: D. Hunter syndrome

X-linked pattern of inheritance. Rationale:
A. Scheie syndrome ● Mucopolysaccharidoses are hereditary disease caused by mutation
B. Hurler syndrome of genes coding for lysosomal enzymes for glycosaminoglycan
C. Sanfilippo syndrome degradation →impaired glycosaminoglycan degradation →
D. Hunter syndrome intracellular accumulation of different degradation products
● Impaired degradation of
○ Heparan sulfate → mental deficiency
○ Dermatan, chondroitin, keratan → mesenchymal
abnormalities
● All mucopolysaccharidoses are autosomal recessive disorders,
EXCEPT Hunter syndrome: X-linked recessive

Source: Mucopolysaccharidoses - Nelson Pediatrics 21st Ed, Page 811

11 The amino acid that is most toxic to the Answer: D. All of the above / C. Leucine
brain and is responsible for the neurologic Rationale:
manifestations in patients with MSUD: ● Valine, Isoleucine and Leucine are all amino acid derivatives that
A. Valine build up in MSUD caused by the deficiency of the branched-chain
B. Isoleucine alpha keto acid dehydrogenase complex (BCKAD), however of the
C. Leucine three, leucine is the most neurotoxic amino acid to the brain.
D. All of the above

12 In addition to an Institutional Review Board’s Answer: C. Parent’s Informed consent and child’s assent
approval, which of the following does one Rationale:
need to secure prior to a child’s participation ● Children are neither legally or developmentally capable. of
in non-therapeutic research? consenting. to their own treatment or participation in research. No
A. Child consent one can consent for an individual other than that person. As a result,
B. Parent’s Informed Consent a proxy, such as a parent, must provide permission in lieu of consent
C. Parent’s Informed consent and and children who are deemed capable, must provide their assent
child’s assent ● Assent means a child’s affirmative agreement to participate in an
D. Parent’s consent, adolescent’s ongoing research
assent and pediatrician’s consent

13 Most likely diagnosis of a patient presenting Answer: B. Herpes simplex encephalitis

with fever, focal seizures, changes in Rationale:
sensorium, and EEG with epileptiform ● Symptoms of fever, focal seizures, changes in sensorium, are all
discharge at frontal or temporal areas: clinical manifestations for encephalitis. Studies concluded that while
A. Amoebic encephalitis seizures and behavioral abnormalities are common features in HSE,
B. Herpes simplex encephalitis focal seizures, and movement disorders are more frequent with JE
C. Enterovirus encephalitis ● Furthermore, thalamic involvement in JE and temporal involvement
D. Japanese B encephalitis in HSE are specific markers of each respective encephalitis.
14 What is the elemental dose of zinc for Answer: A. 20 mg
diarrhea in patients above 6 months of age? Rationale:
A. 20 mg ● In managing AGE, give ORS after every stool (50-100 ml for <2 yo;
B. 10 mg 100- 200 >2yo), continue feeding and give supplemental Zn
C. 5 mg ● Supplemental Zn for 10-14 days:
D. 15 mg ○ <6 months : 10 mg/day
○ >6 months: 20 mg/day

15 IgE mediated allergic reactions, except:: Answer: C. Arthus reaction

A. Acute urticaria Rationale:
B. Anaphylaxis
C. Arthus reaction
D. None of the choices

16 Which ion is the major determinant of Answer: B. Sodium

plasma osmolality? Rationale:
A. Chloride ● The distribution of fluid between intracellular and extracellular
B. Sodium compartments, in contrast, is determined mainly by the osmotic
C. Potassium effect of the smaller solutes— especially sodium, chloride, and other
D. Calcium electrolytes— acting across the cell membrane.
● Aldosterone has the greatest effect on Na+ excretion
● Mole for mole, ADH has the greatest effect on plasma osmolality
 Source: Guyton Chapter 25

17 A 12-year old female adolescent came in the Answer: D. Acute cholecystitis

ER because of pain in the right upper Rationale:
quadrant. She was noted to be slightly ● What was elicited was the Murphy’s sign (Pain on deep palpation
jaundiced. Pain on deep palpation during during inspiration)
inspiration was elicited. What is your most
likely diagnosis?
A. Mesenteric adenitis
B. Liver abscess
C. Acute pancreatitis
D. Acute cholecystitis

18 Which of the following factors increase the Answer: C. Low environment temperature
risk for morbidity and mortality among Rationale:
preterm infants: ● Preterm infants are prone to hypothermia and must be put under a
A. Early enteral nutrition droplight for thermoregulation between 36.5-37.5 degrees Celsius.
B. Low environment temperature ● Early enteral nutrition, Oxygen saturation at 90-95%, Strict infection
C. Oxygen saturation at 90-95% control all benefit the preterm infant
D. Strict infection control
19 What is the classic radiologic finding in a Answer: D.Lytic bone lesion with characteristic onion-skinning
patient with Ewing’s Sarcoma? Rationale:
A. Sunburst appearance ● The diagnosis of Ewing sarcoma should be suspected in a patient
B. Claw sign who presents with pain and swelling, with or without systemic
C. Pathologic fracture symptoms, and with a radiographic appearance of a primarily lytic
D. Lytic bone lesion with characteristic bone lesion with periosteal reaction, the characteristic onion-skinning
onion-skinning ● Sunburst appearance
○ Classic radiographic appearance of Osteosarcoma which is
one of the differential diagnosis for Ewing’s sarcoma
● Claw Sign
○ The claw sign is advocated as a discriminant of renal
versus non-renal origin of tumors.
○ Examples where a claw sign is useful include:
■ Meningioma vs intra-axial brain tumor
■ Wilms tumor vs neuroblastoma
■ Renal angiomyolipoma vs retroperitoneal
liposarcoma

Source: Nelson 21st ed page 2691

20 Which of the following is NOT a CT scan Answer: C. Subdural hemorrhage

findings of tuberculous meningitis? Rationale:
A. Infarct ● CT or MRI of the brain of patients with tuberculous meningitis may
B. Subdural hemorrhage be normal during early stages of the disease. As disease progresses,
C. Hydrocephalus basilar enhancement and communicating hydrocephalus with signs
D. Basal enhancement of cerebral edema or early focal ischemia are the most common
findings.
● Often, low-attenuating focal infarcts are seen in the deep gray
matter nuclei, deep white matter, and pons; these infarcts result from
associated vasculitis.
● The triad of hydrocephalus, infarct, and basal meningeal
enhancement make up the CT imaging features of TBM.
Combination of these features increases the specificity for the
disease.

Sources:
● Nelson 21st ed page 1574
● Tuberculous Meningitis Basal Cistern Enhancement Pattern on CT
imaging (2016) TUBERCULOUS MENINGITIS

21 This drug is given to patients with Answer: B. Potassium Chloride

hypokalemic periodic paralysis: Rationale:
A. Furosemide ● The goal is to normalize the serum potassium level by administering
B. Potassium chloride oral potassium chloride, which is believed to be more readily
C. Acetazolamide absorbed compared to other oral potassium solutions, alleviates the
D. Dantrolene symptoms of muscle weakness. IV potassium is not preferred
initially and is reserved for arrhythmias due to hypokalemia or if the
patient has swallowing difficulties or respiratory muscle paralysis.
● Furosemide is a potent loop diuretic indicated in patients with
congestive failure. It inhibits tubular reabsorption of sodium and
chloride in the thick ascending loop of Henle.
● Acetazolamide is a diuretic and carbonic anhydrase inhibitor and is
primarily used for the treatment of glaucoma and altitude sickness.
● Furosemide and Acetazolamide causes further decrease in
potassium therefore worsening the already hypokalemic state
● Dantrolene sodium is a postsynaptic muscle relaxant and is
primarily used for malignant hyperthermia.
● Hypokalemic periodic paralysis is a condition that causes episodes
of extreme muscle weakness. Most often, these episodes involve a
temporary inability to move muscles in the arms and legs.
 Source: Hypokalemic Periodic Paralysis NCBI, Furosemide NCBI,
Acetazolamide NCBI, Dantrolene NCBI

22 What CSF exam shows high specificity for Answer: D. Polymerase Chain Reaction
viral detection? Rationale:
A. Latex Agglutination ● PCR has a 95 to 100% sensitivity for detecting viral meningitis as
B. India Ink well as TB meningitis (can replace AFB Smear)
C. AFB Smear ● Latex Agglutination allows rapid detection of bacterial antigens; Low
D. Polymerase Chain Reaction specificity and can lead to false positives; only used as an adjunct if
bacterial meningitis is highly suspected but GS/CS is equivocal
● India Ink is for fungal detection
● AFB Smear is for TB meningitis

Source: https://www.aafp.org/afp/2003/0915/afp20030915p1103.pdf (good

read for fast CSF Analysis)

23 One of the following is not a diagnostic Answer: C. Seizures

criteria for CoVid-19: Rationale:
A. Fever
B. Dyspnea
C. Seizures
D. Sore throat

Source: Interim Guidelines on the Screening, Assessment and Clinical

Management of Pediatric Patients with Suspected or Confirmed Coronavirus
Disease 2019 (COVID-19) Version 3.1 , 31 August 2020

24 Which of the following statements does not Answer: C. Infant with birth weight of less than 2,500 grams
describe a premature infant? Rationale:
A. Infant with a Ballard score of less ● Ballard score can determine the age of gestation based on the
than 35 physical features of the newborn. A score of 35 is equivalent for 38
B. Infant born before 37 completed weeks AOG, and less than this calculated AOG classifies an infant as
weeks gestation preterm
C. Infant with birth weight of less than ● Both B and D are the same AOG of 37 weeks
2,500 grams ● Option C pertains to the birthweight description of an infant. In this
D. Infant born before 259 days case, low birthweight is considered
gestation
 Source: Gomella’s Neonatology

25 This is the preferred mode of renal Answer: A. Kidney transplantation

replacement therapy for children with End Rationale:
stage renal disease (ESRD) as it is ● ESRD - state in which a patient’s renal dysfunction has progressed to the
associated with improved linear growth, point where homeostasis and survival cannot be sustained by maximal
allows regular school attendance and often medical management. Hence, RRT is necessary.
eliminates dietary restrictions. ● Renal replacement therapy - can be either by dialysis
A. Kidney Transplantation (peritoneal/hemodialysis) or renal transplantation
B. Continuous Renal Replacement ○ Thus, RULE OUT CHOICE B.
Therapy ● For children with ESRD, remember that the ultimate goal is KIDNEY
C. Peritoneal Dialysis TRANSPLANT. This provides the most normal lifestyle and improved
D. Intermittent Hemodialysis mortality & morbidity rates.
○ Successful transplantation leads to accelerated linear growth, allows
for regular school attendance, and eliminates need for dietary
restrictions.
● Read on: Indications of dialysis and the pros vs cons between peritoneal
and hemodialysis (pp 2778-2779)

