KATHMANDU MEDICAL COLLEGE

MD Pediatrics (1st year)

Paper: III (Subspecialties &Recent Advances) Time: 3 hrs

Single best Answers : 1X 50 = 50
1. Followings are the mechanism of action on head cooling for birth asphyxia except
a) Increases energy utilization
b) Reduces/suppresses cytotoxic amino acid accumulation and nitric oxide
c) Inhibits platelet-activating factor, inflammatory cascade
d) Suppresses free radical activity
e) Attenuates secondary neuronal damage
2. Which one of the following statements is FALSE regarding respiratory distress syndrome
(RDS)?
a. It occurs in 60-80% if neonates less than 28 weeks of gestation
b. Surfactant appears in amniotic fluid between 28 to 32 weeks of gestation and mature
levels of pulmonary surfactant are reached only after 35 weeks of gestation
c. Signs of RDS appear immediately within months of birth, although they may not be
recognized for several hours in premature babies
d. Surfactant therapy has dramatically reduced the incidence of brochopulmonary
dysplasia.
3. Recommended Daily Allowance (RDA) of a specific nutrient is:
a. An Estimated Average Requirement (EAR) which is uniformly distributed within the
population + 2 Standard Deviation
b. Not useful for assessing the nutrient intake of individuals or groups
c. Useful for ascertaining the adequacy of individual’s intake or a specific nutrient
d. Easy to establish as mean requirements of all nutrients have been established

4. An infant’s need for carbohydrate sufficient to prevent hypoglycemia and ketosis is:
a. 2.5 gm/kg/day
b. 5.0 gm/kg/day
c. 7.5 gms/kg/day
d. 10 gms/kg/day
5. Sense of smell is present by:
a. 28th. week of gestation.
b. 32nd. week of gestation.
c. 36th. week of gestation.
d. 40th. week of gestation.
6. Which of the following statement(s) is FALSE regarding papilloedema?
a. It is rare in infancy.
b. Visual acuity is diminished in acute papilloedema.
c. Flame shaped hemorrhages appear in the surrounding retina in the later stages.
d. Blind spot is decreased in papilloedema.
7. Which one of the following porphyrias is NOT associated with cutaneous manifestations?
a. Acute intermittent porphyria
b. Porphyria cutaneatarda
c. Erythropoeiticprotoporphyria
 d. Varigate porphyria

8. A 7-month old boy, who had been healthy and developing well, is reported by mother to be
having decreased eye contact even during feeding and increased startle response. Which of the
following tests will be diagnostic to identify the disease the infant is suffering from?
a. Serum ammonia level
b. Serum amino acids level
c. B- hexosaminidase A activity in the leucocytes
d. Urinary organic acids
9. Which of the following conditions is not associated with a high maternal alpha fetoprotein
level?
a. Multiple gestation
b. Congenital nephrosis
c. Trisomy 21
d. Neural tube defects

10.Neruopathologic changes of hypoxic ischemic damage and kernicterus can be differentiated

