FMGE 2025 - Pediatrics Practice Questions

Q: The infant is being evaluated for recurrent episodes of seizures. EEG shows Hypsarrhythmia. Which drug is preferred for management?

ACTH. ***ACTH*** - The EEG pattern shown is **hypsarrhythmia**, which is a disorganized, high-amplitude, and chaotic pattern characteristic of **West syndrome** (infantile spasms). - **Adrenocorticotropic hormone (ACTH)** is a first-line therapy for infantile spasms, particularly in cases not associated with tuberous sclerosis, and is effective in stopping spasms and resolving the hypsarrhythmia pattern. *Vigabatrin* - **Vigabatrin** is also a first-line treatment for infantile spasms but is specifically the drug of choice if the underlying cause is **Tuberous Sclerosis Complex (TSC)**. - It carries a risk of causing irreversible **peripheral visual field defects**, which requires careful ophthalmologic monitoring. *Valproate* - **Valproate** is a broad-spectrum antiepileptic drug but is not a first-line treatment for infantile spasms. - Its use is limited in infants due to the significant risk of fatal **hepatotoxicity**, especially in children younger than two years old. *Carbamazepine* - **Carbamazepine** is typically used for focal seizures and is known to be ineffective or may even **worsen** infantile spasms and other generalized epilepsies. - It is not indicated for the treatment of West syndrome due to its potential to exacerbate the seizures.

Q: A 5 year old boy presented with hematemesis and was found to have splenomegaly, on examination. There was a past history of exchange transfusion in this child for neonatal jaundice. What is the probable diagnosis?

Portal vein thrombosis. ***Portal vein thrombosis***- This is the most probable diagnosis because **extrahepatic portal vein thrombosis (EHPVO)** is the most common cause of portal hypertension and variceal bleeding in pediatric patients.- A past history of **exchange transfusion** (which often utilizes umbilical vein catheterization) is a major risk factor for initiating ascending thrombophlebitis that leads to the development of a **portal vein thrombus**.- Manifestations include **splenomegaly** (due to portal hypertension) and **hematemesis** (due to bleeding from esophageal varices).*Splenic vein thrombosis*- **Isolated splenic vein thrombosis** causes *segmental portal hypertension*, typically resulting in localized high pressure leading mainly to **isolated gastric varices**.- While it causes **splenomegaly**, it is less likely to cause the severe, diffuse portal hypertension and extensive esophageal varices responsible for large-volume hematemesis seen in EHPVO.*Budd-Chiari syndrome*- This syndrome involves obstruction of the **hepatic veins** (or suprahepatic inferior vena cava), leading acutely to symptoms like tender **hepatomegaly**, intractable ascites, and often signs of **liver failure**.- The patient's presentation is characterized by isolated signs of *pre-hepatic portal hypertension* (splenomegaly and variceal bleeding), not the typical constellation of liver congestion seen in Budd-Chiari.*Liver cirrhosis*- Although cirrhosis causes portal hypertension, the history in a 5-year-old points toward a specific **pre-hepatic vascular etiology** (PVT) secondary to a neonatal event rather than a parenchymal disease.- Cirrhosis usually is accompanied by signs of chronic liver failure, such as **jaundice**, **synthetic dysfunction**, or **ascites**, which are absent in this typical EHPVO presentation.

Q: A child was brought with c/o multiple lesions. O/E multiple vesicular lesions are seen on the palms, soles, and oral mucosa. Which of the following is the most likely etiological agent causing the disease?

Coxsackie virus. ***Coxsackie virus*** - The clinical presentation of vesicular lesions on the **palms**, **soles**, and **oral mucosa** is the classic triad for **Hand, Foot, and Mouth Disease (HFMD)**. - **Coxsackievirus A16** and **Enterovirus 71** are the most common causes of HFMD, a typically self-limiting illness in young children that spreads via fecal-oral or respiratory routes. *Varicella-zoster virus* - This virus causes **chickenpox**, which presents as a generalized, pruritic, vesicular rash in various stages of healing, typically starting on the **trunk** and spreading centrifugally. - The characteristic distribution of chickenpox is **centripetal**, and prominent involvement of palms and soles is uncommon. *Measles virus* - Measles presents with **maculopapular rash** that begins on the face and spreads cephalocaudally, accompanied by the **3 Cs** (cough, coryza, conjunctivitis) and **Koplik spots** on the buccal mucosa. - The rash is **not vesicular** and typically **spares the palms and soles**, unlike HFMD. *Human-herpesvirus 6* - HHV-6 is the cause of **roseola infantum** (exanthem subitum), characterized by a high fever that resolves, followed by a blanching **maculopapular rash** on the trunk. - Roseola does not cause vesicular lesions and characteristically **spares the palms and soles**.