Source: Nelson Textbook of Pediatrics 21st Ed

26 A doctor was consulted because a five year Answer: A. Fragile X syndrome

old boy has an intellectual disability. Rationale:
Physical examination showed long face, ● Klinefelter Syndrome - Most common cause of hypogonadism
testes appear to be enlarged, without mass ○ Puberty commences at the normal age but testes remain
lesions present. Which of the following small → RULE OUT
● XYY Syndrome - Normal intelligence but at risk for learning disabilities →
 genetic abnormalities is the most likely RULE OUT
etiology for these findings? ● Fragile X Syndrome - Main clinical manifestations are:
A. Fragile X syndrome ○ Intellectual disability
B. Klinefelter syndrome ○ Autistic behavior
C. XYY syndrome ○ Postpubertal macroorchidism
D. Down syndrome ○ Hyperextensible finger joints
○ Characteristic facial features (large cupped ears, elongated
face, high arched palate)
○ ONLY choice with enlarged testes, thus most likely answer
:)

27 Which of the following micronutrients is not Answer: D. Iron

immediately started in patients with Rationale:
persistent diarrhea? ● Folic acid - Folic acid is an important nutrient for immune and
A. Folic acid lymphatic function. It also plays a key role in DNA synthesis, which is
B. Copper needed for the regeneration of damaged small-bowel mucosal
C. Zinc epithelial cells
D. Iron ● Copper - Shown to have reduction in the duration of diarrhea, the
volume of stool output and the rates of complications
● Zinc - Zinc supplementation is important in both prevention and
therapy of chronic diarrhea, since it promotes ion absorption,
restores epithelial proliferation, and stimulates immune response
● Iron - Iron supplementation and fortification could induce diarrhea
by causing intestinal damage through oxidative stress or by
initiating bacterial dysibiosis and gut inflammation

Take note: Micronutrients should be given for at least 2 wk; multivitamin

(twice the RDA), folic acid (5 mg day 1, then 1 mg/day), zinc (2 mg/kg/day)
and copper (0.3 mg/kg/day)

After the infant has begun to improve and is gaining weight, 3 mg/kg/day of
iron is added.

Thus, iron is not usually immediately started in patients with persistent

diarrhea.

28 Bien is a 4-year old child who will be Answer: A. Recurrent pneumonia

admitted at the pedia ward because of Rationale:
pneumonia. Two months ago, he was ● Recurrent pneumonia - Defined as 2 or more episodes in a single
admitted at the same ward because of year or 3 or more episodes ever, with radiographic clearing between
pneumonia. Bien’s repeat chest x-ray was occurrences
normal during his ff-up check-up 1 week ● Chronic pneumonia - Chronic pneumonia is an illness that lasts at
after his first hospitalization. Bien has: least 6 weeks and is caused by a microorganism.
A. Recurrent pneumonia ● Subclinical pneumonia - not a real term
B. Chronic pneumonia ● Relapse pneumonia - not a real term
C. Subclinical pneumonia
D. Relapse of pneumonia

29 A 2 and half-year old boy arrived at the ER Answer: C. Weight and height
because of poor appetite of 2 weeks Rationale:
duration. On PE, you noted that there are For malnutrition, the term we are looking for is WASTING.
signs of muscle wasting. What ONLY THREE PARAMETERS can be used depending on age of patient:
anthropometrics will you use to assess his 1. WEIGHT FOR LENGTH/HEIGHT
nutritional status? ● REMEMBER!
A. Height-for-age ○ LENGTH = IF < 2 YEARS OLD
B. Length-for-age ○ HEIGHT = IF > 2 YEARS OLD
C. Weight and height 2. MUAC
D. Weight and length 3. BMI
*Since patient is >2 years old, Weight and height is the correct
 answer:

SUPPLEMENT:
● Height for age (length for age if<2)
○ Measures linear growth (does not assess nutritional status)
○ Represents cumulative impact of adverse events
● Weight for age
○ Low value
○ Limited clinical significance
● Weight for height
○ Wasting
○ Acute malnutrition
● Mid upper arm circumference
○ 11.5-12.5 cm = wasting
○ <11.5 cm = severe wasting

Source: Topnotch

30 What cranial nerves are involved when you Answer: D. CN 5, 7

elicited by touching the cornea with a small Rationale:
pledget of cotton and there is symmetric eye REMEMBER- CORNEAL BLINK REFLEX
closure in a comatose patient? ● Closure of the eyelids in response to blowing on the cornea or
A. CN 5, 6 touching it with a wisp of cotton; caused by contraction of
B. CN 4, 5 orbicularis oculi muscles
C. CN 3, 5 ● CRANIAL NERVES INVOLVED: CN 5, 7
D. CN 5, 7 ○ Efferent limb – Facial nerve (CN 7)
○ Afferent limb – Nasociliary nerve of the Ophthalmic division
of Trigeminal nerve (C5)

Source: Topnotch

31 What is the most frequent pathogenic Answer: C. Staphylococcus aureus

bacteria colonizing the umbilical cord? Rationale:
A. Group B Streptococci ● Staphylococcus aureus, Group B streptococcus (GBS) and
B. Escherichia coli Escherichia coli (E. coli) have been the predominant isolates from
C. Staphylococcus aureus the colonized umbilicus in newborns. However, gram-positive
D. Group A Streptococci bacteria (mainly S. aureus) were more commonly isolated from the
cord than Gram-negative bacteria (mainly E. coli).

32 Children understand before they can speak Answer: C. Development is intimately related to the CNS maturation
demonstrates what principle of Rationale:
development? ● The sequence is the same in all children: For example, there is a
A. The sequence is the same in all predictable sequence of developments that occur before walking.
children ● Development follows a cephalocaudal direction: The cephalocaudal
B. Development follows a principle states that development proceeds from top to bottom
cephalocaudal direction meaning a child will gain physical control of their head first then
C. Development is intimately related to move downward to the arms and lastly to the legs.
the central nervous system ● Development is intimately related to CNS maturation: Children must
maturation mature to a certain point before they can progress to new skills
D. Generalized mass activity is (Readiness). For example, a four-month-old cannot use language
replaced by specific individual because the infant’s brain has not matured enough to allow the child
responses to talk. By two years old, the brain has developed further and with
help from others, the child will have the capacity to say and
 understand words. Maturational patterns are innate, that is,
genetically programmed.
● Generalized mass activity is replaced by specific individual
responses: For example, the infant’s first motor movements are very
generalized, undirected, and reflexive, waving arms or kicking before
being able to reach or creep toward an object.

33 Carl, presently a 13-month old infant, was Answer: A. Bruton’s agammaglobulinemia

apparently healthy until age 7 months when Rationale:
he developed recurrent pneumonia which ● Bruton agammaglobulinemia,
warranted several hospitalizations. PE on ○ Also known as X-linked agammaglobulinemia (XLA), is an
latest admission revealed an inherited immunodeficiency disorder. It is characterized by the
undernourished and stunted infant, in absence of mature B cells which in turn leads to severe antibody
respiratory distress with crackles in all lung deficiency and recurrent infections.
fields, a very small tonsil and no palpable ○ Children with inherited profound antibody deficiencies remain
lymph nodes. He should be worked up for: well for the first 6 to 9 months of life because of
A. Bruton’s agammaglobulinemia transplacentally acquired maternal IgG antibodies. The half-life
B. Di George syndrome of IgG is approximately 3 weeks, and it is not until 6 to 9
C. Chediak-Higashi syndrome half-lives, or about 6 months, after birth that maternal IgG falls
D. Duncan disease below protective levels. Thereafter, these children begin to
develop infections such as sinusitis, otitis media, and
pneumonias.S. pneumoniae, H. influenzae, meningococci,
andMycoplasma species are particularly common infectious
agents.
○ On physical examination, the absence of tonsils, chronic cough,
chronic rhinitis, post-nasal drip, and clubbing can be seen.
Growth charts may show evidence of failure to thrive especially
in older children.
● DiGeorge Syndrome
○ Features of DGS include cardiac anomalies, recurrent infections,
abnormal facies, thymic hypoplasia or aplasia, cleft palate,
developmental delay, and hypocalcemia.
○ Recurrent sinopulmonary infections due to T cell deficiency as a
result of thymic hypoplasia
● Chediak-Higashi Syndrome
○ Chediak Higashi syndrome (CHS) is an autosomal recessive
disorder that is characterized by easy bruising, oculocutaneous
albinism and recurrent pyogenic infections.
○ Clinically, a diagnosis should be considered in individuals that
exhibit signs of immunodeficiency; pigment dilution of the skin,
hair, or eyes; congenital or transient neutropenia; and signs of
unexplained neurologic symptoms or neurodegeneration.
● Duncan Disease
○ Affected individuals typically have lymphadenopathy and
hepatosplenomegaly with extensive parenchymal damage
including fulminant hepatitis, hepatic necrosis, and profound
bone marrow failure. Involvement of other organs may include
the spleen ("white pulp" necrosis), heart (mononuclear
myocarditis), and kidney (mild interstitial nephritis).