as follows:
a. There is no specific localization in HIE damage in selected areas of brain
b. Unless properly fixed, neuropathologic examination is unrewarding
c. Neuropathologic changes in kernicterus characteristically involves
subthalamic nucleus, globuspallidus, hippocampus and ventral cochlear nuclei
d. Yellow staining of basal ganglia with or without neurological change is
diagnostic of kernicterus
11. A previously healthy 5-year old boy presents with the acute onset of maroon
colouredhematchezia. Physical examination reveals a pale child who exhibits
tachycardia. His mother reports that he has had occasional unexplained abdominal
discomfort in the past that did not affect his activity. The most likely explanation of his
symptom is:
a. HenochSchonleinpurpura
b. Infectious colitis
c. Meckel diverticulum
d. Superior mesenteric aneurysm
12. A previously well 8- year old boy has had diarrhea for the past 5 weeks, with occasional
bright red and dark red blood mixed with stool. Associated symptoms include episodic
vomiting, decreased appetite, and a 2 kg weight loss. He has not taken any antibiotics in
the past 6 months and has had no recent travel. Findings on physical examination include
mild pallor and a small effusion in his right knee joint. His hemoglobin is 9.2 g/dl and
mean corpuscular volume is 72 fL (normal 78 to 102 fL). Of the following, the most
likely diagnosis is:
a. Allergic colitis
b. Bacterial infectious colitis
c. Pseudomembranous colitis
d. Ulcerative colitis
 13. The most correct statement regarding gastroesophageal reflux in infants and children is:
a. Colic occurring predominantly in the evening hours is a frequent symptom
of reflux
b. Curdled milk in the vomitus indicates gastric hyperacidity in infancy
c. Recurrent pneumonia and malabsorption is a common symptom complex
of reflux in children
d. Regurgitation without weight loss occurs in more than one third of healthy
infants daily
14. Which one of the following vegetative functions can occur without brain stem
coordination?
a. Chewing.
b. Swallowing
c. Primary esophageal peristalsis.
d. Gastric emptying.
15. Syndrome with significant reduction in the number of teeth is:
a. Osteogenesisimperfecta
b. Cleidocranialdysostosis
c. Ectodermal dysplasia
d. Pierre Robin syndrome
16.The most common cause of pancreatic insufficiency in childhood is:
a. Chronic pancreatitis
b. Congenital lipase deficiency
c. Cystic fibrosis
d. Shwachman-Diamond syndrome
17. A 10-yr-old boy develops pancreatitis following a blow to the abdomen. During a 5-day
hospitalization, he is treated with intravenous fluids and analgesics and is discharged home on a
low-fat diet. Four weeks later he has recurrence of abdominal pain and vomiting. The most likely
diagnosis is:
a. Duodenal ulcer due to Helicobacter pylori
b. Chronic pancreatitis
c. Hemorrhagic pancreatitis
d. Pancreatic pseudocyst
18. A 2-mo-old infant has a history of infrequent bowel movements and poor weight gain.
Physical examination reveals a thin, poorly nourished child with abdominal distention. Rectal
examination reveals normal tone, and the infant subsequently passes an explosive, foul-smelling
stool. All the following may be useful in establishing the diagnosis except:
a. Colonoscopy
b. Un-prepped barium enema
c. Rectal suction biopsy
d. Full-thickness rectal biopsy
19. A 14-yr-old boy complains of right upper quadrant pain and fever for 2 wk. Physical
examination reveals hepatomegaly, no icterus, and right lower quadrant fullness. Four weeks
before admission, he had received oral antibiotics for an illness characterized by abdominal pain,
nausea, and emesis. The most likely diagnosis is:
a. Amebiasis
 b. Hepatitis
c. Hepatic abscess (bacterial)
d. Cholangitis
20. The substance most likely to be absorbed and transported sequentially through the mucosa of
the terminal ileum, submucosalvenules and portal vein is:
a.Bile acids
b. Glucose
c. Long chain triglycerides
d. Medium chain triglycerides
21. Of the following medications, which has shown the most promise in the management of
hepatitis B?
a. Adenine arabinoside
b. Cyclosporine
c. Thymosine
d. Interferon alpha
22. You are evaluating a 7- year old girl in your office who has a 6 week history of watery, foul
smelling diarrhea. She also has experienced some bloating and cramping but no weight loss. She
just returned from holiday in her ancestral village. You suspect giardiasis. Which of the
following tests is the simplest and most reliable in helping you confirm your diagnosis?
a. Duodenal biopsy
b. Fecal Giardia antigen test
c. Fecal ova and parasites
d. Stool culture
23. A 6-year old boy has had intermittent periumbilical abdominal pain for the last 2 months.
The pain has awakened him frequently at night and has been associated with nausea and loss of
appetite. These findings are least suggestive of a diagnosis of:
a. Acid peptic disease
a. Biliary tract disease
b. Crohn disease
c. Functional abdominal pain
24. Helicobacter pylori infection in a child is most likely to result in:
a. Chronic active gastritis
b. Duodenal carcinoma
c. Gastric carcinoma
d. Non ulcer dyspepsia
25. Which one of the following statements correctly describes the sequence of cardiac
development?
a. Cardiac looping, fusion of cardiac tubes, cardiac septation and differentiation
b. Fusion of cardiac tubes, cardiac looping , cardiac septation and differentiation
c. Cardiac differentiation, fusion of tubes, cardiac septation and cardiac looping
d. Cardiac differentiation, fusion of tubes, cardiac looping and septation

26. Which one of the following statements is TRUE regarding development of cardiac
functions?
 a. Contraction of heart and exhibition of cardiac cycle is evident in a normal embryo
by 22 days of gestation
b. Septation of ventricles starts by 30 days of life and atria by 26 days of gestation
c. During cardiac looping, the cardiac tube bends dorsally towards right side
d. Fetal heart has higher ability to relax in response to sympathetic stimulation
27. Which one of the following Chromosomal anomalies is associated with the highest
occurrence of congenital heart diseases?
a. Trisomy 13
b. Trisomy 18
c. Turner syndrome
d. Trisomy 21
28. Which one of the following murmurs is not indicative of heart diseases?
a. Systolic murmur of grade III and above
b. Diastolic murmur of any grade
c. Murmurs associated with clicks
d. Medium pitched vibratory systolic murmurs along left sternal border

