A 5-year-old boy in Lucknow is brought to the OPD because he falls often and cannot keep up with other children. He walks with a waddling gait, has enlarged firm calves and, to rise from the floor, turns prone and pushes himself up with his hands on his knees and thighs. His maternal uncle used a wheelchair from the age of 11. Which investigation should be done first?

Muscle biopsy with dystrophin staining

A 7-year-old girl in Gorakhpur with uncorrected tetralogy of Fallot has had fever and worsening headache for 10 days. Today she had a focal seizure and has weakness of the left arm. She is drowsy, with no neck stiffness, and fundoscopy shows early papilloedema. What is the most appropriate next investigation?

Contrast-enhanced CT or MRI of the brain

Lumbar puncture for CSF analysis

Echocardiography for vegetations

EEG to look for a seizure focus

A 3-year-old boy from Varanasi is brought to the paediatric OPD because he turns blue on exertion and squats after running. He has central cyanosis with clubbing, a single second heart sound and an ejection systolic murmur at the left upper sternal border. Chest X-ray shows a boot-shaped heart with oligaemic lung fields. What is the most likely diagnosis?

Total anomalous pulmonary venous return

Transposition of the great arteries

Eisenmenger ventricular septal defect

A 6-year-old boy with steroid-sensitive nephrotic syndrome has had three relapses in the last 6 months, each responding to daily prednisolone within 2 weeks. He has no hypertension or haematuria, and renal function is normal. What is the most appropriate next step in management?

Start a steroid-sparing agent such as levamisole

Treat each relapse with IV methylprednisolone

Daily high-dose prednisolone for a year

Kidney biopsy before any further treatment

A 14-month-old girl with known tetralogy of Fallot becomes deeply cyanosed, irritable and breathless after crying in the morning; the systolic murmur becomes softer. The resident places her in a knee-chest position. How does this position help?

It raises systemic vascular resistance, reducing right-to-left shunt

It relaxes the infundibular muscle of the right ventricle

It lowers pulmonary vascular resistance, increasing lung blood flow

It raises heart rate, increasing the cardiac output

Paediatric cardiology, nephrology and neurology

19 NEET-PG practice questions on Paediatric cardiology, nephrology and neurology, part of Paediatrics. The first 19 are below; the first 5 with answers and explanations (tap Show answer after you have chosen), the rest in Learn with a free account.

