Medical Examination Questions: Pediatric Clinical Assessment
Question 1: WHO Assessment of Diarrhea
Urine output is part of the WHO assessment of diarrhea.
The WHO clinical assessment for dehydration in children with diarrhea includes specific parameters to evaluate fluid status 1, 2:
- Urine output is a critical component, with anuria time (duration since last urination) being a significant indicator of dehydration severity 1
- The WHO dehydration scale incorporates clinical signs including general appearance, eyes (sunken), tears, mouth/tongue (dry mucous membranes), thirst, and skin turgor 2, 3
- While pulse and capillary refill time are important clinical parameters, they are not specifically part of the core WHO assessment criteria 2
- Condition (general appearance) is included in the WHO scale, but "lips" as an isolated finding is not a primary WHO criterion 2
Clinical context: When assessing dehydration, clinicians should specifically ask about the time of last urination and diarrheal frequency, as these correlate strongly with dehydration severity 1.
Question 2: Bilirubin Level with Mid-Abdomen Jaundice
15 mg/dL is the estimated bilirubin level when jaundice extends to the mid-abdomen.
The cephalocaudal progression of jaundice follows a predictable pattern based on bilirubin levels:
- Jaundice progresses from head to toe as bilirubin levels increase
- Mid-abdomen involvement typically corresponds to approximately 15 mg/dL (general medical knowledge)
- Face alone: ~5 mg/dL
- Upper chest: ~10 mg/dL
- Mid-abdomen: ~15 mg/dL
- Soles of feet: ~20 mg/dL
Important caveat: Visual assessment of jaundice is imprecise and should never replace laboratory measurement of bilirubin levels, especially in neonates requiring treatment decisions.
Question 3: Clinical Parameter in Pediatric CAP Risk Classification
Sustained oxygen saturation at room air is a clinical parameter in the risk classification of pediatric community-acquired pneumonia.
The assessment of pneumonia severity in children includes specific respiratory and systemic parameters 4:
- Oxygen saturation measurement via pulse oximetry is essential for assessing severity and determining need for hospital admission 4
- Hypoxemia requiring supplemental oxygen is a major criterion for severe illness 4
- Tachypnea (respiratory rate above WHO age-specific thresholds) is a key minor criterion 4
- Increased work of breathing (retractions, nasal flaring, grunting) indicates severity 4
Other parameters in the question:
- Convulsion is not a standard pneumonia severity criterion (more relevant to febrile seizures or meningitis)
- CRT (capillary refill time) is more specific to sepsis assessment 4
- Decreased appetite alone is not a primary risk classification parameter 4
Clinical application: Pulse oximetry should be performed in every child being assessed for admission with pneumonia 4.
Question 4: Mechanism of Antihistamines in Common Cold
The anticholinergic property is responsible for the effect of antihistamines on rhinorrhea in the common cold.
The mechanism by which first-generation antihistamines like cetirizine reduce rhinorrhea is primarily through their anticholinergic effects rather than pure antihistamine activity (general medical knowledge):
- Anticholinergic properties reduce nasal secretions by blocking muscarinic receptors
- The antihistaminic effect is less relevant for viral rhinorrhea, as histamine is not the primary mediator in viral upper respiratory infections
- First-generation antihistamines have more pronounced anticholinergic effects than second-generation agents
Question 5: Component NOT in Tetralogy of Fallot
Left ventricular hypertrophy is NOT part of Tetralogy of Fallot.
The four classic components of Tetralogy of Fallot are (general medical knowledge):
- Right ventricular outflow tract obstruction (pulmonary stenosis) - INCLUDED
- Ventricular septal defect - INCLUDED
- Overriding aorta (dextroposition over the ventricular septum) - INCLUDED
- Right ventricular hypertrophy - NOT left ventricular hypertrophy
Key distinction: The chronic right ventricular pressure overload from pulmonary stenosis causes RIGHT ventricular hypertrophy, not left ventricular hypertrophy.
Question 6: Ceftriaxone Dosing for Bacterial Meningitis
4.0 grams once a day for 10 days is the appropriate ceftriaxone regimen for acute bacterial meningitis in a 50kg 12-year-old.
Standard dosing for bacterial meningitis (general medical knowledge):
- Ceftriaxone dose: 80-100 mg/kg/day (maximum 4 grams/day)
- For a 50kg patient: 4 grams daily
- Duration: 10-14 days for most bacterial meningitis
- Frequency: Once or twice daily dosing is acceptable
Calculation: 50kg × 80mg/kg = 4000mg = 4 grams daily
Question 7: Most Common Bacterial CNS Infection in Teenagers
Neisseria meningitidis is the most common etiology of bacterial CNS infections in teenagers.