34 Which of the following statement of Answer: A. Breastfeeding is recommended

galactosemia is FALSE: Rationale:
A. Breastfeeding is recommended ● In terms of infant conditions, galactosemia is clearly an absolute
B. It is an autosomal recessive contraindication to breast-feeding. Breast milk is a rich source of
disorder lactose, and the very survival of infants with galactosemia is
C. There is a deficiency in dependent on their receiving a non-lactose-containing formula.
galactose-1-phosphate uridyl ● Galactosemia is an autosomal recessive disorder characterized by
transferase deficient activity of the enzyme galactose-1-phosphate uridyl
D. Presents with sweaty odor transferase.
35 A previously healthy 4-year old was brought Answer: C. G-6-PD deficiency
at the ER for pallor, dark urine and jaundice Rationale:
over the past few days. There was no history ● sulfamethoxazole component of co-trimoxazole can cause clinically
of travel, or exposure to a jaundiced person. significant haemolysis, particularly in subjects with
He is currently taking Co-trimoxazole for glucose-6-phosphate dehydrogenase (G6PD) deficiency
Otitis media. CBC showed low Hgb, normal ● (G6PD) deficiency
BUN, high bilirubin levels. Which of the ○ impaired regeneration of reduced glutathione, an important
following is the MOST likely cause of the antioxidant -> makes RBCs more susceptible to oxidative
symptoms? stress -> can result in episodic hemolytic anemia
A. Aplastic anemia ● Triggers = ↑oxidative stress -> Hemolytic crisis
B. Hepatitis B ○ Fava beans
C. G-6-PD deficiency ○ Drugs: antimalarial drugs (e.g., chloroquine, primaquine),
D. Hemolytic uremic syndrome sulfa drugs (e.g., trimethoprim-sulfamethoxazole),
nitrofurantoin, isoniazid, dapsone, NSAIDs, ciprofloxacin,
chloramphenicol
○ Bacterial and viral infections (most common cause):
Severe enzymatic deficiency can inhibit respiratory burst
activity due to reduced NADPH production in phagocytes.
○ Inflammation: During an inflammatory reaction free radicals
are produced and can diffuse into RBCs.
○ Metabolic acidosis
● Clinical features
○ Majority are asymptomatic
○ Recurring hemolytic crises may occur, especially following
triggers
■ Arise within 2–3 days after increased oxidative
stress
■ Sudden onset of back or abdominal pain
■ Jaundice
■ Dark urine
■ Transient splenomegaly
○ Recurrent severe infections causing symptoms of chronic
granulomatous disease
● Diagnostics
36 More recent concept of pneumonia in Answer: A. Pneumonia results from destruction of complex lower respiratory
children posits that: ecosystem composed of potential pathogens, resident microbes and host
A. Pneumonia results from destruction immune defense
of complex lower respiratory Rationale:
ecosystem composed of potential ● Pneumonia occurs because of
pathogens, resident microbes and ○ impairment of host defenses, invasion by a virulent
host immune defense organism, and/or invasion by an overwhelming inoculum.
B. Pneumonia is a result of invasion of ● Pneumonia follows an upper respiratory tract illness that permits
a sterile lower respiratory tract by a invasion of the lower respiratory tract by bacteria, viruses, or other
single pathogen pathogens that trigger the immune response and produce
C. The lower respiratory tract is kept inflammation
sterile by a number of defense ● The lower respiratory tract air spaces fill with white blood cells, fluid,
mechanism against infection such and cellular debris.
as the mucociliary clearance and ● This process reduces lung compliance, increases resistance,
secretory IgA obstructs smaller airways, and may result in collapse of distal air
D. Pneumonia is the result of invasion spaces, air trapping, and altered ventilation-perfusion relationships
of a sterile respiratory tract by
multiple pathogens Source: UpToDate. Pneumonia in children: Epidemiology, pathogenesis, and
etiology

37 Cerebral schistosomiasis is caused by: Answer: A. S. japonicum

A. S. japonicum Rationale:
B. S. mansoni ● Neuroschistosomiasis is one of the rare and most severe clinical
C. C. sinensis presentations of the disease.
D. S. haematobium ● Caused by granuloma formation around eggs that lodge in the
central nervous system
● Central nervous system involvement may occur in chronic
schistosomiasis caused by any schistosome species, but especially
by S japonicum.
● Usual presentation: focal or generalized tonic-clonic seizures and
focal deficits.

Source: JAMA Neurology; Sciencedirect

https://jamanetwork.com/journals/jamaneurology/fullarticle/788601
https://www.sciencedirect.com/science/article/pii/S1201971219302772

Note: No mention of cerebral schistosomiasis in Jawetz and Nelson’s so I

based it on journals

38 What is the most common cause of poor Answer: B. Infrequent or ineffective feedings
weight gain among breastfed infants during Rationale:
the first four weeks after birth? ● Insufficient milk intake, dehydration, and jaundice in the infant can
A. Maternal endocrine problems become evident within the first week of life. Signs of insufficient milk
B. Infrequent or ineffective feedings intake include: lethargy, delayed stooling, decreased urine output,
C. Infant metabolic disorders weight loss >7% of birth weight, hypernatremic dehydration,
D. Maternal nutritional deficiencies inconsolable crying and increased hunger.
○ Insufficient milk intake may be caused by insufficient milk
production, failure of established breastfeeding, and health
conditions in the infant that prevent proper breast stimulation
● Poor weight gain causes
○ Not consuming an adequate amount of dietary energy
(measured in calories) or not consuming the right combination
of protein, fat, and carbohydrates
○ Not absorbing an adequate amount of nutrients
○ Requiring a higher than normal amount of dietary energy
(measured in calories)

39 A newborn with very low APGAR scores at 1, Answer: D. Patent ductus arteriosus
5 and 10 minutes will most likely have a Rationale:
● Hypoxia, acidosis and congenital heart defects are conditions that
 delay or even failure in closure of which of lead to a sustained high PVR and may interfere with the normal
the following shunt? sequence of events of transition from fetal to neonatal circulation
A. All of the choices ● Constriction of the ductus arteriosus is a gradual process that
B. Ductus venosus results from a reduction of pulmonary vascular resistance (PVR),
C. Patent foramen ovale increasing systemic vascular resistance (SVR) and sensitivity to a
D. Patent ductus arteriosus rise in arterial PaO2 levels

40 The following may be given as prophylaxis Answer: C. Rifampicin

drug for close contact with Rationale:
meningococcemia: ● Household, school, or daycare contacts during the 7 days before
A. Pyrazinamide onset of illness should receive antibiotic prophylaxis
B. Amikacin ● Prophylaxis not routinely recommended for medical personnel
C. Rifampicin except those with intimate exposure (intubation, suctioning,
D. Penicillin mouth-to-mouth resuscitation)
○ Rifampicin 10 mg/kg PO every 12 hrs for a total of 4 doses
(max 600 mg/dose);
○ Ceftriaxone 125 mg single dose IM for <15 yrs old, 250 mg
single dose IM ≥ 15 yrs old;
○ Ciprofloxacin 500 mg PO as single dose ≥ 18 yrs old

41 A 3-year old child was brought by the mother Answer: B. Recent history of viral infection is seen in half of the cases
for check-up because of a sudden onset of Rationale:
bruising. The child was apparently well a day ● A recent history of viral illness is described in 50–65% of children
prior. Idiopathic thrombocytopenic purpura with ITP. In a small number of children, estimated at 1 in 20,000, 1-4
(ITP) was entertained. Which of the wk after exposure to a common viral infection, an autoantibody
following is CORRECT regarding ITP? directed against the platelet surface develops with resultant sudden
A. Hepatosplenomegaly is suggestive onset of thrombocytopenia
B. Recent history of viral infection is ● The classic presentation of ITP is a previously healthy 1-4 yr old child
seen in half of the cases who has sudden onset of generalized petechiae and purpura. There
C. Majority will present with severe may be bleeding from the gums and mucous membranes,
bleeding particularly with profound thrombocytopenia (platelet count <10 ×
D. More than half will succumb due to 109/L). Severe bleeding is rare (<3% of cases in 1 large
intracranial bleeding international study).
● Findings on physical examination are normal, other than petechiae
and purpura. Splenomegaly, lymphadenopathy, bone pain, and pallor
are rare, and suggest other diagnoses (leukemia, syndromes).
● Fewer than 1% of patients develop an intracranial hemorrhage (ICH)

42 Which of the following doesn’t suggest the Answer: C. a 5 year old child with oxygen saturation of 92% breathing room
need for hospitalization in pediatric patients air
with pneumonia? Rationale:
A. A 6 months old infant with ● Not in in hypoxemia; her O2 sat is at >90% at breathing room air
intercostals and subcostal ● A. Toxic appearance
retractions ● B. Complicated pneumonia (presence of pleural effusion)
B. A 2 year old child whose chest x-ray ● D. Age <6 mo.
revealed patchy infiltrates with
effusion
C. A 5 year old child with oxygen
saturation of 92% breathing room
air
D. A 3 month old infant with a
respiratory rate of 70 cycles per
minute
43 If the researcher decided to exclude those Answer: D. 132 cm and 152 cm
boys who are in the bottom 2.5% and those Rationale:
who are in the top 2.5% of the distribution, This is a follow-up question of #61
the shortest now and the tallest would be: ● empirical rule (68 95 99 rule) - for normal distributions
A. 142 cm and 152 cm ○ 68% of observed data points will lie inside one standard
B. 137 cm and 142 cm deviation of the mean
C. 128 cm and 152 cm ○ 95% will fall within two standard deviations
D. 132 cm and 152 cm ○ 99.7% will occur within three standard deviations
● Average is 142cm with standard deviation of 5cm. If 5cm is 1 SD,
then 10cm must be 2 SDs.
● 2 SDs above → 152 cm
● 2 SDs below → 132 cm

44 One complication of Acute Kidney Injury is Answer: A. ST Segment Elevation

hyperkalemia. Which is not an ECG finding in Rationale:
hyperkalemia? ● Hyperkalemia ECG changes
 A. ST segment elevation ○ Peaked T waves ( 7.5 meq/L)
B. Peaked T Wave ○ Loss of P waves; Widening of QRS (8.0 meq/L)
C. Ventricular Arrhythmia ○ ST segment depression; Further widening of QRS ( 9.0
D. Widened QRS meq/L)
○ Bradycardia; Sine wave QRS-T; First degree AV block;
Ventricular Arryhythmia (10 meq/L)

45 Which of the following patient most likely Answer: A. 6-year old child, with grade 2/6 soft murmur at LLSB which
has rheumatic fever? changes in intensity with positioning, ASOT 200 Todd units, ESR normal,
A. 6-year old child, with grade 2/6 soft CRP (-)
murmur at LLSB which changes in Rationale:
intensity with positioning, ASOT A. ASOT 200 todd units (GAS infection), Carditis (Major)
200 Todd units, ESR normal, CRP (-) B. (+) ASOT (GAS infection), Chorea (Major)
B. 8-year old female with involuntary C. Arthritis ( Major), (+) CRP (Minor)
jerky movement which disappears D. ASOT 200 (GAS Infection), Elevated ESR (Minor)
during sleep, ASOT (+), ESR (-), CRP
(-) Criteria for Initial Rheumatic Fever
C. 15-year old male with joint pains ● Evidence of preceding group-A streptococcal infection, PLUS:
and swelling and hematuria, CRP ○ 2 major criteria, or
(+) ○ 1 major criteria + 2 minor criteria
D. 2-year old child with night time joint ● Three circumstances wherein a diagnosis of RF can be made
pains, ASOT 200 Todd units, ESR without strict adherence to Jones Criteria:
slightly elevated, CRP (-) ○ When chorea is the only major manifestation
○ When indolent carditis is the only manifestation upon first
check-up, months after the apparent onset of ARF
○ Apparent ARF in a limited number of patients with
recurrences of ARF in particularly high-risk population

46 The following is a characteristic of Answer: B. Associated with maternal obstetric complication

early-onset neonatal Group B streptococcus Rationale:
(GBS) disease: A. Should be <7 days
A. Presents within 7 – 90 days of life B. Associated with early obstetric complications, generally through the
B. Associated with maternal obstetric maternal genital canal
complication C. Mortality is higher
C. Less severely ill neonates D. Presents with clinically as Temperature irregularities, Change in
D. Usually presents as bacteremia behavior, skin signs like jaundice, sclerema, and other signs of
sepsis