Question 1 · Medium
A 5-year-old boy in Lucknow is brought to the OPD because he falls often and cannot keep up with other children. He walks with a waddling gait, has enlarged firm calves and, to rise from the floor, turns prone and pushes himself up with his hands on his knees and thighs. His maternal uncle used a wheelchair from the age of 11. Which investigation should be done first?
1. ANerve conduction studies
2. BSerum creatine kinase
3. CMRI of the spine
4. DMuscle biopsy with dystrophin staining
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Answer: B · Serum creatine kinase
Gowers sign, calf pseudohypertrophy and proximal weakness in a young boy with an affected maternal uncle (X-linked inheritance) suggest Duchenne muscular dystrophy. Serum creatine kinase is the first test: it is raised many times above the upper limit of normal from early life, before weakness appears. A high CK is followed by genetic testing for deletions or duplications in the dystrophin gene, which confirms most cases; muscle biopsy is kept for boys in whom genetic tests are negative. Corticosteroids such as prednisolone or deflazacort slow the loss of strength.
- A: Nerve conduction is normal in a myopathy and is used to study neuropathies.
- C: MRI of the spine looks for cord lesions, which give upper motor neuron signs.
- D: Biopsy is invasive and is now kept for cases in which genetic testing is negative.
Question 2 · Hard
A 7-year-old girl in Gorakhpur with uncorrected tetralogy of Fallot has had fever and worsening headache for 10 days. Today she had a focal seizure and has weakness of the left arm. She is drowsy, with no neck stiffness, and fundoscopy shows early papilloedema. What is the most appropriate next investigation?
1. ALumbar puncture for CSF analysis
2. BContrast-enhanced CT or MRI of the brain
3. CEchocardiography for vegetations
4. DEEG to look for a seizure focus
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Answer: B · Contrast-enhanced CT or MRI of the brain
Children with cyanotic heart disease and a right-to-left shunt, especially beyond 2 years of age, are at risk of brain abscess, because bacteria in venous blood bypass the filtering lungs; polycythaemia and low oxygen also favour it. Fever, headache, focal deficits and papilloedema point to a space-occupying lesion, so contrast imaging is the investigation of choice. Lumbar puncture is dangerous with raised intracranial pressure and a mass, as it can cause herniation. Treatment is drainage or aspiration with prolonged IV antibiotics.
- A: Lumbar puncture risks herniation with a mass lesion and papilloedema.
- C: Echocardiography may help if endocarditis is suspected but does not address the brain lesion.
- D: EEG cannot show the cause of a focal deficit with raised pressure.
Question 3 · Easy
A 3-year-old boy from Varanasi is brought to the paediatric OPD because he turns blue on exertion and squats after running. He has central cyanosis with clubbing, a single second heart sound and an ejection systolic murmur at the left upper sternal border. Chest X-ray shows a boot-shaped heart with oligaemic lung fields. What is the most likely diagnosis?
1. ATotal anomalous pulmonary venous return
2. BTetralogy of Fallot
3. CTransposition of the great arteries
4. DEisenmenger ventricular septal defect
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Answer: B · Tetralogy of Fallot
Cyanosis with squatting, a single S2 and an ejection murmur from the narrowed right ventricular outflow, with a boot-shaped heart and oligaemic lungs, is tetralogy of Fallot, the commonest cyanotic heart disease after infancy. Its four parts are a large VSD, right ventricular outflow obstruction, an overriding aorta and right ventricular hypertrophy. The murmur comes from the pulmonary stenosis, not the VSD, and becomes shorter as the obstruction worsens. Squatting raises systemic vascular resistance and reduces right-to-left shunting.
- A: TAPVR gives plethoric lungs and, in the obstructed form, pulmonary oedema.
- C: TGA presents with cyanosis in the first days of life, with an egg-on-string heart.
- D: Eisenmenger syndrome develops later, with a loud P2, not oligaemic lungs.
Question 4 · Medium
A 6-year-old boy with steroid-sensitive nephrotic syndrome has had three relapses in the last 6 months, each responding to daily prednisolone within 2 weeks. He has no hypertension or haematuria, and renal function is normal. What is the most appropriate next step in management?
1. AStart a steroid-sparing agent such as levamisole
2. BTreat each relapse with IV methylprednisolone
3. CDaily high-dose prednisolone for a year
4. DKidney biopsy before any further treatment
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Answer: A · Start a steroid-sparing agent such as levamisole
Two or more relapses within 6 months of the initial response (or four in any 12 months) defines frequently relapsing nephrotic syndrome. Repeated high-dose steroid courses cause growth failure, obesity, hypertension, cataract and bone loss, so a steroid-sparing agent is added: levamisole, mycophenolate mofetil, cyclophosphamide or, later, calcineurin inhibitors or rituximab. A kidney biopsy is not needed for frequent relapses in a steroid-sensitive child, as the histology is almost always minimal change. Parents are taught to test urine albumin at home so relapses are caught early.
