Neonatology Practice Questions

Q: Mother of a 6-hour-old neonate has pointed to passage of stool of the following color. Which of the following best describes the clinical possibility?

It is normal meconium passed within first 24 hours. ***It is normal meconium passed within first 24 hours*** - The image depicts a **yellowish-brown, thick, and sticky substance**, similar to what is expected with **transitional stool** or early meconium mixed with milk components. - The neonate is 6 hours old, and the passage of normal meconium usually occurs within the **first 24-48 hours** of life, typically dark green to black but can transition to a lighter color. *Meconium plug syndrome, perform sweat chloride test* - **Meconium plug syndrome** typically presents with delayed passage of meconium and abdominal distension, not with stool of this color or consistency at 6 hours. - A **sweat chloride test** is primarily used to diagnose cystic fibrosis, which can be associated with meconium ileus (a more severe obstruction than meconium plug) but is not the first diagnostic step for a seemingly normal stool passage at this age. *Metabolic liver disease, perform urine for reducing substances* - **Metabolic liver diseases** would typically present with jaundice, hepatomegaly, or other signs of liver dysfunction, not solely with stool of this appearance at 6 hours. The stool color would also be more likely **acholic (pale/white)** if there was significant biliary obstruction. - **Urine for reducing substances** is used to screen for certain metabolic disorders like galactosemia, which would present with symptoms like vomiting, lethargy, and jaundice, not just normal stool. *Biliary atresia, perform hepatobiliary scintigraphy* - **Biliary atresia** causes obstruction of the bile ducts, leading to **acholic (pale or white) stools**, not the yellowish-brown stools seen in the image. - Symptoms of biliary atresia usually manifest later, around **2-8 weeks of age**, with persistent jaundice and pale stools. A **hepatobiliary scintigraphy** would be performed if biliary atresia is suspected later based on clinical presentation.

Q: Child has not passed stool by 2nd day of life. X-Ray study done shows:

Duodenal atresia. ***Duodenal atresia*** - The abdominal X-ray images display the classic **"double bubble sign"**, which is highly characteristic of duodenal atresia. This sign consists of two distinct air-filled loops, one representing the distended stomach and the other the dilated proximal duodenum, with no distal gas. - The clinical presentation of a neonate not passing stool by the second day of life, combined with the characteristic radiological findings, points directly to an **upper gastrointestinal obstruction** like duodenal atresia. *Cystic fibrosis* - While cystic fibrosis can cause **meconium ileus** leading to intestinal obstruction in newborns, it typically presents with diffuse intestinal distension rather than the localized "double bubble" pattern. - Meconium ileus on X-ray would show numerous dilated loops of small bowel with a **"ground-glass" appearance** due to trapped meconium, not the distinct two bubbles seen here. *CHPS* - **Congenital hypertrophic pyloric stenosis (CHPS)** typically manifests later, between 3-6 weeks of age, with projectile non-bilious vomiting, not as early as the second day of life with findings of intestinal obstruction on X-ray. - The X-ray findings in CHPS would show a **distended stomach but without the second bubble** representing a dilated duodenum often seen in duodenal atresia. *Anorectal malformation* - **Anorectal malformations** are lower gastrointestinal obstructions, meaning a significant portion of the bowel would be distended with gas, and the X-ray would not show the isolated "double bubble" sign. - Diagnosis is often made by physical examination demonstrating an **imperforate anus** or abnormal anal opening, in conjunction with plain abdominal radiographs that would show distal intestinal obstruction.

Q: Which of the following diseases can lead to the position shown in the image?

Kernicterus. ***Kernicterus*** - The image shows an infant with **opisthotonus**, a severe form of **spasticity** characterized by extreme arching of the back and neck. This is a classic sign of severe **kernicterus**. - **Kernicterus** is a rare but serious neurological complication of **unconjugated hyperbilirubinemia**, where high levels of **bilirubin** cross the blood-brain barrier and deposit in the brain, particularly the basal ganglia. *Tetany* - **Tetany** is characterized by muscle spasms and cramps, often due to **hypocalcemia**, but typically presents as carpopedal spasm (Trousseau's sign) or facial twitching (Chvostek's sign), not generalized opisthotonus. - While it involves muscle rigidity, the specific arched-back posture seen in the image is not typical of tetany. *Measles* - **Measles** is a viral infection characterized by a distinctive maculopapular rash, fever, cough, coryza, and conjunctivitis. - It does not typically cause severe neurological symptoms like **opisthotonus** as a primary manifestation. *Pertussis* - **Pertussis** (whooping cough) is a bacterial respiratory infection characterized by severe paroxysmal cough followed by a characteristic "whooping" sound. - While severe cases can lead to complications such as seizures or encephalopathy, **opisthotonus** is not a common or defining feature of pertussis.