Q: A 12-year-old girl has developed breast and pubic hair. The mother wants to know which sign of puberty will typically occur next?

Peak height. ***Peak height*** - **Peak Height Velocity (PHV)**, representing the maximal growth rate, is the **next major pubertal milestone** after the onset of **thelarche** (breast budding) and **pubarche** (pubic hair development). - In the typical sequence of female puberty, PHV occurs at Tanner stage 2-3, approximately **1 year before menarche**. - This is a highly predictable, measurable milestone that serves as a clinical marker of pubertal progression. *Vaginal discharge* - Mild physiologic **vaginal discharge** (leukorrhea) due to increasing estrogen often begins very early in puberty, frequently concurrent with or shortly after initial breast budding. - While it may already be present or developing, it is a **subtle, less predictable sign** compared to the major milestone of Peak Height Velocity. - It is not taught as a primary pubertal milestone in standard medical texts. *Menarche* - **Menarche** (first menses) is a **late pubertal event** occurring at Tanner stage 4, typically **2-2.5 years after thelarche**. - It follows Peak Height Velocity by approximately 1 year and signals the deceleration phase of the growth spurt. - This occurs well after the clinical scenario described. *Axillary hair development* - Axillary hair typically develops at **Tanner stage 4**, relatively late in puberty, closer to the time of menarche. - It follows both pubic hair development and Peak Height Velocity in the pubertal sequence.

Q: A 7-year-old male child was brought to the EMR 6 hours after a burn and was having 22% BSA burns. On examination, cool extremities, BP - 92/50mmHg, PR - 56 BPM. Urine output since burn episode: 30ml. What is the next step in management?

Give crystalloid bolus of 10-20 ml/kg. ***Give crystalloid bolus of 10-20 ml/kg*** - Child presents with **hypovolemic shock** (cool extremities, hypotension, bradycardia, oliguria) - Signs indicate inadequate initial resuscitation despite 6 hours post-burn - Immediate management: **rapid crystalloid bolus of 10-20 ml/kg** (Ringer's lactate or normal saline) over 20-60 minutes - After stabilization, continue calculated Parkland formula resuscitation - Target urine output: **1-2 ml/kg/hr** in children *Give a colloid bolus* - Colloids (albumin, plasma) are **not first-line** in initial burn resuscitation - Crystalloids (Ringer's lactate) are preferred initially due to better efficacy and lower cost - Colloids may be considered later if crystalloid requirements are excessive *Give bolus at 30ml/kg/hr* - This rate is **excessively high** and inappropriate - Risk of fluid overload, pulmonary edema, and compartment syndrome - Standard bolus is 10-20 ml/kg given rapidly, not as an hourly rate *Surgical Intervention* - Not the **immediate priority** in shock management - **Resuscitation before surgery** is the principle in trauma care - Surgical debridement/escharotomy may be needed later after stabilization

Q: A 9-month-old infant is brought for a routine check-up. Which of the following developmental milestones is most likely to be present at this age?

Creeps well on hands and knees. ***Creeps well on hands and knees***- By 9 months, most infants can **pull themselves to stand** and are typically proficient in **creeping** (moving on hands and knees), which is essential for independent exploration.- While some infants crawl (belly down) by 7 months, true **creeping** on hands and knees is the expected major **gross motor milestone** by 9 months.*Mature grasp*- A **mature grasp**, also known as the **fine pincer grasp** (using the tips of the index finger and thumb), is typically achieved later, around **10 to 12 months** of age.- At 9 months, infants generally use an **inferior or crude pincer grasp** or release objects with variable control.*Can hop on one foot*- This is a **gross motor milestone** requiring advanced balance and coordination, typically achieved between **3 and 4 years** of age (preschool age).- A 9-month-old infant lacks the necessary **neuromuscular maturity** and lower limb strength for single-leg weight bearing and hopping.*Runs steadily*- The ability to **run steadily** is usually a milestone achieved around **18 to 24 months** of age (toddler years), after the child has mastered independent walking (12–15 months).- At 9 months, the focus is on **non-ambulatory mobility**, such as creeping and cruising along furniture.

Q: A 7-year-old child is brought to the clinic with complaints of fatigue and poor concentration. The mother reports that the child has been eating non-food items such as chalk and soil for the past few months. A peripheral blood smear image shows microcytic, hypochromic red blood cells. Which of the following is the most likely diagnosis?