47 A 4-year old child was brought in because of Answer: D. Shigella

fever, vomiting, abdominal pain and bloody Rationale:
diarrhea. Hydration was instituted but soon ● The most dreaded complication of pediatric diarrhea in the United
after the diarrhea resolved 3 days later, the States is HUS, the leading cause of acquired renal failure in children,
child started to have pallor, irritability and developing in 5–10% of patients infected with STEC. It is usually
lethargy. Oliguria was likewise observed. diagnosed 2-14 days after the onset of diarrhea. HUS is unlikely to
Laboratory tests revealed anemia with occur once diarrhea has remained resolved for 2 or 3 days with no
schistocytes and burr cells on PBS, elevated evidence of hemolysis. Risk factors include age 6 mo to 4 yr, bloody
BUN, Creatinine and microscopic hematuria diarrhea, fever, elevated leukocyte count, and treatment with
with RBC casts on U/A. the most probable antibiotics and antimotility agents. A single serotype of Shigella, S.
etiologic agent responsible for this condition dysenteriae type 1, elaborates the Shiga toxin which increases the
is: severity of illness and is responsible for development of hemolytic
A. Campylobacter uremic syndrome (HUS).
B. E. histolytica
C. E. coli ● Campylobacter
D. Shigella ○ Pseudoappendicitis secondary to mesenteric adenitis is a
notable complication of Yersinia, and sometimes
Campylobacter. It typically presents with fever and abdominal
pain with tenderness localized to the right lower quadrant, with
or without diarrhea, and can be confused with appendicitis. CT
 scan or sonogram may be helpful to distinguish true
appendicitis.
○ Immune-mediated complications that are thought to result from
immunologic cross reactivity between bacterial antigens and
host tissues are more often seen in adults than children. These
include reactive arthritis following infection with the classical
bacterial enteropathogens and Guillain-Barré syndrome
following Campylobacter infection.

● E. histolytica
○ Entamoeba can cause severe ulcerating colitis, colonic dilation,
and perforation. The parasite may spread systemically, most
commonly causing liver abscesses. In high-risk settings, it is
critical to exclude Entamoeba infec tion and tuberculosis before
initiating corticosteroids for presumedulcerative colitis.

● E. coli
○ Five pathotypes of Escherichia coli infect humans: Shiga
toxin–producing (STEC), also known as enterohemorrhagic
(EHEC), enterotoxigenic (ETEC), enteropathogenic (EPEC),
enteroaggregative (EAEC), and enteroinvasive (EIEC).
○ Crampy abdominal pain and nonbloody diarrhea are the first
symptoms of STEC infection, sometimes with vomiting. Within
several days, diarrhea becomes bloody and abdominal pain
worsens and lasts between 1 and 22 days.
○ In contrast to dysentery, the stools associated with STEC
hemorrhagic colitis are large volume and rarely accompanied by
high fever.
○ ETEC produces a secretory watery diarrhea that affects infants
and young children in developing countries and is the major
causative agents of travelers’ diarrhea, accounting for about
half of all episodes in some studies.
○ EPEC remains a leading cause of persistent diarrhea
associated with malnutrition among infants from developing
countries.
○ EIEC, which are genetically, biochemically, and clinically nearly
identical to Shigella, causes rare foodborne outbreaks in
industrialized countries.
○ EAEC has been associated with persistent diarrhea in
immunocompromised persons and sporadic diarrhea in infants
in countries with varying levels of economic development

48 You perform a visual exam to a normal Answer: A. 37 weeks

newborn wherein there is response by Rationale:
turning the head and eyes toward a light. ● At 28 wk of corrected gestational age, a premature infant blinks in
What is the gestational age of this patient? response to a bright light, and at 32 wk, the infant maintains eye
A. 37 weeks closure until the light source is removed. The pupil reacts to light by
B. 36 weeks 29-32 wk of corrected gestational age; however, the pupillary
C. 34 weeks response is often difficult to evaluate, because premature infants
D. 35 weeks resist eye opening and have poorly pigmented irises. A normal
37-week infant turns the head and eyes toward a soft light, and a
term infant is able to fix on and follow a target, such as the
examiner’s face.

Source: Nelson’s pediatrics

49 The new formulation of ORS recommended Answer: D. 75 mmol

by WHO contains a sodium level of: Rationale:
A. 55 mmol
B. 65 mmol
 C. 80 mmol
D. 75 mmol

50 Risk-directed therapy is the standard of Answer: C. Trisomy of specific chromosomes (4, 10, and 17)
current ALL treatment & the following are Rationale:
considered to be HIGH RISK, except ● Children who are younger than 1 yr or older than 10 yr or who have
A. T-cell immunophenotype an initial leukocyte count of >50,000/μL are considered to be high
B. Initial WBC count of >50,000/uL risk.
C. Trisomy of specific chromosomes ● Additional characteristics that adversely affect outcome include
(4, 10 & 17) T-cell immunophenotype or a slow response to initial therapy.
D. Children who are younger than 1 ● Chromosomal abnormalities with poor prognosis:
year old or older than 10 years ○ Hypodiploidy
○ Philadelphia chromosome
○ KMT2A (MLL) gene rearrangements
○ IKZF1 gene mutations
● More favorable characteristics:
○ Rapid response to therapy
○ Hyperdiploidy
○ Trisomy of specific chromosomes (4, 10,nd 17) ←
○ Rearrangements of the ETV6-RUNX1 (formerly TEL-AML1)
genes

Source: Chapter 522, Nelson’s Textbook of Pediatrics 21st ed.

51 Kobe suffered a puncture wound at the sole Answer: C. Staphylococcus aureus

of his right foot, although he was wearing Rationale:
running shoes at the time of the accident. ● Bacteria are the most common pathogens in acute skeletal
The wound was cleaned and he was given infections.
anti-tetanus and amoxicillin. After 3 days, ● S. aureus is the most common cause of osteomyelitis and
the right foot became swollen and painful, suppurative arthritis in children of all age groups, including
rendering walking very difficult for Kobe. He newborns.
was diagnosed to have osteomyelitis and NTKs:
the most likely pathogen in this case is: ● Group B streptococcus and Gram-negative enteric bacilli
A. Bacillus subtilis (Escherichia coli) are also prominent pathogens in neonates.
B. Pseudomonas aeruginosa ● > 6 yo: S. aureus, group A streptococci, or Pseudomonas aeruginosa
C. Staphylococcus aureus
D. Group A beta-hemolytic strep
 Source: Chapter 704, Nelson’s Textbook of Pediatrics 21st ed.

52 Which of the following tests will differentiate Answer: A. Repetitive nerve stimulation
muscle disease from neuromuscular Rationale:
junction? ● Myasthenia Gravis is one of the few neuromuscular disorders in
A. Repetitive nerve stimulation which electromyography (EMG) is more specifically diagnostic than
B. Red ragged fibers from biopsy a muscle or nerve biopsy
C. Polymerase chain reaction ○ A decremental response is seen to repetitive nerve
D. Single fiber electromyography stimulation–the muscle potentials diminish rapidly in
amplitude until the muscle becomes refractory to further
stimulation
○ A decline of greater than 10% between waves 1 : 4 on
repetitive stimulation is diagnostic for a decremental
response, and suggestive of a disorder of neuromuscular
transmission.

Source: Chapter 630, Nelson’s Textbook of Pediatrics 21st ed.

53 Blood flow to the brain and upper Answer: B. Left Ventricle

extremities in fetal circulation is primarily Rationale:
coming from which of the following
chambers?
A. Right ventricle
B. Left ventricle
C. Left atrium
D. Right atrium
 ● In the figure, 21% of the blood is supplied to the brain and the upper
extremities, all of which comes from the 31% in the left ventricle.
● This is because the blood supply to these areas comes out before
the ductus arteriosus joins the descending aorta.

54 A 2-year-old male came in due to pallor. CBC Answer: B. Hemoglobin Electrophoresis

revealed decreased hemoglobin, decreased Rationale:
MCV, normal RDW, normal RBC count, and ● Since the patient has low hemoglobin, the patient has ANEMIA.
normal reticulocyte hemoglobin Specifically, Microcytic Anemia since the MCV is low.
concentration. What will be the next
diagnostic test you will recommend?
A. Osmotic fragility test
B. Iron studies
C. Schilling’s test
D. Hemoglobin electrophoresis

● A normal RDW suggest Thalassemia.

● Reticulocyte hemoglobin content - provides an indirect measure of
the functional iron available for new red blood cell production over
the previous 3-4 days. Since it is normal, Iron Deficiency anemia is
unlikely.
● Hemoglobin Electrophoresis - is a blood test used to measure and
identify the different types of hemoglobin in your bloodstream.
● The distinguishing finding in beta thalassemia is a hemoglobin
electrophoresis with the finding of elevated Hgb A2 and F. Both will
be increased in beta thalassemia trait without iron deficiency, and
will be normal or decreased in alpha thalassemia and isolated iron
deficiency anemia.

NTKs:
● Osmotic fragility test - used to measure erythrocyte resistance to
hemolysis while being exposed to varying levels of dilution of saline
solution
● Shilling’s Test - The Schilling test was a medical investigation used
 for patients with vitamin B₁₂ deficiency. The purpose of the test was
to determine how well a patient is able to absorb B12 from their
intestinal tract.
● B12 deficiency presents as Macrocytic Anemia

https://www.aafp.org/afp/2001/1015/p1379.html

55 When you say that a test is highly sensitive, Answer: D. The probability that a patient who has the disease will test
which of the following statements is least positive is very high.
accurate? Rationale:
A. The probability that a patient who ● Sensitivity - the ability of the test to correctly identify patients with
does not have a disease will test the disease
negative is very high ● Specificity - the ability of the test to correctly identify people without
B. There are few false negative results the disease.
C. The test will rarely miss
actual/positive cases
D. The probability that a patient who
has the disease will test positive is
very high

56 A pregnant woman contracted German Answer: B. Baby may develop pulmonary stenosis
measles during the second month of Rationale:
pregnancy, which of the following may ● The classic triad of clinical manifestations associated with CRS
occur? among surviving neonates are hearing impairment, congenital heart
A. Coarctation of the aorta is probable defects – in particular, branch pulmonary artery stenosis and patent
B. Baby may develop pulmonary ductus arteriosus – and eye anomalies such as cataract(s),
stenosis pigmentary retinopathy (salt and pepper type), chorioretinitis or
C. Fetal demise congenital glaucoma.
D. Nothing

57 Overuse injuries are caused by repetitive Answer: D. Training error

micro-trauma that exceeds the body’s rate of Rationale:
repair. The most common identified factor ● Training errors are the most common cause of overuse injuries.
for overuse injuries is:
A. Nutritional deficiency
B. Muscle imbalance
C. Anatomic causes such as pes
planus and external tibial torsion
D. Training error