- B: IV pulses are not needed for steroid-sensitive relapses and add steroid exposure.
- C: Prolonged daily high-dose steroids cause the toxicity the plan is meant to avoid.
- D: Biopsy is for steroid resistance or atypical features, not for frequent relapses alone.
Question 5 · Medium
A 14-month-old girl with known tetralogy of Fallot becomes deeply cyanosed, irritable and breathless after crying in the morning; the systolic murmur becomes softer. The resident places her in a knee-chest position. How does this position help?
1. AIt relaxes the infundibular muscle of the right ventricle
2. BIt lowers pulmonary vascular resistance, increasing lung blood flow
3. CIt raises heart rate, increasing the cardiac output
4. DIt raises systemic vascular resistance, reducing right-to-left shunt
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Answer: D · It raises systemic vascular resistance, reducing right-to-left shunt
During a hypercyanotic spell, infundibular spasm and falling systemic resistance divert more right ventricular blood through the VSD into the aorta, so the murmur, which comes from flow across the outflow tract, becomes softer. Flexing the knees onto the chest compresses the femoral arteries and raises systemic vascular resistance, so more blood goes to the lungs; it also increases venous return. Oxygen, morphine (which calms the child and relaxes the infundibulum), IV fluids and propranolol follow, with phenylephrine if needed. A spell is an indication for early surgical repair.
- A: Infundibular relaxation is the effect of morphine and propranolol, not the posture.
- B: Pulmonary resistance is not the main target of the posture.
- C: Raising heart rate worsens the spell; beta-blockers help by slowing it.
Question 6 · Hard
A 3-year-old boy in Kochi has had fever for 6 days not responding to antibiotics. He has red eyes without discharge, cracked red lips, a polymorphous rash, swollen hands and feet and a 2 cm unilateral cervical node. CRP is 98 mg/L, platelets 4.6 lakh/µL and serum albumin 2.9 g/dL. What is the best management?
1. AParacetamol and observation until the fever settles
2. BIV ceftriaxone and vancomycin, and blood cultures
3. CIV immunoglobulin with aspirin, and an echocardiogram
4. DOral prednisolone alone, and review in a week
Answer and explanation in LearnFree account
Question 7 · Medium
A 3-month-old boy is brought to the OPD in Kozhikode because he sweats while feeding, takes long to finish feeds and has gained little weight. He breathes 64/min, the liver is 3 cm below the costal margin, and there is a grade 3/6 pansystolic murmur at the left lower sternal border. Chest X-ray shows cardiomegaly and pulmonary plethora. What is the most likely diagnosis?
1. ALarge ventricular septal defect
2. BOstium secundum atrial septal defect
3. CTetralogy of Fallot
4. DMild pulmonary valve stenosis
Answer and explanation in LearnFree account
Question 8 · Hard
A 5-year-old boy with nephrotic syndrome in relapse has massive oedema. After a dose of IV furosemide on the ward, he develops abdominal pain, cold hands and feet, a capillary refill time of 4 seconds and a pulse of 140/min, with BP 90/60 mmHg. Haematocrit has risen from 38% to 47% and urine sodium is 8 mmol/L. What is the next best step?
1. AA further dose of IV furosemide for the oedema
2. BIncrease oral prednisolone to 3 mg/kg/day
3. CVolume expansion with IV albumin or saline; stop diuretics
4. DIV ceftriaxone for suspected peritonitis only
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Question 9 · Medium
A 12-year-old boy in Ranchi complains of headaches and leg pain on running. BP in the right arm is 160/96 mmHg; femoral pulses are weak and delayed compared with the radial pulse. There is an ejection click at the apex, and the chest X-ray shows notching of the lower borders of several ribs. Which other cardiac anomaly is most often associated with his condition?
1. AMitral valve prolapse
2. BPulmonary valve stenosis
3. CBicuspid aortic valve
4. DEbstein anomaly of the tricuspid
Answer and explanation in LearnFree account
Question 10 · Easy
An 18-month-old boy has a generalised tonic-clonic seizure lasting 2 minutes on the first day of a viral fever with a temperature of 39.4 °C. Within an hour he is alert and playful, and examination shows only a red throat. What is the most appropriate next step?
1. AReassure parents and treat the fever
2. BMRI brain before discharge
3. CEEG and start oral valproate
4. DLumbar puncture and IV antibiotics
Answer and explanation in LearnFree account
Question 11 · Medium
An 8-year-old boy in Kottayam has had three seizures in 6 months, all within an hour of falling asleep. His mother finds him awake but unable to speak, drooling, with twitching of the left side of his face that sometimes spreads to a generalised seizure. He is developing normally and his neurological examination is normal. The EEG shows spikes over the centrotemporal regions that increase during sleep. What is the most likely diagnosis?
1. AJuvenile myoclonic epilepsy
2. BBenign rolandic epilepsy
3. CChildhood absence epilepsy
4. DLennox-Gastaut syndrome
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Question 12 · Easy