29. Which one of the following is NOT a feature of Right Ventricular Hypertrophy in ECG?
a. QR pattern in right precordial leads
b. Monophasic R wave in V1
c. Axis > 90 degrees
d. Increased voltage of S waves in V 5-6
30. Which one of the following congenital heart diseases is associated with increased
pulmonary blood flow?
a. Tetralogy of Fallot
b. Tricuspid atresia
c. Total anomalous pulmonary venous return without obstruction
d. Pulmonary atresia with intact septum
31. “Scimitar” syndrome, a crescentic shadow of vascular density seen along the right border
of heart is seen in :
a. ASD secundum
b. ASD primum
c. Sinus venosus ASD with partial anomalous pulmonary venous return
d. Sinus venosus ASD
32. .A full term newborn baby with a birth weight of 3 kg was delivered normally without
any apparent abnormality at birth was reported to have become tachypneic and cyanosed
within 2 hours of birth. On examination, you detect parasternal heave, single S2 and a
soft systolic mumur along left sternal border. ECG showed right ventricular dominance,
chest X ray showed mild cardiomegaly. Hyperoxia test was negative. What is the most
likely diagnosis?
a. d- transposition of great arteries
b. d- TGA with intact ventricular septum
c. Total anomalous pulmonary venous return, infracardiac type
d. Truncus arteriosus
33. A 3 months old infant was brought to you for consultation with complaints of frequent
episodes of irritability, excessive sweating, breathlessness and pallor. On clinical examination
you find gallop rhythm and holostylolic apical murumur. An ECG taken shows QR pattern with
inverted T waves in lead I and a VR, deep Q waves in V5 and 6. What is the most likely
diagnosis?
a. Kawasaki disease
b. Anomalous left coronary artery with pulmonary artery
c. Ectopic origin of coronary artery with aberrant course
d. Anomalous origin of right coronary artery from pulmonary artery
34.A 9 months old infant was brought with the complaints of excessive irritability and
restlessness. On examination, you find that the heart rate is 250/ min, and palpable tender liver 3
cm below the costal margin. An ECG was recorded which showed fusion beats and wide QRS
complex. What is the most likely diagnosis?
a. WPW syndrome
b. Supraventricular tachycardia
c. Malignant premature ventricular complexes
d. Ventricular tachycardia
35.Which one of the following patients fulfill the Duke criteria for the diagnosis of Infective
Diagnosis?
a. A 3 year old child with aortic stenosis with evidence of endocarditis on
echocardiography
b. A 5 years old child with aortic stenosis with evidence of endocarditis on
echocardiography and mild fever, negative blood culture and no evidence of
embolic and immune complex phenomenon
c. A 13 years old child with rheumatic mitral regurgitation with high fever, two
blood culture positive for S. viridans and echocardiographic evidence of infective
endocarditis
d. A 15 years old child with no evidence of heart lesion, with high fever, one blood
culture positive for S. aureus and echocardiographic evidence of vegetations.

36. A 3 years old girl with normal growth and development but complaints of recurrent cough
and wheeze was not responding to bronchodilator therapy and was referred to you. On
examination, you find that she has tachycardia, low volume pulse, mild pedal edema, enlarged
tender liver. Echocardiographic evaluation shows a large heart with poor contractility. What is
the most likely diagnosis?
a. Pericardial effusion
b. Hypertrophic cardiomyopathy
c. Restrictive cardiomyopathy
d. Dilated cardiomyopathy
37. Paroxysmal suprventricular tachycardia in young children is most commonly due to which
one of the following?
a. Reentrant rhythm
b. Atrial flutter
c. Electrolyte disturbances
d. Automatic ectopic foci
38. A 7 – year old boy has been brought to OPD for loud snoring, difficult and obstructed
breathing at night for three months. He was reported to have become inattentive in school. Father
is obese and has history of snoring in sleep. Physical examination was unremarkable except for
tonsillar hypertrophy. What is the most appropriate next step for making the diagnosis?
a. Neuropsychiatric consultation
b. Lateral soft tissue radiograph of the neck
c. CT study of upper airway
d. Diagnostic testing for sleep apnea

39. A 3.5 kg male baby infant born at term after an uncomplicated pregnancy and delivery
develops respiratory distress shortly after birth and requires mechanical ventilation. He has been
on mechanical ventilation for the last 4 weeks. Chest radiograph reveals a normal cardiothymic
silhouette but the lung fields show a diffuse ground glass appearance. Surfactant replacement
fails to improve gas exchange. Over the first week of life, hypoxemia worsens. Results of routine
cultures and echocardiographic findings are negative. His elder sibling was a female who died at
the age of one month with respiratory distress. Which one of the following is the most likely
diagnosis?
a. Total anomalous pulmonary venous return
b. Meconium aspiration
c. Neonatal pulmonary alveolar proteinosis
d. Disseminated herpes simplex infection

