Guidelines suggest that when hypothermia manifests in the context of a shockable rhythm, it might get harder to defibrillate. Therefore, defibrillation is recommended to occur at temperatures below 30°C, and to be limited in three shocks.

A 3 year old should be able to match two colours, copy a circle, walk up and down the stairs, and jump up and down. By the time they are 4 they can copy a cross, draw a person with three parts, count to 10, stand on one foot.

History of fever is suggestive of an infective focus. A straight nasal bones excludes a nasal bone fracture. A nasal septal abscess is defined as a collection of pus between the cartilage or bony septum and it is an uncommon disease which should be suspected in a patient with acute onset of nasal obstruction and recent history of nasal trauma.

Achondroplasia is one of the commonest forms of skeletal dysplasias that lead to dwarfism. Multiple skeletal deformities are associated with it but the common cranial abnormalities are macrocephaly, frontal bossing, depressed nasal bridge, narrowed foramen magnum, and the presence of communicating hydrocephalus. A prominent maxilla is not associated with achondroplasia.

The coeliac axis supplies the liver and stomach and from the oesophagus to the first half of the duodenum. The second half of the duodenum to the first two thirds of the transverse colon is supplied by the superior mesenteric artery. The inferior mesenteric supplies the last third of the transverse colon (approximately from the splenic flexure) to the first third of the rectum. The last two thirds of the rectum are supplied by the middle rectal artery. The greater curvature of the stomach is supplied by branches of the splenic artery, which itself comes from the coeliac axis.

Compared to the rest of the options, Meckel’s diverticulum with ectopic gastric mucosa seems to be the most probable diagnosis, as it can lead to fresh bleeding.Fresh red bleeding can be caused by haemorrhoids, polyps or a massive GI bleed.

Hirschsprung’s disease is characterized by congenital absence of the autonomic plexus (Meissner’s and Auerbach’s plexus) in the intestinal wall. Usually limited to the distal colon, it can occasionally involve the entire colon or even the small bowel. There is abnormal or absent peristalsis in the affected segment, resulting in continuous spasm of smooth muscle and partial/complete obstruction. This causes accumulation of intestinal contents and dilatation of proximal segment. Skip lesions are highly uncommon. This disease is seen early in life with 15% patients presenting in first month, 60% by 1 year of age and 85% by the age of 4 years. Symptoms include severe and complete constipation, abdominal distension and vomiting. Patients with involvement of ultra-short segments might have mild constipation with intervening diarrhoea. In older children, symptoms include failure to thrive, anorexia, and lack of an urge to defecate. On examination, an empty rectum is revealed with stool palpable high up in the colon. If not diagnosed in time, it can lead to Hirschsprung’s enterocolitis (toxic megacolon), which can be fulminant and lead to death. Diagnosis involves a barium enema or a rectal suction biopsy. Barium enema shows a transition in diameter between the dilated, normal colon proximal to the narrowed, affected distal segment. It is to be noted that barium enema should be done without prior preparation, which can dilate the abnormal segment, leading to a false-negative result. A 24-hour post-evacuation film can be obtained in the neonatal period – if the colon is still filled with barium, there is a high likelihood of Hirschsprung’s disease. Full-thickness rectal biopsy is diagnostic by showing the absence of ganglion cells. Acetylcholinesterase staining can be done to highlight the enlarged nerve trunks. Abnormal innervation can also be demonstrated by rectal manometry.

This clinical case is most probably due to intussusception complicated by sepsis. Regardless of the cause, the baby is sick and in a critical condition. The first thing to do is to preserve the vital signs and resuscitate with IV fluids. As sepsis is suspected, you should also start on triple antibiotics.

Amniotic fluid is the protective liquid that surrounds the fetus in utero. It prevents the fetus from injury, protects the umbilical cord from compression, and provides necessary nutrients and a medium for growth and movement. Amniotic fluid originates from the maternal plasma initially, but by 16th week of gestation, fetal kidneys start making urine which contributes to further production of the amniotic fluid. Amniotic fluid contains a number of chemical substances including hormones, tumour markers, nutrients, electrolytes, and immunoglobulins. Main substances found in amniotic fluid include carbohydrates, proteins, lipids, lactoferrin, insulin-like growth factor, granulocyte colony-stimulating factor, erythropoietin, etc. Interleukin-1 is not a component of AF.