58 A 3-week old baby was brought to your clinic Answer: B. Patient is purely breastfed
because of yellowish discoloration of the Rationale:
skin. You proceeded with your history taking.
Which of the following in the history will help
 in your decision that you are not dealing with
pathologic jaundice?
A. Baby’s stool noted to become light
in color
B. Patient is purely breastfed
C. Jaundice noted to appear on the
second week of life
D. Baby’s urine noted to stain diaper

59 A 6-months old male home delivered was Answer: C. VItamin K deficiency

brought to the emergency room because of Rationale:
seizure and bulging anterior fontanelle. ● von Willebrand disease
Cranial ultrasound revealed a subdural ○ Typically presents with mucosal bleeding
collection of blood at the right frontal area. ○ Epistaxis, easy bruising, and menorrhagia in women are
CBC platelet was normal, Protime was 56% common complaints.
and APT was 60 with control of 30 seconds. ○ No reliable screening test
What is the probable diagnosis? ○ Panel of tests required for VWF
A. von Willebrand disease ■ VWF:Ag - measures the total amount of VWF protein
B. Disseminated intravascular present
coagulation ■ VWF activity test or VWF:RCo - uses ristocetin cofactor
C. Vitamin K deficiency activity assay which provides a measure of the amount of
D. Factor VIII and IX deficiency functional VWF.
● DIC - platelet counts may be profoundly depressed.
○ DIC is triggered by any life-threatening severe systemic disease
associated with hypoxia, acidosis, tissue necrosis, shock, or
endothelial damage.
○ Prothrombin time (PT), partial thromboplastin (PTT), and
thrombin time (TT) are prolonged.
● Vitamin K deficiency
○ The patient in the question is presenting a Vitamin K deficiency
bleeding (VKDB)
○ Patient may be presenting a Late-onset VKDB (after 2 weeks up
to 6 months)
○ Early-onset VKDB - first 24 hours after birth
○ Intracranial - most common site of bleeding in late VKDB
● D. Factor VIII (Hemophilia A) and Factor IX (Hemophilia B)
○ Hemarthrosis (bleeding of joints) - hallmark of hemophilic
bleeding
○ Only 2% will present with intracranial hemorrhage
○ Prolonged PTT due to reduced level of Factor VIII or Factor IX; in
severe hemophilia, PTT value is usually 2-3 times the upper limit
of normal
○ Platelet count, bleeding time, PT, and thrombin time are normal
Review! 3 Forms of Vitamin K deficiency bleeding (VKDB)
(Nelson page 972)

Source: Nelson Textbook of Pediatrics (21st Edition)

60 One is a false statement about Answer: C. Usually preceded by a traumatic event

Osgood-Schlatter disease: Rationale:
A. Is usually relieved by rest ● Osgood-Schlatter (OS) Disease is an irritation of the patellar tendon
B. Common among physically active at its insertion into the tibial tubercle or a traction apophysitis of the
athletes tibial tubercle growth plate.
 C. Usually preceded by a traumatic ● A. In most patients, OS disease is a self-limited process and resolved
event with rest.
D. Pain is usually felt at the tibial ● B. OS disease presents in slightly older patients with most
tubercle symptoms between the ages of 10 and 15 yr. These conditions are
most common in very physically active children.
● C. There is typically no acute traumatic inciting event, and the
history of an acute traumatic onset of symptoms should raise the
possibility of a tibial tubercle fracture or patellar sleeve fracture.
● D. Anterior knee pain, very specifically over the tibial tubercle (OS
disease) is the most common patient complaint.

Source: Nelson Textbook of Pediatrics (21st Edition), page 3620

61 In a random survey of 1000 eleven –year old Answer: C. 2

boys, the mean height was 142 cm and the Rationale:
standard deviation was 5 cm. A histogram ● The boy was above average with a height of 152 cm., 10 cm higher
suggested the heights were approximately than the mean height which is 142 cm.
normally distributed. One boy was 152 cm ● In the problem, it is stated that 1 standard deviation is 5cm.
tall. He was above average by how many ● So, since the kid is 10 cm deviated from the mean height, he is 2 SDs
standard deviation/s? above average (1 SD = 5 cm)
A. 4 ● Average is 142cm with standard deviation of 5cm. The kid is 152cm,
B. 1 which is 10cm above the mean. If 5cm is 1 SD, then 10cm must be 2
C. 2 SDs above average.
D. 3 NTK:
● A standard deviation (or σ) is a measure of how dispersed the data is
in relation to the mean.

62 Maternal systemic lupus erythematosus is Answer: D. Congenital heart block

associated with which of the following Rationale:
conditions? ● Maternal complications such as gestational diabetes, teratogenic
A. Coarctation medications, systemic lupus erythematosus, or substance abuse
B. Congenital mitral regurgitation can be associated with cardiac problems.
C. Congenital lupus nephritis ● Congenital complete AV block in children is presumed to be caused
D. Congenital heart block by autoimmune injury of the fetal conduction system by maternally
derived immunoglobulin G antibodies (anti-SSA/Ro, anti-SSB/La) in a
mother with overt or, more often, asymptomatic systemic lupus
erythematosus (SLE) or Sjögren syndrome
● Cardiac complications of SLE include: Pericarditis, Libman-Sacks
endocarditis, coronary arteritis, coronary atherosclerosis (with
steroids), congenital heart block (table 449.3)

Source: Nelson Textbook of Pediatrics (21st Edition), chapter 449

63 The type of idiopathic nephritic syndrome Answer: C. Focal segmental glomerulosclerosis

which usually presents for the first time in Rationale:
the older/adolescents age group, mostly ● FSGS
unresponsive to steroid therapy and ○ MOST COMMON cause of end-stage renal disease in
progresses to end stage renal disease. adolescents.
A. Membranous nephropathy ○ Glomeruli show lesions that are both focal (present only in a
B. Minimal change disease proportion of glomeruli) and segmental (localized to ≥ 1
C. Focal segmental intraglomerular tufts).
glomerulosclerosis ○ Children with steroid-resistant nephrotic syndrome, most often
D. Mesangial proliferation caused by FSGS, generally have a much poorer prognosis.
○ Immunofluorescence= positive for IgM and C3 staining:
○ Electron microscopy: segmental scarring of the glomerular tuft
with obliteration of the glomerular capillary lumen
○ Only 20% of patients with FSGS respond to prednisone
NTKs:
● MCNS
 ○ Present in 85–90% of patients <6 yr of age
○ Found in only 20–30% of adolescents who present for the first
time with nephrotic syndrome
○ Characteristics: glomeruli appear normal or show a minimal
increase in mesangial cells and matrix
○ Immunofluorescence microscopy = negative
○ Electron microscopy = effacement of the epithelial cell foot
processes
○ More than 95% of children with minimal change disease
respond to corticosteroid therapy
● Mesangial proliferation
○ Diffuse increase in mesangial cells and matrix on light
microscopy
○ IF: trace to 1+ mesangial IgM and/or IgA staining.
○ EM = increased numbers of mesangial cells and matrix as well
as effacement of the epithelial cell foot processes.
○ Approximately 50% of pX respond to corticosteroid therapy.

Source: Nelson Textbook of Pediatrics (21st Edition), chapter 545

64 Which of the following breathing patterns Answer: B. Weak persistent grunting during expiration
among neonates indicates a serious Rationale:
pulmonary pathology? ● Preterm infants may breathe with a Cheyne-Stokes Rhythm, known
A. Preterm infant with periodic as periodic respiration, or with a complete irregularity.
respiration or Cheyne-Stokes ● The breathing of newborn infants at rest is almost entirely
rhythm diaphragmatic , so during inspiration, the soft front of the thorax is
B. Weak, persistent grunting during usually drawn inward while the abdomen protrudes.
expiration ● A weak, persistent or intermittent groaning, whining cry, or grunting
C. Diaphragmatic breathing of a during expiration can signify potentially serious cardiopulmonary
newborn infant disease or sepsis and warrants immediate attention. When benign,
D. Grunting which resolves 30 – 60 the grunting resolves 30-60 min after birth.
minutes after birth ● Occasional grunting is acceptable; grunting with every breath is
abnormal.
● Grunting respirations usually occur in the first few hours of life.

Sources:
● Gomella 8th edition. Chapter 7. Newborn Physical examination
● Nelson Textbook of Pediatrics (21st Edition), chapter 113

65 Which of the following choices is NOT a Answer: D. Increased intracranial pressure

common feature of encephalitis? Rationale:
A. Seizures ● Take Note: CNS infections may be DIFFUSE or FOCAL
B. Personality changes ○ DIFFUSE: meningitis and encephalitis
C. Flu-like symptoms ○ FOCAL: brain abscess
D. Increased intracranial pressure ● Based on the criteria provided by the WHO, seizures, altered mental
status (personality changes), and acute onset of fever satisfy the
definition of encephalitis
○ Increased ICP is not one of them and is more commonly
present in meningitis
66 Which statement is true regarding viral Answer: D. Candida arthritis can complicate systemic infection in neonates
arthritis in children? even without indwelling vascular catheter
A. Arthritis seldom accompanies viral Rationale:
syndromes ● Numerous viruses are associated with postinfectious arthritis
B. The pathogenesis of viral arthritis and may result in particular patterns of joint involvement.
is not immune-mediated ● In addition to causing arthritis by means of direct microbial
C. Primary viral infections of the joints infection, infection can lead to the generation and deposition of
are common immune complexes as well as antibody or T cell–mediated
D. Candida arthritis can complicate cross-reactivity with self.
systemic infection in neonates ● Reactive arthritis typically follows enteric infection with
even without indwelling vascular Salmonella sp., Shigella flexneri, Yersinia enterocolitica,
catheter Campylobacter jejuni, or genitourinary tract infection with
Chlamydia trachomatis.
● Nearly 85% pediatric fungal arthritis occurs in infants. In general, two
forms of arthritis are seen primary as a result of acute candidiasis
seen in hospitalized, preterm, septicemic infants with indwelling
catheters and secondary presenting later following disseminated
candidiasis.

Source: Nelson’s Textbook of Pediatrics, NCBI

67 What is the confirmatory test for Down Answer: B.Fluorescent in-situ hybridization
syndrome? Rationale:
A. Conglomeration of phenotypic ● FISH is a technique that can be used for rapid diagnosis in the
signs prenatal detection of common fetal aneuploidies including
B. Fluorescent in-situ hybridization chromosomes 13, 18, and 21, as well as sex chromosomes
C. Cytogenetic studies
D. Ultrasound Source: Chapter 81. Nelson’s Textbook of Pediatrics.