Q: Which of the following is the best diagnosis of this neonate who is excessively hungry, warm with flushed skin?

Neonatal thyrotoxicosis. ***Neonatal thyrotoxicosis*** - The image shows a neonate with **exophthalmos** and signs of being **hypermetabolic** (excessively hungry, warm, flushed skin), all consistent with hyperthyroidism. - This condition occurs when **maternal thyroid-stimulating immunoglobulins** cross the placenta, causing transient hyperthyroidism in the newborn. *Neonatal lupus* - Neonatal lupus is primarily characterized by **congenital heart block** and **dermatological manifestations** (e.g., erythematous annular lesions) but does not typically present with severe metabolic hyperactivity or exophthalmos as seen here. - It is caused by the transplacental passage of maternal autoantibodies (anti-Ro/SSA and anti-La/SSB). *Congenital hypothyroidism* - Congenital hypothyroidism would present with symptoms opposite to those described, such as **lethargy**, **poor feeding**, **cold and mottled skin**, and **constipation**. - Physical features often include a **puffy face**, **macroglossia**, and an **umbilical hernia**. *Progeria* - Progeria is a rare genetic disorder characterized by **accelerated aging** that typically manifests later in infancy or early childhood with features like **alopecia**, **thin skin**, and **skeletal abnormalities**, which are not depicted or described as primary symptoms here. - It does not cause the acute signs of hypermetabolism seen in neonatal thyrotoxicosis.

Q: Preterm child on cow milk due to death of mother is having blood in stools. X-ray abdomen was done. Diagnosis is:

Rigler sign. ***Rigler sign*** - Rigler sign (also called **double wall sign**) refers to **visualization of both sides of the bowel wall** on X-ray due to **free intraperitoneal air (pneumoperitoneum)**, indicating bowel perforation. - In the clinical context of a **preterm infant on cow milk with bloody stools**, this presentation is highly suggestive of **Necrotizing Enterocolitis (NEC) with perforation**. - The X-ray shows Rigler sign as evidence of pneumoperitoneum, a serious complication of NEC requiring urgent surgical intervention. - **Key NEC radiological findings** include: pneumatosis intestinalis (intramural gas), portal venous gas, and pneumoperitoneum (Rigler sign) in cases with perforation. *Double bubble appearance* - This sign shows **two distinct air-filled structures** (distended stomach and duodenum) on abdominal X-ray, indicating **duodenal obstruction** from duodenal atresia or annular pancreas. - Not associated with bloody stools or NEC in preterm infants. *Claw sign* - The claw sign is seen in **intussusception**, where the bowel telescopes into itself, creating a soft tissue mass with a crescent-shaped gas pattern. - Typically occurs in older infants (6-18 months), not preterm neonates, and presents differently from NEC. *Bird of prey sign* - This sign is associated with **sigmoid or cecal volvulus**, showing a distended bowel loop with a beak-like configuration. - Represents large bowel obstruction, not the typical presentation of a preterm infant with feeding intolerance and bloody stools from NEC.

Q: Neonate born at 34 weeks with premature rupture of membranes develops respiratory distress. CXR was performed. All are considered in differential diagnosis except:

Tetralogy of Fallot. ***Tetralogy of Fallot*** - **Tetralogy of Fallot** is a **cyanotic congenital heart defect** characterized by VSD, pulmonary stenosis, right ventricular hypertrophy, and overriding aorta. - It presents primarily with **cyanosis** (not respiratory distress) and would show **normal or oligemic lung fields** on CXR, not the diffuse parenchymal lung disease patterns seen in RDS, pneumonia, or alveolar proteinosis. - **Not part of the differential diagnosis** for a preterm neonate with PROM presenting with respiratory distress and lung infiltrates on imaging. *Congenital pneumonia* - This is a significant concern in a neonate born prematurely with **premature rupture of membranes (PROM)**, as ascending infection is a known risk factor. - Chest X-ray findings can include **diffuse hazy infiltrates** or **patchy consolidation**, consistent with infections. - Would be considered in the differential diagnosis. *Hyaline membrane disease* - Also known as **respiratory distress syndrome (RDS)**, this is common in **premature infants at 34 weeks** due to **surfactant deficiency**. - The chest X-ray typically shows **diffuse reticulogranular ground-glass opacities** and **air bronchograms**. - Most common cause of respiratory distress in preterm neonates and a key differential. *Congenital alveolar proteinosis* - This is a rare genetic disorder where **surfactant proteins accumulate in the alveoli**, leading to impaired gas exchange and respiratory distress. - Chest X-ray findings often include **diffuse alveolar infiltrates** or consolidation, which can resemble other neonatal lung diseases. - Though rare, must be considered in the differential for neonatal respiratory distress.

Q: A term neonate presents with respiratory distress. The chest X-ray is shown below. Which of the following radiological findings is seen?

Fluid in transverse fissure. ***Fluid in transverse fissure*** - The image shows **prominent linear opacities** in the lungs, particularly noticeable in the right lung consistent with **fluid accumulation within the fissures**. - This finding, along with other signs of fluid retention like **perihilar streaking** and **mild cardiomegaly**, is characteristic of **Transient Tachypnea of the Newborn (TTN)**, which results from delayed clearance of lung fluid at birth. *Chemical pneumonitis* - **Chemical pneumonitis** typically appears as **patchy or diffuse infiltrates** or consolidation on chest X-ray, often resulting from aspiration of gastric contents or meconium. - The X-ray findings here are more consistent with interstitial fluid rather than an inflammatory reaction to aspirated substances. *Air-leak* - **Air-leak syndromes** (e.g., pneumothorax, pneumomediastinum) would show collections of **free air** outside the lung parenchyma, such as an absent lung marking or air outlining mediastinal structures. - These findings are not present in the provided image. *Patchy atelectasis* - **Patchy atelectasis** would present as areas of **lung collapse**, often with volume loss or increased opacification in specific segments or lobes. - While there is some increased density, the predominant pattern is **interstitial prominence** and fissural fluid rather than focal collapse.

Q: The image shows:

Symmetrical IUGR. ***Symmetrical IUGR*** - The image displays a neonate with **proportionately small body parts**, including the head and trunk, which is characteristic of symmetrical intrauterine growth restriction. - This type of IUGR typically results from **early gestational insults** (e.g., genetic abnormalities, infections) affecting overall cell number and size. *Asymmetrical IUGR* - Asymmetrical IUGR (also known as "head-sparing" IUGR) is characterized by a **normal head size** relative to a disproportionately small body. - This condition usually occurs due to **late-onset fetal malnutrition** or placental insufficiency, where the brain is preferentially supplied with nutrients. *Proteus syndrome* - Proteus syndrome involves **overgrowth of various tissues** (skin, bone, adipose tissue), leading to asymmetrical and disorganized growth. - The image shows a uniformly small infant, not focal or multi-tissue overgrowth, ruling out Proteus syndrome. *Poland syndrome* - Poland syndrome is a rare birth defect characterized by **missing or underdeveloped muscles on one side of the body**, primarily affecting the chest and arm. - The infant in the image does not exhibit unilateral muscle deficiency or limb abnormalities typical of Poland syndrome.

Q: Which of the following is the first line of management of the condition shown?

Parenteral vitamin K. ***Parenteral vitamin K*** - The image shows an actively **bleeding umbilical stump**, which is a classic presentation of **vitamin K deficiency bleeding** (VKDB) in a neonate. - **Parenteral vitamin K** is the first-line treatment for VKDB because it rapidly replenishes clotting factors, addressing the underlying coagulopathy. *Silver nitrate topical application* - **Silver nitrate** is used to cauterize and treat **umbilical granulomas**, which appear as pinkish-red, moist, fleshy growths, typically not actively bleeding. - It would be ineffective and potentially harmful for an actively bleeding umbilical stump due to vitamin K deficiency. *Ligation of stump with silk thread* - **Ligation with a silk thread** is indicated for a persistent, non-bleeding **umbilical granuloma** that is not responsive to silver nitrate. - It is not appropriate for treating active bleeding due to coagulopathy and could worsen the condition if the underlying cause is not addressed. *Topical neosporin powder* - **Topical neosporin powder** is an antibiotic used for preventing **bacterial infections** of the umbilical stump or minor skin wounds. - It does not have any hemostatic properties and would not stop bleeding caused by a systemic clotting deficiency.