Treating persons infected with C. trachomatis prevents adverse reproductive health complications and continued sexual transmission, and treating their sex partners can prevent reinfection and infection of other partners. Treating pregnant women usually prevents transmission of C. trachomatis to neonates during birth. Chlamydia treatment should be provided promptly for all persons testing positive for infection. Treatment delays have been associated with complications (e.g. PID) in a limited proportion of women. To minimise disease transmission to sex partners, persons treated for chlamydia should be instructed to abstain from sexual intercourse for 7 days after single-dose therapy or until completion of a 7-day regimen and resolution of symptoms if present. To minimise risk for reinfection, patients also should be instructed to abstain from sexual intercourse until all of their sex partners are treated. Persons who receive a diagnosis of chlamydia should be tested for HIV, GC, and syphilis.

The most appropriate next step in the management would be to refer the patient for an ENT opinion. Rationale:This child has clinical signs of adenotonsillar hypertrophy, symptoms of persistent snoring and features of obstructive sleep apnoea (OSA). Suspected OSA warrants referral to an ENT specialist. Other options:- Capillary blood gas: The investigation consists of overnight oxygen saturation monitoring or polysomnography.- Chest X-ray: A chest x-ray is not indicated.- Phenoxymethylpenicillin (Penicillin V) is the first-line treatment for tonsillitis. However, with a history of several months and no suggestion of fever or sore throat, acute tonsillitis is unlikely.- Weight loss advice: Obesity is a risk factor for obstructive sleep apnoea (OSA) amongst other health problems. The child’s weight should be highlighted and advice and support for weight loss provided however referral to ENT is warranted for further investigation.

Lead Poisoning Symptoms: Abdominal pain, bluish line on the gums (Burton line), wrist/foot drop, anaemia, nephropathy, encephalopathy, cognitive impairmentDiagnosis: Detectable in bloodBasophilic stippling of erythrocytes (disorder of heme synthesis) on smearTreatment: Succimer, Dimercaprol, EDTA

A complete course of DPT should be given.

USG of the scrotum is important to exclude any abnormality with testicles, epididymis and scrotum. This presentation can be acute epididymo-orchitis or testicular torsion. USG of the scrotum will help to confirm the diagnosis.

Bilious (green) gastric aspirate or emesis indicates that the intestines are obstructed below the ampulla of Vater.Gastrointestinal (GI) endoscopy is actually considered an essential diagnostic and therapeutic technique. Upper GI endoscopy in neonatal age allows for exploration of the oesophagus, stomach and duodenum| instead lower GI endoscopy easily reaches the sigmoid-colon junction.

Scarlet fever is a childhood infectious disease caused by group A Streptococcus. It produces a papular rash, which is classically described as a sand-paper rash. The rash initially appears on the trunk, groin, and underarms and then spreads to extremities, usually sparing the palms and soles. Circumoral area is also spared, giving it pallor-like appearance. Diseases like erythema multiforme, contact dermatitis, staphylococcal scalded skin syndrome, and rubella produce a rash that classically affects the palms and soles.

The red reflex examination is an important part of the paediatric ocular assessment. The red reflex is abnormal in conditions like retinoblastoma, retinopathy of prematurity, cataract, and retinal detachment. Amblyopia is a cortical developmental disorder that results in defective visual inputs to both the eyes. The disorder occurs during the cortical plasticity stage of embryonic development. The red reflex is normal in this case since there is no hindrance to the reflection of light from the ocular media and fundus.

The adult height potential may be calculated for a male child by (father’s height in cm + mother’s height in cm) / 2 then add 7 cm.In the scenario provided: (170 + 150)/2 + 7 = 167 cm = 1.67 m.For a female child by (father’s height in cm + mother’s height in cm) / 2 then minus 7 cm.This can then be plotted on a height centile chart to find the mid-parental centile.Causes of short stature include:- Normal variant (often familial)- Constitutional delay of growth and puberty- Chronic illness, e.g. cystic fibrosis, inflammatory bowel disease- Endocrine: growth hormone deficiency, hypothyroidism, steroid excess syndromes: Turner’s, Down’s, Prader-Willi- Skeletal dysplasias, e.g. achondroplasia

Due to breakdown of the red blood cell membrane in haemophilic patients, cholesterol crystals are formed by the lipids. On the other hand lipofuscin deposition does not occur in haemolysis or haemorrhage. Neutrophil accumulation suggests acute inflammation. Anthracotic pigment is an exogenous carbon pigment that deposits in the lung from dust. Russell bodies are intracellular accumulations of immunoglobins in plasma cells. Curschmann’s spirals and Charcot Leyden crystals are pathognomonic of asthma.