68 Which of the following is highly heritable? Answer: Hypertrophic cardiomyopathy

A. Ventricular septal defect Rationale:
B. Pulmonary stenosis ● Hypertrophic cardiomyopathy (HCM) is an autosomal dominant
C. Dilated cardiomyopathy disease caused by a mutation in sarcomere protein genes which
D. Hypertrophic cardiomyopathy affect contraction of the heart. Familial Hypertrophic
cardiomyopathy occurs as an autosomal dominant
Mendelian-Inherited disorder in approximately 50% of cases.

Source: StatPearls NCBI

69 A 2-year old male infant came in because of Answer: C. Barium Study

recurrent vomiting noted since 1 month of Rationale:
age, patient was managed as a case of ● Upper gastrointestinal series (barium study) is the imaging test of
GERD with milk modification and given choice and the gold standard in the evaluation and diagnosis of
intermittent ranitidine for 1 – 2 weeks during malrotation and volvulus.
episodes of vomiting. You want to rule out
the possibility of malrotation as the cause of Source: Page 1953. Nelson’s Textbook of Pediatrics.
the recurrent vomiting. What is the most
cost effective diagnostic test that you can
request?
A. Milk scan
B. Endoscopy
C. Barium study
D. Esophageal pH monitoring

70 When there is decreased flow to the foramen Answer: B. Aortic valve or C. Mitral valve
ovale during the fetal circulation, which valve Rationale:
may become hypoplastic? ● Hypoplastic left heart syndrome (HLHS) is a type of congenital heart
A. Tricuspid valve disease that results in the underdevelopment of the left-sided
B. Aortic valve structures of the heart, including the mitral valve, left ventricle, aortic
C. Mitral valve valve, the ascending aorta, and aortic arch. The factors leading to
 D. Pulmonic valve this defect can be categorized into two groups, obstruction of
outflow from the left ventricle (obstruction of the left ventricular
outflow tract, aortic valve atresia or stenosis) or obstruction of flow
into the left ventricle (mitral valve atresia or stenosis, restrictive
foramen ovale).
● If there is a decreased flow to the foramen ovale, it could lead to
either aortic valve or mitral valve hypoplasia since both of them
won't be able to receive sufficient blood flow.

Source: Hypoplastic left heart syndrome. StatPearls NCBI.

71 The recommended dose of the following Answer: C. Isoniazid: 10-15 mg/kg/day

drugs. Choose the correct answer. Rationale:
A. Amoxicillin: 30-50 mg/kg/dose ● Amoxicillin:
B. Paracetamol: 5-20 mg/kg/day ○ Oral: 20-90 mg/kg daily in divided doses
C. Isoniazid: 10-15 mg/kg/day ● Paracetamol
D. Phenobarbital maintenance: 10-20 ○ IV: 7.5-15 mg/kg. Max 30 mg/kg/day to 3g daily (depending
mg/kg/day on weight)
○ Oral: Max 60 mg/kg/day to 750mg x 4 doses in 24 hours
● Isoniazid: 10-15 mg/kg (up to 300 mg) daily as a single dose
● Phenobarbital:
○ Status epilepticus: 15-20 mg/kg
○ Seizures: 3-6 mg/kg/day or 5-8 mg/kg/day

Source: MIMS
Disclaimer: Indi ko sure sa question kay wala indications

72 Which type of hypersensitivity reaction is Answer: D. Type II

Antibody-mediated hypersensitivity? Rationale:
A. Type I ● Type I - Immediate hypersensitivity
B. Type IV ● Type II - Antibody-mediated hypersensitivity
C. Type III ● Type III - Immune complex-mediated hypersensitivity
D. Type II ● Type IV - Delayed hypersensitivity

73 A patient came at the OPD and complained Answer: B. CN 6

of double vision, during neuro examination Rationale:
you elicited incomplete abduction of the ● CN 3 (Oculomotor) - raise eyelids, most extraocular movements,
eyes on lateral gaze. What cranial nerve is pupilary constriction, change lens shape
involved? ● CN 6 (Abducens) - lateral eye movement
A. CN 3 ● CN 4 (Trochlear) - downward, inward eye movement
B. CN 6 ● CN 7 (Facial) - facial expression, taste
C. CN 4
D. CN 7

74 Which of the following drugs is the Answer: D. Amphotericin B

treatment for cryptococcal meningitis: Rationale:
A. Isoniazid ● Cryptococcal meningitis is cause by c. neoformans
B. Acyclovir ● Among patients with HIV infection and cryptococcal meningitis,
C. Cyclophosphamide induction therapy with amphotericin B (0.7–1 mg/kg/d) plus
D. Amphotericin B flucytosine (100 mg/kg/d for 2 weeks) followed by fluconazole (400
mg/d) for a minimum of 10 weeks is the treatment of choice
● Isoniazid is used for TB Meningitis
● Acyclovir is efficacious in treating herpes simplex meningitis and can
be used to treat herpes zoster meningitis
● Cyclophosphamide treatment for unrelenting CNS vasculitis
secondary to tuberculous meningitis.

75 Which of the following will require packed Answer: A. Hemoglobin 7 g/dL in patient with marrow failure
red blood cell transfusion? Rationale:
 A. Hemoglobin 7 g/dL in patient with
marrow failure ● In children with oncologic diagnosis who are critically ill or at risk for
B. Hemoglobin 7 g/dL in an critical illness, and hemodynamically stable, we suggest an Hb
asymptomatic patient with SLE concentration of 7– 8 g/dL be considered a threshold for RBC
nephritis transfusion.
C. Hemoglobin 7 g/dL in a ● Children with HUS, SLE, active bleeding, or prolonged AKI can
perioperative period require trans- fusion of packed red blood cells if their hemoglobin
D. Hemoglobin 7 g/dL in a leukemia level falls below 7 g/dL.
patient with no signs of ● If very severe anemia (or Hb 4-6 g/dL AND respiratory distress): Give whole
cardiopulmonary distress blood 10 mL/kg slowly over 3 hr. If signs of heart failure, give 5-7 mL/kg
packed cells rather than whole blood as well as Give furosemide 1 mL/kg IV
at the start of the transfusion

Sources: Nelson

NTK:
Infants of <4 months of age require red blood cells transfusion if
● Hgb < 12 g/dl in first 24 h of life
● Hct is<20% with symptoms of anaemia with low reticulocyte count
● Hct < 30% on oxygen therapy with FiO2 > 35%/continuous positive
airway pressure or with clinical signs like apnoea, bradycardia,
tachycardia and low weight gain
● Hct > 35% on oxygen in hood or on intermittent mandatory
ventilation (IMV) with mean airway pressure (MAP) > 6 cm of H2O
● Hct > 45% in presence of cyanotic congenital heart disease
● Blood losses > 10%.[6]
Infants of more than 4 months of age require red blood cells transfusion if
● Acute loss of >15% of estimated blood volume
● Hypovolemia not responsive to other treatment
● Post-operative anaemia (Hgb < 10 g/dl)
● Pre-operative Hgb < 12 g/dl in presence of severe cardiopulmonary
disease
● Severe chronic anaemia with Hgb < 7 g/dl.

Source: Bharadwaj A, Khandelwal M, Bhargava SK. Perioperative neonatal and

paediatric blood transfusion. Indian J Anaesth. 2014;58(5):652-657.
doi:10.4103/0019-5049.144679

76 A 1-year old boy was seen at the ER with Answer: C. Large Volume Emesis
consideration of upper intestinal Rationale:
obstruction. Which of the following supports ● High obstruction usually present as large volume emesis, frequent
the impression? billous emesis
A. Feculent vomitus ● Low obstruction usually present as moderate/ marked abdominal
B. Diffuse pain over entire abdomen distention with emesis that is progressively feculent, diffuse pain
C. Large volume emesis over entire abdomen
D. Marked abdominal distention
 Source: Pedia Plat

NTK:

77 A 6-month old male had high grade fever Answer: C. Roseola

and appears well when afebrile in 3 days. He Rationale:
was given paracetamol as needed. On the ● Roseola
day of consultation, fever lysed but ○ Fever 3-5 days
macula-papular rash were noted on the face ○ High grade fever
and progress to body and extremities. What ○ Fusiness
is the probable diagnosis? ○ Seizures
A. Drug eruption ○ Rashes appear when fever abates
B. Rubella ○ Nagayama spots
C. Roseola ○ Bulging of anterior fontanelle
D. Measles ● Rubella
○ Low grade fever
○ No photophobia
○ Cephalocaudal maculopapular rash
○ Most characteristic sign: retroauricular, posterior cervical
and postoccipital symmetrical lymphadenopathy
○ Enanthem: Forcheimer spots
● Measles
○ Coryza, cough, conjunctivitis
○ High grade fever
○ Maculopapular rashes appear at peak of fever
○ Photophobia
 ○ Cephalocaudal progression
○ Branny desquamation when rash reaches soles
○ Enanthem: Koplik spots

78 The type of Renal Tubular Acidosis (RTA) Answer: B. Type IV

characterized by metabolic acidosis, Rationale:
hypoaldosteronism, hyperkalemia, alkaline ● Type I - Distal RTA
or acidic urine and absence of Fanconi ○ May have accompanying hypokalemia, hypercalciuria,
lesions. nephrolithiasis, and nephrocalcinosis
A. Type III ○ Failure to thrive is the MOST COMMON presenting
B. Type IV complaint because of chronic metabolic acidosis
C. Type II ○ Cannot acidify their urine: Urine ph >5.5 despite metabolic
D. Type I acidosis
○ NTK: May also cause rickets (together with vit D disorders,
Ca deficiency, and phosphorus deficiency)
● Type II –Proximal RTA
○ RARELY present in isolation and is usually a part of Fanconi
syndrome (generalized dysfunction of proximal tubule)
○ Increased excretion of Na and HCO3 in the urine
○ Fanconi syndrome – glycosuria, aminoaciduria,
hypophosphatemia and low serum uric acid d/t renal
phosphate wasting
○ Rickets and/or failure to thrive may be the presenting
complaint/s
○ Ability to acidify urine is INTACT with urine ph <5.5
○ However, bicarbonate therapy increases HCO3 losses in the
urine and urine pH INCREASES
● Type III – Mixed RTA
○ Occurs in patients with autosomal recessive osteoporosis
caused by mutations in the gene for carbonic anhydrase II
● Type IV – Hyperkalemic RTA
○ Renal excretion of acid and K is impaired
○ A result of hyperkalemia, absence of aldosterone, or
inability of kidney to respond to aldosterone
○ With severe aldosterone deficiency, accompanied by
hyponatremia and volume depletion from renal salt wasting
○ NTK: Gordon Syndrome – Autosomal recessive disorder;
causes volume expansion and hypertension