Q: An image of a newborn infant is shown. What is the most likely diagnosis?

Infant of diabetic mother. ***Infant of diabetic mother*** - The image depicts a **large for gestational age (LGA)** or **macrosomic** infant with a **plethoric appearance** and significant subcutaneous fat, which are classic signs of an infant of a diabetic mother. - Maternal hyperglycemia leads to fetal hyperinsulinemia, causing increased fetal growth and fat deposition. *Beckwith Wiedemann syndrome* - While infants with Beckwith-Wiedemann syndrome can be LGA, they typically present with characteristic features such as **macroglossia**, **omphalocele**, **ear creases/pits**, and **hemihyperplasia**, which are not clearly evident in this image. - The overall appearance of diffuse adiposity is more consistent with uncontrolled maternal diabetes. *Congenital hypothyroidism* - Infants with congenital hypothyroidism are often **hypotonic**, have a **hoarse cry**, prolonged jaundice, and a characteristic **coarse facial appearance** with a large tongue and umbilical hernia, and are typically *not* macrosomic. - The appearance in the image does not align with the typical features of congenital hypothyroidism. *IUGR baby* - An **intrauterine growth restriction (IUGR)** baby is small for gestational age (SGA) due to various factors impeding fetal growth. - The infant in the image is clearly **macrosomic**, and not small, directly contradicting the definition of IUGR.

Question 1

Mother of a 6-hour-old neonate has pointed to passage of stool of the following color. Which of the following best describes the clinical possibility?

Accepted Answer

It is normal meconium passed within first 24 hours

Answer

Meconium plug syndrome, perform sweat chloride test

Answer

Metabolic liver disease, perform urine for reducing substances

Answer

Biliary atresia, perform hepatobiliary scintigraphy

Question 2

Child has not passed stool by 2nd day of life. X-Ray study done shows:

Accepted Answer

Duodenal atresia

Answer

Cystic fibrosis

Answer

CHPS

Answer

Anorectal malformation

Question 3

Which of the following diseases can lead to the position shown in the image?

Accepted Answer

Kernicterus

Answer

Tetany

Answer

Measles

Answer

Pertussis

Question 4

Which of the following is the best diagnosis of this neonate who is excessively hungry, warm with flushed skin?

Accepted Answer

Neonatal thyrotoxicosis

Answer

Neonatal lupus

Answer

Congenital hypothyroidism

Answer

Progeria

Question 5

Preterm child on cow milk due to death of mother is having blood in stools. X-ray abdomen was done. Diagnosis is:

Accepted Answer

Rigler sign

Answer

Double bubble appearance

Answer

Claw sign

Answer

Bird of prey sign

Question 6

Neonate born at 34 weeks with premature rupture of membranes develops respiratory distress. CXR was performed. All are considered in differential diagnosis except:

Accepted Answer

Tetralogy of Fallot

Answer

Congenital pneumonia

Answer

Hyaline membrane disease

Answer

Congenital alveolar proteinosis

Question 7

A term neonate presents with respiratory distress. The chest X-ray is shown below. Which of the following radiological findings is seen?

Accepted Answer

Fluid in transverse fissure

Answer

Chemical pneumonitis

Answer

Air-leak

Answer

Patchy atelectasis

Question 8

The image shows:

Accepted Answer

Symmetrical IUGR

Answer

Asymmetrical IUGR

Answer

Proteus syndrome

Answer

Poland syndrome

Question 9

Which of the following is the first line of management of the condition shown?

Accepted Answer

Parenteral vitamin K

Answer

Silver nitrate topical application

Answer

Ligation of stump with silk thread

Answer

Topical neosporin powder

Question 10

An image of a newborn infant is shown. What is the most likely diagnosis?

Accepted Answer

Infant of diabetic mother

Answer

Beckwith Wiedemann syndrome

Answer

Congenital hypothyroidism

Answer

IUGR baby

Neonatology — MCQs

Neonatology — MCQs

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