Iron deficiency anemia. ***Iron deficiency anemia*** - The patient's history of **pica** (craving and eating non-food items like chalk and soil) is a classic clinical sign of iron deficiency. - The peripheral blood smear confirms this diagnosis by showing **microcytic** (small) and **hypochromic** (pale) red blood cells, which result from impaired hemoglobin synthesis due to a lack of iron. *Vitamin B12 deficiency* - This condition causes **macrocytic anemia**, where red blood cells are larger than normal (high MCV), which is the opposite of the findings in this case. - Peripheral smear findings in B12 deficiency typically include **macro-ovalocytes** and **hypersegmented neutrophils**, neither of which is described or shown. *Thalassemia major* - Although thalassemia causes a **microcytic, hypochromic anemia**, it is a genetic disorder that typically presents in infancy with severe symptoms like failure to thrive and massive **hepatosplenomegaly**. - Pica is not a characteristic feature of thalassemia; it is strongly associated with iron deficiency anemia. *Lead poisoning* - Lead poisoning can cause microcytic anemia, but a key finding on the peripheral smear is **basophilic stippling**, which is not the prominent feature here. - While pica can be a risk factor for lead ingestion, pica itself is a more direct and classic symptom of underlying **iron deficiency**.

Q: A 5-year-old child is brought to the clinic with abdominal pain, irritability, and developmental delay. On examination, the child has pallor and a bluish line on the gums. Laboratory tests reveal microcytic anemia, and a peripheral blood smear shows red blood cells with basophilic stippling. Which of the following is the most likely diagnosis?

Lead poisoning. ***Lead poisoning***- All the symptoms—**abdominal pain** (colic), **irritability**, **developmental delay**, microcytic anemia, and the finding of a **bluish line on the gums** (Burton line)—are highly suggestive of chronic lead toxicity in a child. - The hallmark **basophilic stippling** on the blood smear is caused by lead inhibiting the enzyme **pyrimidine 5'-nucleotidase**, preventing RNA degradation.*Iron deficiency anemia*- While it causes **microcytic anemia** and pallor, it typically does not present with the severe neurodevelopmental regression or **abdominal colic** described.- Basophilic stippling is rare in iron deficiency anemia; the characteristic peripheral smear findings are severe **microcytosis** and **hypochromia**.*Sideroblastic anemia*- This condition is characterized by the presence of **ring sideroblasts** in the bone marrow and high iron levels, which requires specific testing for confirmation.- Although it can rarely present with basophilic stippling, it lacks the specific history of severe neurological and gastrointestinal symptoms (colic, developmental delay) associated with **lead exposure**.*Thalassemia minor*- This is a mild, often asymptomatic **microcytic, hypochromic anemia** caused by reduced globin chain synthesis, usually identified via routine screening or elevated **HbA2** on electrophoresis.- Thalassemia does not cause **basophilic stippling** (unless unstable Hb variants are present) and fundamentally lacks the systemic toxicity signs like **Burton lines** and **developmental delay**.

Q: A child presents with abdominal distension and an enlarged liver by 8cm below the costal margin. The liver is smooth on palpation. Which of the following is the most likely diagnosis?

Glycogen Storage Disease (GSD). ***Glycogen Storage Disease (GSD)***- GSDs, particularly Type I (**Von Gierke Disease**), cause massive, **smooth hepatomegaly** due to the accumulation of normal or abnormal glycogen within hepatocytes.- The presentation in childhood with severe abdominal distension and an enlarged, non-tender, **smooth liver** is highly characteristic of these metabolic disorders.*Lysosomal Storage Disease (LSD)*- While LSDs (e.g., Gaucher, Niemann-Pick) can cause hepatomegaly, they often involve the **Reticuloendothelial system**, leading to prominent **splenomegaly** as well, which is not mentioned here.- Clinical features usually include severe **neurological impairment** or **skeletal abnormalities**, differentiating them from GSDs which primarily affect the liver and glucose metabolism initially.*Hepatocellular Carcinoma (HCC)*- HCC usually results in a **firm, nodular, or irregular** liver surface on palpation, reflecting tumor growth, rather than a uniformly smooth enlargement.- Although rare in children, when it occurs, it is typically associated with rapidly worsening symptoms, weight loss, and often underlying conditions like **cirrhosis** or **hepatitis**.*Autoimmune Hepatitis*- This condition involves chronic **inflammation and destruction of hepatocytes**, often leading to symptoms of liver failure (jaundice) and elevated **transaminases**.- Long-standing autoimmune hepatitis progresses to cirrhosis, resulting in a **fibrotic or nodular** liver, rarely presenting as primary, massive, smooth hepatomegaly in a child.

Q: A 12-year-old child presents with short stature. On evaluation, the bone age is found to be less than the chronological age. There are no dysmorphic features, and the child is otherwise healthy. What is the most likely diagnosis?

