• a. Should not exceed 40 dB
• b. Should not exceed 20 dB
• c. 200 sq feet per patient bed
• d. Minimum 3 meters
• e. 8–12 beds
• f. Ideal: 1:1, Minimal: 1:2

• a. Ellis Classification:
  • Ellis Class 1: Fracture involving enamel only
  • Ellis Class 2: Fracture involving enamel and dentin
  • Ellis Class 3: Fracture involving enamel, dentin, and dental pulp
• b. Treatment difference:
  • 4-year-old (Primary tooth): No attempt at reimplantation (to avoid damage to underlying permanent tooth germ).
  • 14-year-old (Permanent tooth): Immediate reimplantation and splinting as soon as possible.
• c. Transport media:
  • Hank's Balanced Salt Solution (HBSS)
  • Cold pasteurized milk
  • Saline
  • Underneath patient's tongue (buccal vestibule) if child is cooperative and conscious (risk of aspiration).

Procedure	Site of sample collection	Earliest gestational age to perform the test
CVS / CVB	Chorionic villi (placental tissue)	10–12 weeks (earliest 11 weeks)
Amniocentesis	Amniotic fluid	15–18 weeks
Cordocentesis (PUBS)	Fetal umbilical cord blood	18–20 weeks

• a. No
• b. No (Doctrine of emergency / implied consent applies)
• c. Yes (Emancipated minor)
• d. Yes (Mature minor rule)
• e. No (Courts / doctors act in best interest of child to preserve life)

• a. Guedel Oropharyngeal Airway.
• b. To maintain airway patency by preventing the tongue from falling back against the posterior pharyngeal wall.
• c. Measured from the corner of the mouth (or center of incisors) to the angle of the mandible (or tragus of ear).
• d. Insert with concavity pointing upward toward hard palate; once halfway or reaching posterior pharynx, rotate 180° into proper position over the tongue. (In infants, insert directly over tongue using tongue depressor without rotation).
• e. Complications: Laryngospasm/gagging/vomiting in conscious patient, airway trauma/dental injury, worsening obstruction if size is incorrect.

• a. Chédiak–Higashi Syndrome.
• b. Autosomal recessive; Mutation in LYST / CHS1 gene (lysosomal trafficking regulator).
• c. Progressive peripheral neuropathy, ataxia, cranial neuropathies, intellectual disability, seizures.
• d. Allogeneic hematopoietic stem cell transplantation (HSCT) for curative treatment; high-dose Ascorbic acid (Vitamin C) for partial neutrophil function improvement, antibiotics for infections.

• a. 4. Molluscum contagiosum
• b. 3. Condyloma acuminata
• c. 5. Pityriasis rosea
• d. 5. Pityriasis rosea

• a. Clubbing of fingers (Grade 4).
• b. Grading of Clubbing:
  • Grade 1: Increased softness and fluctuation of the nail bed (loss of Lovibond angle).
  • Grade 2: Obliteration of the normal angle between the nail and nail fold ($>{180}^{\circ }$).
  • Grade 3: Accentuated longitudinal curvature and convexity of the nail ("Parrot beak" / "drumstick" appearance).
  • Grade 4: Broadened terminal pulp of digit with hypertrophic pulmonary osteoarthropathy (HPOA).
  • Grade 5: Shiny, glossy changes of nail and adjacent skin with longitudinal striations.

• a. Amrinone (Inamrinone).
• b. Dose (rate of infusion) and total duration of therapy.
• c. Phosphodiesterase-3 (PDE-3) inhibitor (Inodilator).
• d. Inhibits breakdown of cAMP in myocardium and vascular smooth muscle $\to$ increases intracellular cAMP $\to$ increases cardiac inotropy and produces systemic/pulmonary vasodilation.

• a. i. Give 10 mL/kg fluid (low CVP indicating inadequate preload post-cardiopulmonary bypass).
• b. i. Pyrethroids (e.g. Transfluthrin, Prallethrin).
• c. i. Oxygen therapy (Oxygen cannot bind to ferric ${\text{Fe}}^{3+}$ heme; Methylene blue, Ascorbic acid, and Exchange transfusion are specific treatments).
• d. ii. Hydrocarbons (and alcohols, metals like iron/lead/lithium, and strong acids/alkalis).

• a. iii. Observe the child for at least 6 hours (Gastric lavage and emesis are strictly contraindicated due to high aspiration risk).
• b. Repeat chest X-ray at 6 hours post-ingestion (or earlier if respiratory symptoms/tachypnea develop).
• c. Prophylactic antibiotics have no proven role and are not recommended unless secondary bacterial infection is documented.
• d. Chemical Pneumonitis / Hydrocarbon aspiration pneumonia.