Source: Nelson Textbook of Pediatrics, 21st Ed

79 Multi-drug resistant tuberculosis is defined Answer: C. At least INH and Rifampicin

as resistant to: Rationale:
A. At least PZA and EMB
B. At least INH and PZA
C. At least INH and Rifampicin
D. At least Rifampicin and EMB
 Source: National Tuberculosis Control Program Manual of Procedures 6th
edition 2020 Department of Health, Philippines

80 The most common organism causing Answer: B. Coagulase negative Staphylococci

peritonitis in patient with peritoneal dialysis Rationale:
catheter ● Peritoneal dialysis (PD) is reported to be the dialysis modality of
A. Staphylococcus aureus choice in children with end-stage renal disease (ESRD). Peritonitis
B. Coagulase negative Staphylococci secondary to bacterial causes is the most frequent cause of
C. Pseudomonas species morbidity and permanent technical failure in pediatric patients.
D. Escheria coli ● Coagulase-negative Staphylococcus (CON-S) is the most common
isolated organism, followed by methicillin-sensitive S. aureus.
● CON-S characteristically infects the peritoneum by the transluminal
route following touch contamination & is commonly associated with
recurrent peritonitis due to biofilm formation.
● S. aureus infections are associated with a catheter exit-site/tunnel
infection with/without S. aureus nasal carriage, & is associated with
recurrent peritonitis secondary to a catheter tunnel infection.
● Pseudomonas are the most common Gram-negative species
causing catheter exit-site and/or tunnel infections that result in
peritonitis which can be extremely resistant to treatment. The
organism may also form a biofilm on the catheter, thereby precluding
successful antibiotic management without catheter removal.
● Gram-negative peritonitis (E. coli) is troublesome as it commonly
results in severe abdominal pain, is associated with dramatic
alterations in the peritoneal membrane transport capacity, and may
result in technique failure

81 In which of the following circumstances Answer: B (but A is also possible however it included >24hours of life which
does jaundice in neonates warrant further is known as physiologic jaundice)
investigation? Rationale:
A. Jaundice appears in the first ● Jaundice is considered pathologic if it presents:
24-36hours of life ○ Within the first 24 hours after birth
B. Serum bilirubin is rising at a rate of ○ The total serum bilirubin level rises by more than 5 mg per
more than 5 mg/dL per day dL (86 mol per L) per day
C. Indirect bilirubin is greater than ○ Higher than 17 mg per dL (290 mol per L)
2mg/dL ○ Infant has signs and symptoms suggestive of serious
illness.
 D. Serum bilirubin is greater than
12mg/dL in a full term infant Source: Porter, M., Dennis, B. (2002). Hyperbilirubinemia in the term newborn.
American Family Physician.

82 Serum C3 is usually decreased in post Review: C. In 6-8 weeks

streptococcal Glomerulonephritis. When do Rationale:
you expect it to normalize?
A. In 8-10 weeks
B. In 10-12 weeks
C. In 6-8 weeks
D. In 4-6 weeks

Source: Nelson’s 21st edition

83 Which of the following disorders is most Answer: A. Language Disorder

commonly found in children with Rationale:
Attention-deficit Hyperactivity Disorder? ● ADHD is characterized by inattention, including increased
A. Language disorder distractibility and difficulty sustaining attention; poor impulse control
B. Eating disorder and decreased self-inhibitory capacity; and motor overactivity and
C. Seizure disorder motor restlessness.
D. Reading disorder ● Of children with ADHD
○ 30–35% have developmental language disorders
○ 20–25% have coexisting anxiety disorders
○ 15–25% have learning disabilities
○ 15–20% have diagnosed mood disorder
○ Children with ADHD can also have concurrent diagnoses of
sleep disorders, memory impairment, and decreased motor
skills.
Source: Nelsons

84 The most common etiologic agent of Answer: B. Coagulase negative Staphylococci

cerebrospinal fluid shunt infection: Rationale:
A. Staphylococcus aureus ● Cerebrospinal fluid (CSF) shunting is required for the treatment of
 B. Coagulase negative Staphylococci many children with hydrocephalus.
C. Fungi ● CSF shunt infection
D. Gram negative bacilli ○ Coagulase-negative staphylococci (CoNS), specifically S.
epidermidis, are the most common cause of nosocomial
bacteremia, usually in association with central vascular
catheters.
○ Coagulase-negative staphylococci are isolated in more than
half the cases
○ S. aureus is isolated in approximately 20%
○ Gram- negative bacilli in 15% of cases

Source: Nelsons

85 At what age does the fastest rate of growth Answer: D. First month
after birth is attained? Rationale:
A. 6 – 12 months ● Infants regain or exceed birthweight by 2 wk of age and should grow
B. After 12 months at approximately 30 g (1 oz) per day during the 1st month. This is
C. First 6 months the period of fastest postnatal growth.
D. First month ● Growth can be divided into 4 major phases:
○ Fetal growth - the fastest growth phase
○ Infantile growth - sensitive to nutrition as well as congenital
conditions
○ Childhood growth - most steady and predictable
○ Adolescent growth - associated with a decrease in growth
velocity prior to the onset of puberty; this deceleration
tends to be more pronounced in males.

Source: Nelsons

86 A 9-month old male with high grade fever Answer: D. Rubeola

and maculopapular rashes started on the Rationale:
face and teary eyed, consulted at the ● Rubeola: Coryza, Cough, Conjunctivitis, High grade fever,
outpatient. What is the probable diagnosis? Maculopapular rashes at peak of fever, Cephalocaudal progression,
A. Roseola photophobia
B. Rubella ● Rubella: Low grade fever, Cephalocaudal maculopapular rashes,
C. Kawasaki disease Retroauricular , posterior cervical and postoccipital symmetrical
D. Rubeola lymphadenopathy (Most characteristic sign; begins 24 hrs before
rash), no photophobia
● Roseola: Fever 3 to 5 days, High grade fever, macules and papules
surrounded by white halos, rashes appear after fever abates
● Kawasaki disease:

87 Which of the following anti-tuberculous Answer: B. Ethambutol

drugs has optic neuritis as a complication? Rationale:
A. Rifampicin ● Ethambutol is the most commonly implicated drug. It is generally
B. Ethambutol well tolerated, but known to cause optic neuritis, more specifically
C. Pyrazinamide retro bulbar neuritis causing blurred vision, decreased visual acuity,
D. Isoniazid central scotomas, and loss of red-green color vision.
● Hepatotoxicity (decreasing hepatotoxicity): Pyrazinamide (most
hepatotoxic) > Rifampin > Isoniazid
● Oliguria or anuria due to renal disorder, Thrombocytopenia, anemia,
shock: Rifampicin
● Psychosis and convulsion: Isoniazid

88 Allergies to this food are most likely to remit Answer: C. Cow’s milk
or resolve as the patient grows older: Rationale:
A. Shrimp ● It is generally thought that some childhood food allergies, such as
B. Fish those to milk and egg, are more likely to resolve than others, such as
C. Cow’s milk peanut, tree nuts, fish, and shellfish allergies, which frequently
D. Peanuts persist into adulthood.
89 Violaceous discoloration with swelling over Answer: D. Juvenile dermatomyositis
the periorbital area is a characteristic Rationale:
Cutaneous finding in patient with: ● Characteristic skin findings are often the presenting sign of JDM.
A. Systemic lupus erythematosus ● An ill-defined, erythematous to violaceous, scaly, minimally pruritic
B. Behcet’s disease eruption occurs in photodistributed areas such as the face, upper
C. Juvenile scleroderma trunk, and extensor extremities.
D. Juvenile dermatomyositis ○ Circumscribed periocular involvement of this heliotrope
rash involving the eyelids may take the appearance of
“raccoon eyes,” particularly in young children.
○ Distinctive erythematous, scaly papules overlying the
knuckles and other joints (Gottron papules) are helpful in
suggesting the diagnosis in the absence of associated
muscle weakness (Fig. 664.5 ).
● Other cutaneous features include nail fold and gingival margin
telangiectasia, palmar hyperkeratosis (“mechanic's hands”),
ulceration resulting from vasculopathy or underlying calcinosis,
lipodystrophy, and a poikilodermatous (dyspigmentation and
telangiectasia) eruption over the shoulder girdle (“shawl sign”).
● Cutaneous features may precede the systemic illness, which is
primarily characterized by muscle weakness and pain.
● The differential diagnosis includes atopic dermatitis, other
connective tissue diseases, lichen planus, medication reactions, and
infectious exanthems.
● Lesional skin demonstrates epidermal atrophy and vacuolar
degeneration at the dermal-epidermal junction, often similar to LE.
 ● JDM is distinct from adult dermatomyositis in both presentation and
prognosis.
● Pediatric patients have more difficulty with gastrointestinal
vasculopathy and cutaneous calcifications, and JDM is not a
paraneoplastic phenomenon as in adults.
● A rare clinical variant known as amyopathic dermatomyositis occurs
when only skin, and not muscle, is involved.

Source: Kliegman, R., Stanton, B., St. Geme, J., Schor, N., Behrman, R. and
Nelson, W., 2019. Nelson textbook of pediatrics. 21st ed. Elsevier.