The primary intestinal loop is formed from the midgut which gives rise to the distal half of the duodenum, the jejunum, ascending colon, proximal two thirds of the transverse colon and the ileum.

Breast milk jaundice is thought to be associated with one or more abnormalities in the maternal milk itself. Breast milk jaundice syndrome generally needs no therapy if serum bilirubin concentrations remain below 270 mmol/l in healthy full-term infants. When the serum bilirubin concentration is above 270 mmol/l and rising, temporary interruption of breastfeeding may be indicated.

Klinefelter’s syndrome: The low follicle-stimulating hormone (FSH) and luteinising hormone (LH), together with the low testosterone, suggests a hypogonadotropic hypogonadism. We know that there is no mental retardation, and we are told that physical examination is normal and sense of smell would usually not be tested. Consequently a diagnosis of Kallman’s is suggested. We are not told of a family history of growth delay, thus this is unlikely to be constitutional delay. The thyroid-stimulating hormone (TSH) is normal, making hypothyroidism unlikely and this together with the normal prolactin make hypopituitarism most unlikely.

This history is suggestive of Henoch-Schönlein Purpura following a respiratory infection. A typical rash involving thighs and buttocks is often seen in this age group. Coagulation profile is the suitable answer from the given answers.

The mesonephric duct is one of the paired embryogenic tubules that drain the primitive kidney (mesonephros) to the cloaca. It also gives off a lateral branch forming the ureteric bud. In both the male and the female the Wolffian duct develops into the trigone of the urinary bladder. When the ducts are exposed to testosterone during embryogenesis, male sexual differentiation occurs: the mesonephric duct develops into the rete testis, the ejaculatory ducts, the epididymis, the ductus deferens and the seminal vesicles.

Klinefelter’s syndrome is the most common sex chromosome linked disorder with a karyotype of 47XXY. The incidence of the disease is 1 in 500-1000 male births. Childhood presentation consists of unusual growth spurt along with learning difficulties and delayed speech. The adolescence is marked by abnormal sexual maturation leading to hypogonadism and sub-fertility in adulthood.

The trigeminal nerve is responsible for the sensory innervation of the head, and the muscles of mastication. The nerve is divided into three branches, the ophthalmic nerve (V1) the mandibular nerve (V2) and the maxillary nerve (V3) which all exit the skull through their respective foramina. An easy way to remember these foramina is with the following mnemonic:Standing Room Only, for V1-V3 respectivelyV1- Superior orbital FissureV2- foramen RotundumV3 foramen Ovale

The symptoms and signs described are suggestive of otitis externa. The key treatment for otitis externa is ear cleaning and antibiotic drops with steroid.

Insufficient surfactant production in premature infants leads to respiratory distress syndrome or surfactant deficient lung disease (SDLD), characterized by structurally immature lungs. There are many risk factors of this disease, some of them include male gender, caesarean section, infants of diabetic mothers, being the second born of the premature twins, perinatal asphyxia, sepsis, and hypothermia. Maternal hypertension is not a recognized risk factor for respiratory distress syndrome| instead, pregnancy-induced hypertension and chronic maternal hypertension are the protective factors against this disease.

Multiple endocrine neoplasia type 1 is a rare, autosomal dominant disorder characterized by a higher propensity to develop various endocrine and nonendocrine tumours. The primary endocrine tumours that are a part of this disorder include carcinoid tumours and tumours of parathyroid, enteropancreatic, and anterior pituitary origin. Carcinoid tumours encountered in MEN type 1 are mostly of the foregut region. Non-endocrine tumours found in MEN type 1 include meningiomas and ependymomas, lipomas, angiofibromas, collagenomas, and leiomyomas. The pathogenesis of MEN type 1 is the inactivating mutation of the tumour suppressor gene MEN 1, which encodes the protein menin.

Frequent regurgitation of milk and microcytic anaemia is suggestive of a hiatus hernia. The reflux causes regurgitation of milk and frequent ulceration of the lower oesophageal mucosa potentially resulting in blood loss and anaemia. Duodenal atresia usually presents with bilious vomiting and pyloric stenosis presents with projectile vomiting. Alpha 1 antitrypsin deficiency and cystic fibrosis usually do not present with vomiting.