• a. ii. Urinary retention (Urinary incontinence / frequency occurs due to bladder detrusor contraction).
• b. Antidotes:
  • i. Atropine (Antimuscarinic agent to reverse muscarinic symptoms)
  • ii. Pralidoxime (2-PAM) (Cholinesterase reactivator to reverse nicotinic effects)
• c. Irreversible inhibition of Acetylcholinesterase enzyme $\to$ accumulation of excess acetylcholine at muscarinic, nicotinic, and CNS synapses.
• d. DUMBELS Mnemonic:
  • D: Diarrhea / Defecation
  • U: Urination
  • M: Miosis
  • B: Bronchorrhea, Bronchospasm, Bradycardia
  • E: Emesis
  • L: Lacrimation
  • S: Salivation / Sweating

• a. Cholinergic toxidrome / Organophosphate (OP) poisoning.
• b. Ingestion or dermal exposure to Organophosphates or Carbamate insecticides.
• c. Management steps:
  • 1. Decontamination (remove clothes, wash skin) + ABC resuscitation
  • 2. Intravenous Atropine titrated to clear chest secretions and achieve heart rate $>80\text{/min}$
  • 3. Pralidoxime (2-PAM) infusion
  • 4. Airway suctioning and ventilatory support
• d. Organophosphate-Induced Delayed Polyneuropathy (OPIDN) and Intermediate Syndrome.

• a. Inhalational Airway Injury / Acute Airway Obstruction:
  • Identified by: Singed nasal hairs/eyebrows, facial burns, carbonaceous sputum, hoarseness of voice, stridor, and wheezing.
• b. Management steps:
  • i. Early endotracheal intubation to secure airway
  • ii. 100% humidified oxygen (to manage carbon monoxide toxicity)
  • iii. Aggressive IV fluid resuscitation via two wide-bore cannulae
  • iv. Analgesia, prevention of hypothermia, and aseptic wound coverage
• c. Parkland Formula:
  $\text{Total Resuscitation Fluid (RL)}=4\text{ mL}\times \text{Weight (kg)}\times \mathrm{\%}\text{ Burn}$
  $=4\times 16\times 60=3840\text{ mL of Ringer Lactate}$
  • First 8 hours: Give 50% ($1920\text{ mL}$)
  • Next 16 hours: Give remaining 50% ($1920\text{ mL}$)
  • In children: Add baseline maintenance fluids with $5\mathrm{\%}$ Dextrose.

• a. Ataxia–Telangiectasia (Louis–Bar Syndrome).
• b. Autosomal recessive; mutation in ATM gene on chromosome 11q22.
• c. Oculomotor apraxia, choreoathetosis, dysarthria, cutaneous anergy, high incidence of lymphoreticular malignancies (leukemias/lymphomas), hypersensitivity to ionizing radiation.
• d. Marked deficiency or absence of IgA and IgE (with elevated serum alpha-fetoprotein / AFP).

• a. Parkland Fluid Calculation:
  $\text{Resuscitation fluid}=4\text{ mL}\times 12\text{ kg}\times 25\mathrm{\%}=1200\text{ mL of Ringer Lactate (RL)}$
  $\text{Plus maintenance fluid}=100\text{ mL/kg}\times 10+50\times 2=1100\text{ mL of }{D}_{5}0.45\mathrm{\%}\text{ NS}$
  $\text{Total 24-hr fluid}=1200+1100=2300\text{ mL}$
• b. 24 hours.
• c. 50% of resuscitation volume given in first 8 hours from time of injury; remaining 50% given over the next 16 hours.
• d. No (colloids are not indicated in the initial 24 hours for $<85\mathrm{\%}$ BSA burns).
• e. Colloids (albumin / FFP) are indicated after the initial 24 hours (or in massive burns $>85\mathrm{\%}$ BSA after 8–24 hours) when capillary leak subsides.

• a. Physostigmine $\to$ Anticholinergic toxicity (Atropine, Datura)
• b. Pyridoxine $\to$ INH, Gyromitra mushroom toxicity
• c. Diphenhydramine $\to$ Drug-induced acute dystonic reactions
• d. DMSA (Succimer) $\to$ Lead, Arsenic, Mercury
• e. Flumazenil $\to$ Benzodiazepines (Diazepam)
• f. Naloxone $\to$ Opioids, Clonidine
• g. Calcium disodium EDTA $\to$ Lead poisoning
• h. Glucagon $\to$ Beta-blocker overdose

• a. Definitions:
  • Drowning: Process of experiencing respiratory impairment from submersion or immersion in liquid (fatal or non-fatal).
  • Near drowning: Survival for at least 24 hours after submersion in liquid.
• b. Complications:
  • Electrolytes: Hyperkalemia, Hyponatremia (freshwater) or Hypernatremia (seawater), Metabolic acidosis.
  • Hematological: Intravascular hemolysis and Disseminated Intravascular Coagulation (DIC).
• c. Non-cardiogenic pulmonary edema / Acute Respiratory Distress Syndrome (ARDS) (bilateral alveolar infiltrates).