Age-specific bacterial meningitis pathogens (general medical knowledge):
- Teenagers/adolescents: Neisseria meningitidis is most common
- Young children: Streptococcus pneumoniae
- Infants: Group B Streptococcus, E. coli
- Post-Hib vaccine era has dramatically reduced H. influenzae type b
Clinical relevance: Meningococcal vaccination is particularly important for adolescents due to this epidemiology.
Question 8: Definition of Neonatal Sepsis
A systemic response to an infection in an infant less than 1-month old describes neonatal sepsis.
Neonatal sepsis is specifically defined as 4:
- Systemic response to infection in neonates (infants <28-30 days old)
- Should be suspected with tachycardia, respiratory distress, poor feeding, poor tone, poor color, tachypnea, or reduced perfusion 4
- Particularly concerning with maternal chorioamnionitis or prolonged rupture of membranes 4
Incorrect options:
- Prematurity (<37 weeks) is a risk factor, not the definition
- Elevated bilirubin is jaundice, not sepsis
- Localized infection is not sepsis (which is systemic by definition)
Question 9: Abnormal Measurements Indicating Neonatal Sepsis
Heart rate, respiratory rate, and temperature are the measurements that indicate sepsis when abnormal in neonates.
Vital sign abnormalities diagnostic of neonatal sepsis 4:
- Heart rate: Tachycardia or bradycardia
- Respiratory rate: Tachypnea (>60 breaths/min) 5
- Temperature: Fever or hypothermia
Therapeutic endpoints for neonatal sepsis include 4:
- Normal heart rate thresholds for age
- Capillary refill ≤2 seconds
- Warm extremities
- Urine output >1 mL/kg/h
- Normal glucose and calcium concentrations
Why other options are incorrect:
- Gestational age and weight are risk factors, not diagnostic measurements
- Glucose abnormalities occur but are not primary diagnostic criteria
Question 10: Epidemiology and Risk Factors for Neonatal Sepsis
Prematurity is the most important predisposing factor for neonatal infection.
Risk factors for neonatal sepsis 4:
- Prematurity is the single most important predisposing factor for neonatal infection
- Prolonged rupture of membranes (>18-24 hours) increases risk of amnionitis 4
- Maternal chorioamnionitis significantly increases risk 4
Incorrect statements:
- PROM <24 hours does NOT usually result in amnionitis (>18-24 hours is the threshold)
- Maternal immunity generally protects against vertical transmission of many viral diseases
- Neonatal sepsis is far more common than neonatal UTI
Question 11: Most Common Bacterial Pathogen in 4-Year-Old with CAP
Streptococcus pneumoniae is the most common bacterial pathogen causing community-acquired pneumonia in a 4-year-old.
Age-specific bacterial pneumonia pathogens 4:
- Streptococcus pneumoniae is the most prominent invasive bacterial pathogen across all pediatric age groups 4
- Mycoplasma pneumoniae is more common in school-aged children and adolescents 4
- Chlamydia pneumoniae affects older children
- Staphylococcus aureus is less common but causes severe disease
Treatment implication: Amoxicillin is first-line therapy for preschool children with CAP because it provides appropriate coverage for S. pneumoniae 4.
Question 12: Highest Risk for Subsequent Epilepsy After Febrile Seizure
Focal febrile seizures have the highest risk for subsequent epilepsy.
Risk factors for developing epilepsy after febrile seizures (general medical knowledge):
- Focal (partial) seizures carry the highest risk
- Complex febrile seizures (prolonged, focal, or recurrent) increase risk
- Family history of epilepsy increases risk
- Recurrent febrile seizures alone do not significantly increase epilepsy risk
Key distinction: Focal features suggest underlying neurological abnormality, conferring highest epilepsy risk.
Question 13: Phoenix Sepsis Score Characteristics
The score is based on vital signs, laboratory tests, and interventions and aims to provide a standardized evidence-based approach to early sepsis detection in children.
Phoenix Sepsis Score features (general medical knowledge):
- Assesses organ dysfunction in respiratory, cardiovascular, coagulation, and neurologic systems
- Uses vital signs, laboratory values, and clinical interventions
- Provides standardized approach to pediatric sepsis detection
- Score ≥2 (not 3) typically indicates organ dysfunction
- Septic shock requires cardiovascular dysfunction component
Question 14: Sequential Core Steps in EINC
Immediate and thorough drying; early skin-to-skin contact; properly timed cord clamping; non-separation of mother and baby are the sequential core steps in EINC (Essential Inborn Newborn Care).
EINC protocol sequence (general medical knowledge):
- Immediate thorough drying (stimulates breathing)
- Early skin-to-skin contact (thermoregulation)
- Properly timed cord clamping (delayed 1-3 minutes)
- Non-separation of mother and baby (bonding, breastfeeding)
Critical pitfall: Routine suctioning is NOT recommended for vigorous newborns and is not part of EINC.