40. A 7 year old girl presents with history of low grade fever and non productive cough for two
months. After treatment with an oral antibiotic, the child began to show signs of improvement.
However, the child subsequently experienced a productive cough and wheezing. At the time of
presentation in the emergency, she had mild dyspnea and fever of three days’ duration.
Spirometry reveals a severe obstructive pattern. Which one of the following is most likely
diagnosis?
a. Pulmonary alveolar microlithiasis
b. Wilson Mikity Syndrome
c. Bronchial obliterans
d. Postviral syndrome

41. A child on mechanical ventilation for Acute Respiratory Distress Syndrome, change nursing
in supine position should alternate with prone position. This measure is used to:
a. Redistribute total body oedema
b. Equalize pulmonary blood flow to dependent and independent lung segments
c. Prevent atelectasis and increased consolidation in dependent lung segments
d. Decrease the risk of pressure sores

42. A 1-month old infant develops signs of respiratory distress after coughing and sneezing for 3
days. He has marked subcostal and intercostals retractions and a respiratory rate of 80
breaths/minute. Breath sounds are markedly diminished on both sides. Diffuse crackles can be
heard bilaterally. There is no stridor. Arterial oxygen saturation in 100% oxygen by non
rebreather mask is 80%. The skin is pale and peripheral arterial pulses are weak. What is the
most appropriate next step?
 a. Administration of corticosteroids
b. Intubation of trachea and starting mechanical ventilation
c. Administration of normal saline
d. Administration of diuretics
43. The pathophysiologic change seen only as a result of chronic inflammation of airways is:
a. Airway constriction
b. Airway oedema
c. Airway remodeling
d. Airway modeling
44. The strongest predictor of wheezing progressing to asthma is:
a. Atopy
b. Allergic rhinitis
c. Family history
d. Upper respiratory tract infection associated with wheezing
45. The fluid accumulation seen in patients with parapneumonic effusion is due to :
a. Decreased plasma oncotic pressure
b. Decreased interstitial space hydrostatic pressure
c. Increased capillary permeability
d. Increased capillary hydrostatic pressure

46. The latest time after the onset of pharyngitis due to Group A- beta hemolytic Streptococcus
that initiation of penicillin therapy can be expected to prevent acute rheumatic fever is:
a. 3 days
b. 6 days
c. 9 days
d. 12 days

47. Within the genus Staphylococcus, the defining characteristics of the species S. aureus are
production of the extracellular enzyme coagulase and:
a. Microencapsulation
b. Production of alpha hemolysin
c. Production of slime
d. Production of protein A
48. The viral infection that is MOST likely to involve the central nervous system and present
with focal neurological findings is:
a. Coxackievirus
b. Enterovirus
c. Herpes simplex virus
d. St. Louis virus
49. Which one of the factors is involved in the pathogenesis of septic shock?
a. Endotoxin acts on the endothelial cells to increase the size of cell junctions, leading to
fluid loss
b. Interleukin-1 beta stimulates the myocardium, leading to tachycardia
c. Superantigens induce a very rapid humoral antibody response that, in turn, activates
complement
 d. Tumor necrosis factor alpha is released, the effects of which lead to fever and
vasodilatation
50.The best test to confirm a diagnosis of rabies earliest in a suspected human rabies case is
a. Reverse transcriptase-polymerase chain reaction test of the saliva for rabies antigen
b. Cerebrospinal fluid rabies antibody test
c. Direct fluorescent antibody test of the saliva for rabies specific antigen
d. Viral culture

Short answer question (SAQ) 10 X 5 = 50

1. Outline the complications of congenital acyanotic heart diseases.
2. Enlist the problems and its management of infants born to a diabetic mother.
3.Outline the recent advances on treatment of HIE.
4. Newer antiepileptic drugs
5. Human papilloma vaccine
6. Supraventricular Tachycardia
7. Mention the role of various free radicals of oxygen in diseases. How the injury to the cells
can be minimized?
8. Enumerate the usages of immunoglbulins in clinical practice. Mention the various
schedules in ITP.
9. Breiflydiscuss antenatal diagnosis and prevention of thalassemia.
10. Write down the management of hypoglycemia in the newborn.
1st Year (Paper III) Recent Advances

Answers:
1) A 46) C
2) D 47)D
3) A 48) C
4) C 49) D
5) B 50) A
6) B
7) A
8) C
9) C
10) A
11) C
12) D
13) D
14) D
15) C
16) C
17) D
18) A
19) C
20) A
21) D
22) B
23) D
24) A
25) B
26) A
27) B
28) D
29) C
30) C
31) C
32) B
33) B
34) B
35) C
36) D
37) A
38) D
39) C
40) C
41) C
42) D
43) D
44) A
45) C