• a. Non-invasive spectrophotometric method to measure percentage oxygen saturation of arterial hemoglobin (${\text{SpO}}_2$).
• b. Spectrophotometry & Photoplethysmography: Deoxyhemoglobin absorbs more red light ($660\text{ nm}$); Oxyhemoglobin absorbs more infrared light ($940\text{ nm}$). The ratio of pulsatile (AC) to non-pulsatile (DC) absorbance determines ${\text{SpO}}_2$.
• c. Limitations:
  • i. Poor peripheral perfusion / hypothermia / shock
  • ii. Dyshemoglobinemias (Carboxyhemoglobin reads falsely high ~95%, Methemoglobin reads fixed ~85%)
  • iii. Motion artifacts, nail polish, ambient light interference
• d. Described by the Oxygen-Hemoglobin Dissociation Curve (sigmoid curve; ${\text{SpO}}_2\text{ 90\%}\approx {\text{PaO}}_2\text{ 60 mmHg}$, ${\text{SpO}}_2\text{ 75\%}\approx {\text{PaO}}_2\text{ 40 mmHg}$).

• a. Scorpion Envenomation (Red Scorpion - Mesobuthus tamulus) with autonomic storm and acute pulmonary edema.
• b. Local infiltration of $1\text{–}2\mathrm{\%}$ Lignocaine without adrenaline at the sting site and ice application.
• c. Oral Prazosin ($30\text{ mcg/kg/dose}$ stat, repeated at 3 hours then every 6 hours until peripheries are warm).
• d. Digoxin, Atropine, and Beta-blockers are contraindicated.
• e. Dobutamine infusion ($5\text{–}15\text{ mcg/kg/min}$) for cardiogenic pulmonary edema and myocardial dysfunction.

• a. Do it RIGHT:
  • R: Reassure the patient (calm anxiety)
  • I: Immobilize the bitten limb (like a fractured bone; do NOT use tourniquet)
  • G H: Get to Hospital immediately
  • T: Tell the doctor about any systemic symptoms (ptosis, bleeding, oliguria)
• b. 20-Minute Whole Blood Clotting Test (20WBCT) in a dry, clean glass tube.
• c. Systemic envenomation: Non-clotting blood ($>20\text{ min}$ on 20WBCT), spontaneous systemic bleeding, neurotoxicity (ptosis, dysphagia), or hemodynamic instability.
• d. 10 vials of polyvalent ASV infused over 1 hour in dilution.

• a. Infantile (Strawberry) Hemangioma.
• b. Classification:
  • By depth: Superficial, Deep, and Mixed (Compound)
  • By biology (ISSVA): Vascular tumors (proliferating) vs Vascular malformations (structural).
• c. GLUT-1 (Glucose Transporter-1) positive in infantile hemangiomas.
• d. Complications: Ulceration, bleeding, secondary infection, visual axis obstruction / amblyopia (periorbital), airway obstruction (subglottic).

• a. Definitions:
  • i. External ophthalmoplegia: Paralysis of extraocular muscles supplied by 3rd (Oculomotor), 4th (Trochlear), and/or 6th (Abducens) cranial nerves with sparing of pupillary sphincter.
  • ii. Internal ophthalmoplegia: Paralysis of intrinsic pupillary and ciliary muscles (Parasympathetic fibers of 3rd CN) leading to fixed dilated pupil and loss of accommodation.
• b. Internuclear Ophthalmoplegia (INO): Impairment of conjugate horizontal eye movement characterized by adduction deficit in ipsilateral eye and horizontal nystagmus of abducting contralateral eye; caused by a lesion in the Medial Longitudinal Fasciculus (MLF) in the brainstem.

Emergency rigid/flexible endoscopic retrieval of the button battery from the esophagus.

Reason: Button batteries lodged in the esophagus cause rapid liquefaction necrosis and esophageal perforation within 2 to 4 hours due to generation of external electrical current, release of sodium hydroxide (alkali burn), and direct pressure necrosis.

• a. The study of epidermal epidermal ridge patterns on the palmar and plantar surfaces of hands and feet.
• b. Ridge pattern that opens toward the ulnar side of the hand (most common pattern in normal individuals; high frequency of ulnar loops on all digits is characteristic of Down syndrome).
• c. A triradius is the confluence of three opposing ridge systems forming a Y-shape; normally found beneath each finger base (a, b, c, d) and at the proximal palm base (t).
• d. Normal atd angle: $\approx {40}^{\circ }\text{–}{45}^{\circ }$. In Down syndrome, the axial triradius is displaced distally ($t^{″}$), widening the atd angle to $>{70}^{\circ }\text{–}{75}^{\circ }$.
• e. Creases:
  • Sydney line: Extension of proximal transverse palmar crease completely across the palm to the ulnar border.
  • Kennedy crease: Deep vertical crease between first and second toes on the sole (associated with Down syndrome).