Question 15: Management of Newborn with RR 70-80/min and Alar Flaring
Suction secretions should be performed for a newborn with tachypnea and alar flaring in the first hour of life.
Initial management of newborn tachypnea 5:
- Tachypnea is defined as respiratory rate >60 breaths/min 5
- RR of 70-80/min with alar flaring indicates respiratory distress 6
- Maintain airway patency and provide adequate oxygenation 5
- Suctioning may be needed if secretions are obstructing airway
Clinical context: This presentation is consistent with transient tachypnea of the newborn, which typically appears within two hours of birth 6. However, maintaining airway patency takes priority.
Question 16: Total Fluid Requirement Calculation
150 mL/day is the total fluid requirement for a 2.5kg neonate on NPO status.
Neonatal fluid calculation (general medical knowledge):
- Day 1: 60-80 mL/kg/day
- Day 2: 80-100 mL/kg/day
- Day 3: 100-120 mL/kg/day
- Day 4+: 120-150 mL/kg/day
For a 2.5kg infant in the first day of life with respiratory distress:
- 2.5kg × 60 mL/kg = 150 mL/day (using higher end due to increased insensible losses from tachypnea)
Question 17: Virologic Serologic Studies in Dengue Fever
In secondary Dengue infections, most Dengue antibody is the IgG class.
Dengue serology patterns (general medical knowledge):
- Secondary infections: Predominantly IgG response (rapid, high-titer)
- Primary infections: IgM appears first, then IgG
- IgM antibodies persist for 2-3 months (not 2-4 weeks)
- Blood samples should be collected early (days 1-5) for PCR or after day 5 for serology
- Serologic methods cannot distinguish specific dengue serotypes
Question 18: Cause of Hyperbilirubinemia
Increased bilirubin load, hemolytic is the cause of hyperbilirubinemia in this neonate.
Analysis of laboratory findings:
- Positive direct Coombs test indicates immune-mediated hemolysis
- ABO incompatibility (Mother O+, Baby A+) causes hemolytic disease
- Elevated reticulocyte count (7.5%) confirms hemolysis
- Indirect hyperbilirubinemia (17.5 of 18 mg/dL) indicates unconjugated bilirubin
- Anemia (Hgb 10 g/dL, Hct 30%) supports hemolysis
Mechanism: ABO incompatibility causes maternal anti-A antibodies to cross placenta and destroy fetal red blood cells, increasing bilirubin load through hemolysis.
Question 19: Treatment of Choice for Hemolytic Hyperbilirubinemia
IVIG (Intravenous Immunoglobulin) is the treatment of choice for this neonate with ABO hemolytic disease.
Treatment for immune-mediated hemolytic jaundice (general medical knowledge):
- IVIG (0.5-1 g/kg) is first-line for ABO or Rh hemolytic disease with positive Coombs test
- IVIG reduces need for exchange transfusion by blocking antibody-mediated hemolysis
- Phototherapy is adjunctive but not sufficient alone for hemolytic disease
- Exchange transfusion reserved for IVIG failure or severe cases
- Total bilirubin of 18 mg/dL at day 4 with hemolysis requires aggressive treatment
Rationale: IVIG blocks Fc receptors, preventing further hemolysis and reducing bilirubin production.
Question 20: Diagnosis of Term Newborn with Tachypnea
Transient tachypnea of the newborn is the most likely diagnosis for a term newborn delivered by scheduled cesarean section with tachypnea, fluid in interlobar fissures, and hyperaeration on chest radiograph.
Diagnostic features of TTN 7, 6:
- Tachypnea (RR >60/min) is the hallmark sign, typically appearing within two hours of birth 6
- Scheduled cesarean section is a major risk factor due to insufficient activation of epithelial sodium channels that normally facilitate fetal lung fluid absorption 6
- Characteristic imaging: Fluid in interlobar fissures and hyperaeration are classic chest X-ray findings 7
- Ultrasound findings (if performed): Bilateral confluent B-lines in dependent areas with normal superior fields 7
Differential diagnosis exclusions:
- Bronchopulmonary dysplasia requires chronic oxygen dependence in premature infants (not applicable to term newborn)
- Air leak syndrome presents with pneumothorax/pneumomediastinum, not interlobar fluid
- Meconium aspiration requires history of meconium-stained fluid and shows patchy infiltrates/hyperinflation, not interlobar fluid
Management: Supportive care with supplemental oxygen to maintain appropriate saturation is the mainstay of treatment 6. Most cases resolve within 24-72 hours 7, 6.