90 A 24-month old female was admitted due to Answer: A. Diphtheria

fever & complained of sore throat. At the Rationale:
clinic, she was weak looking & irritable. The The manifestations of C. diphtheriae infection are influenced by the anatomic
tonsils were enlarged & covered with grayish site of infection, the immune status of the host, and the production and
exudates, enlarged & tender cervical nodes, systemic distribution of toxin.
bull-neck appearance & inspiratory stridor.
What is the most probable diagnosis? Respiratory Tract Diphtheria
A. Diphtheria ● In a classic description of 1,400 cases of diphtheria in California
B. Epiglottitis (1954), the primary focus of infection was the tonsils or pharynx
C. Peri-tonsillar abscess (94%), with the nose and larynx the next 2 most common sites. After
D. Retropharyngeal abscess an average incubation period of 2-4 days (range 1-10 days), local
signs and symptoms of inflammation develop.
● Infection of the anterior nares is more common among infants and
causes serosanguineous, purulent, erosive rhinitis with membrane
formation. Shallow ulceration of the external nares and upper lip is
characteristic. In tonsillar and pharyngeal diphtheria , sore throat is
the universal early symptom. Only half of patients have fever, and
fewer have dysphagia, hoarseness, malaise, or headache.
● Mild pharyngeal injection is followed by unilateral or bilateral
tonsillar membrane formation, which can extend to involve the uvula
(which may cause toxin-mediated paralysis), soft palate, posterior
oropharynx, hypopharynx, or glottic areas (Fig. 214.1 ). Underlying
soft tissue edema and enlarged lymph nodes can cause a bull-neck
appearance. The degree of local extension correlates directly with
profound prostration, bull-neck appearance, and fatality due to
airway compromise or toxin-mediated complications (Fig. 214.2 ).
● The characteristic adherent membrane, extension beyond the faucial
area, dysphagia, and relative lack of fever help differentiate
diphtheria from exudative pharyngitis caused by Streptococcus
pyogenes or Epstein-Barr virus. Vincent angina, infective phlebitis
with thrombosis of the jugular veins (Lemierre syndrome), and
mucositis in patients undergoing cancer chemotherapy are usually
differentiated by the clinical setting. Infection of the larynx, trachea,
and bronchi can be primary or a secondary extension from the
pharyngeal infection.
● Hoarseness, stridor, dyspnea, and croupy cough are clues.
Differentiation from bacterial epiglottitis, severe viral
laryngotracheobronchitis, and staphylococcal or streptococcal
tracheitis hinges partially on the relative paucity of other signs and
symptoms in patients with diphtheria and primarily on visualization
of the adherent pseudomembrane at laryngoscopy and intubation.
● Patients with laryngeal diphtheria are at significant risk for
suffocation because of local soft tissue edema and airway
obstruction by the diphtheria membrane, a dense cast of respiratory
epithelium, and necrotic coagulum.
● Establishment of an artificial airway and resection of the
pseudomembrane can be lifesaving, but further obstructive
complications are common, and systemic toxic complications are
inevitable.
Cutaneous Diphtheria
● Classic cutaneous diphtheria is an indolent, nonprogressive infection
characterized by a superficial, ecthyma-like, nonhealing ulcer with a
gray-brown membrane. Diphtheria skin infections cannot always be
differentiated from streptococcal or staphylococcal impetigo, and
these conditions frequently coexist. In most cases, a primary
process, such as dermatosis, laceration, burn, bite, or impetigo,
becomes secondarily infected with C. diphtheriae. Extremities are
more often affected than the trunk or head. Pain, tenderness,
erythema, and exudate are typical. Local hyperesthesia or
hypesthesia is unusual. Respiratory tract colonization or
symptomatic infection with toxic complications occurs in the
minority of patients with cutaneous diphtheria. Among infected
adults in the Seattle outbreak, 3% with cutaneous infections and 21%
with symptomatic nasopharyngeal infection, with or without skin
involvement, demonstrated toxic myocarditis, neuropathy, or
obstructive respiratory tract complications. All had received at least
20,000 units of equine antitoxin at the time of hospitalization.

Infection at Other Sites

● C. diphtheriae occasionally causes mucocutaneous infections at
other sites, such as the ear (otitis externa), the eye (purulent and
ulcerative conjunctivitis), and the genital tract (purulent and
ulcerative vulvovaginitis). The clinical setting, ulceration, membrane
formation, and submucosal bleeding help differentiate diphtheria
from other bacterial and viral causes. Rare cases of septicemia are
described and are universally fatal. Sporadic cases of endocarditis
occur, and clusters among intravenous drug users have been
reported in several countries; skin was the probable portal of entry,
and almost all strains were nontoxigenic. Sporadic cases of
pyogenic arthritis, mainly from nontoxigenic strains, have been
reported in adults and children. Diphtheroids isolated from sterile
body sites should not be routinely dismissed as contaminants
without careful consideration of the clinical setting.
 Source: Kliegman, R., Stanton, B., St. Geme, J., Schor, N., Behrman, R. and
Nelson, W., 2019. Nelson textbook of pediatrics. 21st ed. Elsevier.

91 The development of vaccine in the late Answer: A. Haemophilus influenzae type B

1980s has dramatically decreased the Rationale:
incidence of pneumonia caused by: ● Haemophilus influenzae type b (see Chapter 221) was also an
A. Haemophilus influenzae type B important cause of bacterial pneumonia in young children but
B. Streptococcus pyogenes became uncommon following licensure of a conjugate vaccine in
C. Group B Strep 1987.
D. Mycoplasma pneumoniae ● Please read Chapter 221 (Haemophlis influenzae) and Chapter 197
including the Expanded Program on Immunization (EPI) of the
Department of Health

Source: Kliegman, R., Stanton, B., St. Geme, J., Schor, N., Behrman, R. and
Nelson, W., 2019. Nelson textbook of pediatrics. 21st ed. Elsevier.

92 Example of Type III Reactions: Answer: A. Arthus Reactions

A. Arthus Reactions Rationale:
B. Anaphylaxis ● Arthus Reactions fall under Type III Hypersensitivity Reactions
C. Hemolytic Anemia (Immune Complexes)
D. All of the choices ○ Here, the excess antigen forms soluble immune complexes
with an existing antibody
○ This can be seen in repeated injections of an antigenic
substance (e.g., Tetanus, Diphtheria Toxoid) into skin or
tissues of a previously immunized individual
● Anaphylaxis falls under Type I Hypersensitivity Reactions
(IgE-Mediated)
● Hemolytic Anemia falls under Type II Hypersensitivity Reactions
(Antibody Target Cell Reaction)

Sources:
● Gells & Coombs
● Principles of Immunology - Abnormal Responses (B10M3L3)

93 Analyze the following hemodynamic data: Answer: B. Tetralogy of Fallot

Rationale:
● In TOF, there is R-L shunting as evidenced by the high RV pressure
 (90/5)
● Patient is cyanotic because of the 85% O2 Sat (Aorta)
● RV & LV pressures are more or less equal (RV: 90/5; LV: 92/6)
because of a hole that is big enough to cause pressure equalization.
Note that RV pressure should normally only be ¼ of the LV pressure
● The pulmonary valve is also stenotic because due to decreased
pressure. You can see the pressure change in the pulmonary artery
(RV: 90/5; PA: 34/12)

What is the most likely cardiac lesion which

may present as in the above hemodynamic
picture?
A. Atrial Septal Defect
B. Tetralogy of Fallot
C. Patent Ductus Arteriosus
D. Pulmonary Stenosis
Sources:
● Nelson Textbook of Pediatrics
● Cardiac Hemodynamics (B12M1L4)

94 What is the most likely pulse oximetry Answer: A. 99%

reading at the lower extremities? Rationale:
A. 99% ● Healthy children have SpO2 >95%.
B. 85% ● Pulse oximetry (oxygen-hemoglobin saturation, SpO2) should be
C. 92% assessed in children with respiratory or cardiac illness/compromise
D. 75% and also in children with underlying abnormalities of oxygenation.
● The practitioner should consider evaluating for any underlying
respiratory or cardiac causes in children with SpO2 <93–95%. For
children with underlying abnormalities, the child’s baseline SpO2
should be assessed and alterations from that baseline should be
investigated further

Source: Nelson Textbook of Pediatrics

95 A 6-year old male asthmatic child was Answer: A. Severe

brought to the ER because of difficulty of Rationale:
breathing. He was observed to be agitated,
tachypneic, and preferred to sit and
answered questions in phrases. PE revealed
respiratory rate of 65 cycles/minute,
presence of intercostals and suprasternal
retractions, and diffuse expiratory wheeze in
all lung fields. He was also tachycardic.
Based on the signs and symptoms, the
child’s asthma exacerbation is
A. Severe
B. Moderate
C. Mild
D. Very severe

Source: Pedia Platinum 1st ed. (2020)

96 Further questioning of the child’s caregiver Answer: D. Moderate Persistent Asthma

 revealed the following: Patient has been on Rationale:
inhaled steroids for 5 months now; he has ● Old GINA (2002) Guidelines
cough and shortness of breath almost daily
hence is also given salbutamol nebulization
almost daily; he has nighttime awakening 3x
a week because of paroxysms of cough. His
FEV on peak flow monitoring taken earlier in
the morning was 70% of predicted. This
child has:
A. Intermittent asthma
B. Severe persistent asthma
C. Mild persistent asthma
D. Moderate persistent asthma

Source:
https://www.slideshare.net/crisbertc/global-initiative-for-asthma-guidelines-2
008

97 Ronald is a 5-year old male who was brought Answer: C. Minimal Change Disease
in for consult due to facial edema. 5 days Rationale:
prior to admission, he had cough and colds
and a day later was noted with facial
puffiness and bubbly urine. On physical
examination, he is noted to have BP of
90/60 with facial edema and bipedal edema.
His urinalysis showed protein of 4+ with
serum albumin of 7 g/dL and elevated
serum cholesterol. With the above
syndrome, what is the most probable
pathology for his case?
A. Mesangial Proliferation
B. Focal Segmental
Glomerulosclerosis
C. Minimal Change Disease
D. Membranous Glomerulonephritis

Source: Nelson’s Pediatrics. 2019. Chap 545, p. 2754

98 With Ronald’s case, the underlying Answer: B. Podocyte

abnormality is usually an increased Rationale:
permeability of the glomerular capillary wall, ● Podocyte plays a crucial role in the development of proteinuria and
which leads to massive proteinuria and the progression of glomerulosclerosis
 hypoalbuminemia. What part of the ● Podocyte is a highly differentiated epithelial cell located on the
glomerulus plays the crucial role in the outside of the glomerular capillary loop
development of proteinuria and progression ● Podocyte functions as structural support of the capillary loop, is a
to glomerulosclerosis? major component of the glomerular filtration barrier to proteins, and
A. Endothelium is involved in synthesis and repair of the glomerular basement
B. Podocyte membrane
C. Basement membrane ● Podocyte injury or genetic mutations of genes producing podocyte
D. Parietal epithelium proteins may cause nephrotic-range proteinuria

Source: Nelson’s Pediatrics. 2019. Chap 545, p. 2752

99 Queenie has the following anthropometric Answer: D. 10 kg

measurements at birth: Rationale:
Weight = 2.5 kg Weech formula:
Length = 45 cm
HC = 34 cm
CC = 31 cm
She is presently 12 months old.
Based on Weech’s formula, what is the
expected weight of Queenie at present?
A. 14 kg
B. 12 kg
C. 8 kg
D. 10 kg Computation:
Queenie’s age = 12 months
Expected weight = 1 x 2 + 8 = 10 kg
NTKs:
● 10% physiologic weight loss during 1st week of life
● Birth weight is regained or exceeded at 2nd week of life
● Average 30g/day is gained during 1st month of life
● Birth weight is doubled at 4 months of age
● At first year of age, 3x the birth weight

100 Queenie has the following anthropometric Answer: C. 70cm

measurements at birth: Rationale:
Weight = 2.5 kg ● Expected length by one year of age is a 50% increase from birth
Length = 45 cm length
HC = 34 cm ● Average length gain in 1st year is 25cm (birth to 3 months: +9cm, 3-6
CC = 31 cm months: +8cm; 6-9mo: +5cm; 9-12mo: +3cm)
She is presently 12 months old. Computation:
What will be her expected length at present? Queenie’s birth length = 45 cm
A. 55 cm Birth length + 25cm = 70cm
B. 80 cm
C. 65 cm
D. 70 cm