• a. Classical Triad / Tetrad:
  • i. Partial ptosis (paralysis of Müller's superior tarsal muscle)
  • ii. Miosis (pupillary constriction due to unopposed parasympathetic tone)
  • iii. Anhidrosis (loss of ipsilateral facial sweating)
  • iv. Apparent enophthalmos (and heterochromia iridis if congenital / $<2$ years)
• b. Interruption of the 3-neuron sympathetic pathway supplying the eye (from hypothalamus $\to$ ciliospinal center of Budge C8-T2 $\to$ superior cervical ganglion $\to$ orbit).
• c. Pharmacological tests:
  • 4–10% Cocaine test: Normal pupil dilates; Horner pupil fails to dilate.
  • 0.5–1.0% Apraclonidine test: Reversal of anisocoria (Horner pupil dilates due to denervation supersensitivity).
  • 1% Hydroxyamphetamine test: Differentiates preganglionic from postganglionic lesion.

• a. Basophilic Stippling (Punctate basophilia in erythrocytes due to ribosomal aggregation).
• b. Differential diagnoses:
  • i. Lead Poisoning (Plumbism)
  • ii. Thalassemia / Sideroblastic anemia
  • iii. Pyrimidine 5'-nucleotidase deficiency
• c. Porter Index (Desferal Therapeutic Index):
  $\text{Porter Index}=\frac{\text{Mean daily dose of Deferoxamine (mg/kg)}}{\text{Serum Ferritin (mcg/L)}}$
  Calculated to monitor chelation safety; index must be kept $<0.025$ to prevent deferoxamine-induced ototoxicity and retinal toxicity.

• a. Lead Poisoning (Plumbism).
• b. Elevated urinary Coproporphyrin (CPU $>150\text{ mcg/L}$) and urinary Delta-Aminolevulinic Acid (ALA-U $>5\text{ mg/L}$).
• c. Chelation therapy:
  • Oral DMSA (Succimer)
  • Parenteral ${\text{CaNa}}_2\text{EDTA}$ + Dimercaprol (BAL) for severe envenomation / lead encephalopathy
• d. Chelation is indicated if venous blood lead level is $\ge 45\text{ mcg/dL}$ (normal $<5\text{ mcg/dL}$).

• a. Slipped Capital Femoral Epiphysis (SCFE).
• b. Radiological signs:
  • Blanch sign of Steel (double density crescent from overlapping displaced metaphysis and epiphysis)
  • Trethowan's sign / Klein's line fails to intersect lateral aspect of femoral head.
• c. Avascular Necrosis (AVN) / Osteonecrosis of femoral head and Chondrolysis.

• a. Jamshidi Bone Marrow Biopsy Needle.
• b. Bone marrow trephine core biopsy.
• c. No absolute platelet cutoff is required (thrombocytopenia alone is not a contraindication; manual pressure is maintained post-procedure).

• a. L-asparaginase / steroid-induced Acute Pancreatitis complicated by Diabetic Ketoacidosis (DKA).
• b. Management:
  • Immediately stop offending drugs (L-asparaginase and high-dose steroids).
  • Treat DKA with IV fluid replacement, continuous regular insulin infusion ($0.05\text{–}0.1\text{ U/kg/hr}$), and potassium monitoring.
  • Bowel rest, IV analgesia (opioids), serum lipase/amylase monitoring, and abdominal ultrasound.

• a. Congenital Erythropoietic Porphyria (Günther Disease) / Erythropoietic Protoporphyria.
• b. Wood's lamp examination of urine and teeth (erythrodontia showing pink-red fluorescence under UV light) and urinary/fecal porphyrin quantification.
• c. Causes of generalized hyperpigmentation: Addison's disease, Hemochromatosis, Niemann–Pick disease, Chronic renal failure, Phenothiazine / busulfan toxicity.
• d. Porphyrinogenic drugs: Barbiturates (Phenobarbitone), Sulfonamides, Carbamazepine, Phenytoin, Griseofulvin.

• a. Erythema Nodosum (Septal Panniculitis).
• b. Associated conditions:
  • i. Infections: Streptococcal pharyngitis (most common), Primary Tuberculosis, Salmonella, Yersinia, EBV, Histoplasmosis.
  • ii. Inflammatory Bowel Disease: Crohn's disease, Ulcerative colitis.
  • iii. Systemic diseases: Sarcoidosis (Löfgren syndrome), Behçet disease, SLE.
  • iv. Drugs: Sulfonamides, Penicillins, Oral contraceptives.