A 6-year-old boy weighing 20 kg is brought to casualty having a generalised tonic-clonic seizure that began 7 minutes ago. His airway is positioned, oxygen is given, glucose is 96 mg/dL and an IV line is in place. What is the drug of first choice now?
1. AIV lorazepam
2. BIV phenytoin
3. CIV levetiracetam
4. DIV phenobarbitone
Answer and explanation in LearnFree account
Question 13 · Medium
A preterm baby born at 28 weeks in a NICU in Hyderabad is on the ventilator on day 4. She has bounding pulses, a wide pulse pressure, a continuous murmur below the left clavicle and rising oxygen needs; echocardiography confirms a haemodynamically significant patent ductus arteriosus. Oral ibuprofen is started. How does this drug close the duct?
1. AIt stimulates nitric oxide release in the duct wall
2. BIt inhibits cyclooxygenase, lowering prostaglandin E2
3. CIt raises arterial oxygen tension in the duct
4. DIt blocks endothelin receptors on ductal muscle
Answer and explanation in LearnFree account
Question 14 · Medium
The parents of a 13-month-old girl who had her first simple febrile seizure ask about the chance of another. The paediatrician considers four factors: 1. Her first seizure occurred before 18 months of age. 2. Her mother had febrile seizures as a child. 3. The seizure occurred at a temperature of only 38.3 °C. 4. The seizure came within an hour of the onset of fever. Which factors raise her risk of recurrence?
1. A1 and 2 only
2. B1, 2 and 3 only
3. C2 and 4 only
4. D1, 2, 3 and 4
Answer and explanation in LearnFree account
Question 15 · Medium
A term baby boy in the postnatal ward of a district hospital becomes deeply cyanosed 8 hours after birth. There is no murmur and no respiratory distress, and SpO2 stays at 65% even on 100% oxygen. Chest X-ray shows a narrow upper mediastinum with an egg-shaped heart. What is the most important immediate treatment while transfer is arranged?
1. AIV prostaglandin E1 infusion
2. BIV propranolol
3. CIV furosemide
4. DIV indomethacin
Answer and explanation in LearnFree account
Question 16 · Easy
A 4-year-old girl in Indore has had puffiness of the eyelids for a week and now has a swollen abdomen. BP is 96/60 mmHg; urine shows 4+ protein with no red cells, serum albumin is 1.8 g/dL, cholesterol 380 mg/dL, and creatinine and C3 are normal. What is the most likely histology if a biopsy were done?
1. AFocal segmental glomerulosclerosis
2. BMinimal change disease
3. CMembranous nephropathy
4. DMembranoproliferative glomerulonephritis
Answer and explanation in LearnFree account
Question 17 · Medium
An 8-year-old girl is referred from a school health check-up in Mysuru for a murmur. She is asymptomatic. There is a soft ejection systolic murmur in the left second intercostal space and the second heart sound is widely split and does not vary with respiration. ECG shows right axis deviation with an rSR' pattern in V1. What is the most likely diagnosis?
1. APatent ductus arteriosus
2. BSmall muscular ventricular septal defect
3. COstium primum atrial septal defect
4. DOstium secundum atrial septal defect
Answer and explanation in LearnFree account
Question 18 · Medium
In a paediatric nephrology clinic in Chandigarh, the consultant reviews four children with nephrotic syndrome for kidney biopsy: 1. An 8-month-old with onset at 6 months. 2. A 5-year-old with persistent proteinuria after 6 weeks of daily prednisolone. 3. A 7-year-old with persistently low serum C3. 4. A 4-year-old with two steroid-responsive relapses in a year. In which children is biopsy indicated?
1. A1, 2 and 4 only
2. B2, 3 and 4 only
3. C1, 2 and 3 only
4. D2 and 3 only
Answer and explanation in LearnFree account
Question 19 · Hard
A 9-month-old girl in Patna has had diarrhoea for 3 days, and her grandmother has been giving her large amounts of plain boiled water instead of ORS. She is brought to casualty with a generalised seizure that does not stop after a dose of IV midazolam. Capillary glucose is 88 mg/dL; serum sodium is 116 mmol/L and potassium 3.4 mmol/L. What is the most appropriate next step?
1. AIV 10% dextrose bolus
2. BA bolus of IV 3% saline
3. CIV phenytoin loading dose
4. DIV calcium gluconate
Answer and explanation in LearnFree account

Paediatric cardiology, nephrology and neurology

A 6-year-old boy with steroid-sensitive nephrotic syndrome has had three relapses in the last 6 months, each responding to daily prednisolone within 2 weeks. He has no hypertension or haematuria, and renal function is normal. What is the most appropriate next step in management?

A 14-month-old girl with known tetralogy of Fallot becomes deeply cyanosed, irritable and breathless after crying in the morning; the systolic murmur becomes softer. The resident places her in a knee-chest position. How does this position help?

An 18-month-old boy has a generalised tonic-clonic seizure lasting 2 minutes on the first day of a viral fever with a temperature of 39.4 °C. Within an hour he is alert and playful, and examination shows only a red throat. What is the most appropriate next step?

A 6-year-old boy weighing 20 kg is brought to casualty having a generalised tonic-clonic seizure that began 7 minutes ago. His airway is positioned, oxygen is given, glucose is 96 mg/dL and an IV line is in place. What is the drug of first choice now?