Constitutional delay of growth and puberty. ***Constitutional delay of growth and puberty*** - This condition is the most common cause of short stature in healthy children, defined by a delayed maturation profile resulting in **bone age significantly less** than the chronological age. - The child is otherwise healthy and lacks dysmorphic features, suggesting a normal eventual final height, albeit with delayed onset of **puberty** and growth spurt. *Familial short stature* - Children with this diagnosis are genetically programmed to be short, leading to a final adult height consistent with their parents' stature. - A key differentiating feature is that the **bone age is commensurate** with the chronological age, which contradicts the finding in this patient. *Achondroplasia* - This is a specific form of **skeletal dysplasia** characterized by marked physical findings, including **rhizomelic short limbs** (shortening of proximal segments) and **macrocephaly**. - The presence of *no dysmorphic features* in this child strongly argues against the diagnosis of achondroplasia. *Chondrodysplasia* - This term encompasses a broad group of disorders involving defects in cartilage and bone development, which typically result in **disproportionate short stature** and specific skeletal abnormalities. - The description of the child being *otherwise healthy* and lacking dysmorphic features makes a significant, underlying generalized skeletal dysplasia highly improbable.

Question 1

The infant is being evaluated for recurrent episodes of seizures. EEG shows Hypsarrhythmia. Which drug is preferred for management?

Accepted Answer

ACTH

Answer

Valproate

Answer

Vigabatrin

Answer

Carbamazepine

Question 2

A 5 year old boy presented with hematemesis and was found to have splenomegaly, on examination. There was a past history of exchange transfusion in this child for neonatal jaundice. What is the probable diagnosis?

Accepted Answer

Portal vein thrombosis

Answer

Splenic vein thrombosis

Answer

Liver cirrhosis

Answer

Budd-Chiari syndrome

Question 3

A child was brought with c/o multiple lesions. O/E multiple vesicular lesions are seen on the palms, soles, and oral mucosa. Which of the following is the most likely etiological agent causing the disease?

Accepted Answer

Coxsackie virus

Answer

Varicella-zoster virus

Answer

Measles virus

Answer

Human-herpesvirus 6

Question 4

A 12-year-old girl has developed breast and pubic hair. The mother wants to know which sign of puberty will typically occur next?

Accepted Answer

Peak height

Answer

Vaginal discharge

Answer

Axillary hair development

Answer

Menarche

Question 5

A 7-year-old male child was brought to the EMR 6 hours after a burn and was having 22% BSA burns. On examination, cool extremities, BP - 92/50mmHg, PR - 56 BPM. Urine output since burn episode: 30ml. What is the next step in management?

Accepted Answer

Give crystalloid bolus of 10-20 ml/kg

Answer

Give a colloid bolus

Answer

Give bolus at 30ml / kg / hr

Answer

Surgical Intervention

Question 6

A 9-month-old infant is brought for a routine check-up. Which of the following developmental milestones is most likely to be present at this age?

Accepted Answer

Creeps well on hands and knees

Answer

Runs steadily

Answer

Can hop on one foot

Answer

Mature grasp

Question 7

A 7-year-old child is brought to the clinic with complaints of fatigue and poor concentration. The mother reports that the child has been eating non-food items such as chalk and soil for the past few months. A peripheral blood smear image shows microcytic, hypochromic red blood cells. Which of the following is the most likely diagnosis?

Accepted Answer

Iron deficiency anemia

Answer

Lead poisoning

Answer

Thalassemia major

Answer

Vitamin B12 deficiency

Question 8

A 5-year-old child is brought to the clinic with abdominal pain, irritability, and developmental delay. On examination, the child has pallor and a bluish line on the gums. Laboratory tests reveal microcytic anemia, and a peripheral blood smear shows red blood cells with basophilic stippling. Which of the following is the most likely diagnosis?

Accepted Answer

Lead poisoning

Answer

Thalassemia minor

Answer

Iron deficiency anemia

Answer

Sideroblastic anemia

Question 9

A child presents with abdominal distension and an enlarged liver by 8cm below the costal margin. The liver is smooth on palpation. Which of the following is the most likely diagnosis?

Accepted Answer

Glycogen Storage Disease (GSD)

Answer

Autoimmune Hepatitis

Answer

Hepatocellular Carcinoma (HCC)

Answer

Lysosomal Storage Disease (LSD)

Question 10

A 12-year-old child presents with short stature. On evaluation, the bone age is found to be less than the chronological age. There are no dysmorphic features, and the child is otherwise healthy. What is the most likely diagnosis?

Accepted Answer

Constitutional delay of growth and puberty

Answer

Achondroplasia

Answer

Chondrodysplasia

Answer

Familial short stature

FMGE 2025 — Pediatrics