top of page

NBME Pediatrics Form 4 - Answers & Explanations

Updated: Jul 27, 2020

1) Observe hand-washing techniques

• Poor hand-washing is the major cause of Rotavirus transmission (fecal-oral route)

2) Acute osteomyelitis

• Point tenderness, ↑ ESR, ↑ uptake by bone scan = osteomyelitis

• Metaphysis (highly vascular) is the most common site of osteomyelitis in children (usually develops secondary to hematogenous spread)

3) Increased insulin secretion

• Maternal hyperglycemia in the 2nd and 3rd trimesters → ↑ insulin

• After delivery, fetal insulin production takes time to decrease but maternal glucose exposure ends as soon as the umbilical cord is clamped → neonatal hypoglycemia

4) Placement of the newborn under warming lights

• Neonatal hypothermia

• Acrocyanosis occurs when blood vessels shrink in response to cold temperatures (common in newborns)

5) Sodium

• D5W is isotonic, however the body rapidly consumes the glucose → fluid becomes hypotonic → hyponatremia → seizure

6) Spirochete Borrelia burgdorgeri (spirochete) → Lyme disease • Erythema migrans = red circular lesion with a clear center

7) Administration of adenosine

• Paroxysmal supraventricular tachycardia (PSVT)

• If stable, vagal maneuvers should be attempted to terminate the tachycardia (eg, ice bag); If vagal maneuvers do no convert the SVT to normal sinus rhythm, IV adenosine should be administered

• If unstable → synchronized direct current cardioversion

8) Heat exhaustion

• High heat and humidity impair the the body’s capacity for dissipating heat (via evaporation)

• Heat exhaustion clinical criteria: Athlete has difficulty continuing exercise, ↑ Body temperature, and no significant dysfunction of the CNS (eg, seizure, delirium) is present

• Hyponatremia dehydration would have altered mental status

9) Reassurance that this growth pattern is within normal limits

• This baby is tracking along the 5th percentile - changing the diet is not indicated if the child is just constitutionally small

• Growth failure is either persistent weight below the 5th percentile, or falling of the growth chart (crossing 2 major percentile lines)

10) Administration of methylene blue • Methylene blue is the first line treatment for Methemoglobinemia - reduces Fe3+ to Fe2+

11) Vaginal foreign body

• Toilet paper is the most common vaginal foreign body

• Presents with foul-smelling vaginal discharge, intermittent vaginal bleeding or spotting

12) Acute renal failure • Post-strep glomerulonephritis can occur even if the infection was treated (with penicillin)

13) Twisting of there spermatic cord

• Testicular torsion → absence of cremasteric reflex + acute onset pain 14) Cor pulmonale

• Clinical features of cor pulmonale: peripheral edema, ↑ JVP, loud S2, right sided heave, pulsatile liver/hepatomegaly from congestion

• Decline of FVC during the past year indicates primary chronic lung disease

15) Galactosemia

• Classic galactosemia (absence of galactose-1-phosphate uridyltransferase) presents as soon as lactose is introduced into the diet (present in breast milk) → feeding intolerance, failure to thrive, jaundice, hepatomegaly, and infantile cataracts

• ⊖ dipstick glucose assay and a ⊕ reducing test = substance other than glucose is present in urine (ie, galactose, lactose, and fructose)

• Fructose intolerance doesn’t present until the baby consumes fructose containing food (eg, juice, fruit)

16) Juvenile arthritis • Inflammatory/rheumatologic joint pain is classically worse in the morning

• ↑ WBC/platelet count, ↓ RBC, ↑ inflammatory markers

17) Thyroid dysgenesis

• Inactivity, slow feeding, constipation, ↓ T4 = Hypothyroidism

• The most common cause of congenital hypothyroidism worldwide is thyroid dysgenesis

18) Antibody deficiency

• Bruton agammaglobulinemia → ↓ Ig of all classes → recurrent bacterial infections

• Scant lymph nodes and tonsils (primary follicles and germinal centers absent)

19) Decreased synthesis of global chains • Hypochromic microcytic anemia • Thalassemia has normal RDW and Target cells • RDW would be increased in iron deficiency due to anisocytosis

20) Acute lymphoblastic leukemia • ↓ Hb (pallor), ↓ platelets (petechiae), ↑ WBC, diffuse adenopathy

21) Anemia of chronic disease • JIA → ↑↑↑ acute phase reactants → anemia of chronic disease

22) Blood under the periosteum of the parietal bone

• Cephalohematoma is a subperiosteal hemorrhage that causes no overlying skin discoloration and is limited to one bone only (doesn’t cross suture lines)

• Subgaleal hemorrhage is under the galea aponeurotica

• Caput succedaneum is a soft tissue swelling that can cross suture lines

23) Increased renin production • Umbilical artery catheterization → showers of emboli/thrombi → lodge in renal artery → renal artery thrombosis → ↑ renin release → HTN

24) Triamcinolone • Triamcinolone is a synthetic corticosteroid • Eczema (atopic dermatitis) tends to happen in people with allergies or asthma

• Eczema should be treated with long-acting steroids or emollients

25) Staphylococcus aureus

• Large dense consolidation and fixed effusion are consistent with an abscess (Staph aureus loves to dorm abscesses)

Staph aureus resistent to amoxicillin

26) Exchange transfusion

• Most likely due to Rh hemolytic disease of newborn

• Total Bilirubin >25 (or trending that way) and resistant to phototherapy → exchange transfusion

• Bilirubin is toxic to cochlear nuclei; hyperbilirubinemia → hearing loss in newborns

27) IgA nephropathy

• Episodic hematuria that occurs concurrently with respiratory or GI infections

• PSGN typically occurs 2-3 weeks after an infection and would have decreased complement levels

28) Reassurance that this is a benign murmur

• Features of a benign murmur: early or mid-systolic, grade ≤ 2/6, low-low-pitched musical pure, insignificant medical history

29) Partial obstruction of the right main stem bronchus

• Majority of aspirated foreign bodies end up in right mainstream bronchus → focal monophonic wheezing

• Foreign body creates a kind of one-way valve → hyperinflation

30) Decrease his intake of milk and fruit juice

• > 95th percentile for weight and BMI = obese

• Milk and fruit juices have a lot of sugar

31) Cellular shift • Ketotic metabolic acidosis → H+ moves into cells in exchange for K+ moving out

32) HIV infection • Given the patients age, he most likely has an acquired immunodeficiency (eg, HIV)

33) Administration of 0.9% saline, intravenously Management should begin with a bolus of normal saline

34) Pneumococcal meningitis • Low glucose with granulocytic predominance on CSF analysis is consistent with bacterial meningitis

35) Intramuscular lorazepam

• PCP intoxication → treat their aggression and calm them down with a benzo

36) Cystic fibrosis

• Highly viscous mucus → Impaired mucociliary escalator (→ history or respiratory problems) and bronchiectasis

37) Congenital heart disease with right-to-left shunt

Tetralogy of Fallot tet spell

• Baby cries and becomes agitated → RVOT (right ventricular outflow obstruction) worsens → reversal of shunt across VSD → cyanosis

• RVOT → ↓ blood flow through lungs → ↓ pulmonary vascularity

• Systolic murmur is coming from the RVOT, not from the VSD

38) Herpes zoster • Immunosuppression (chemo) + painful vesicular rash in dermatomal distribution

• HSV is usually in peri-oral and genital areas (not confined to a dermatome)

39) Reassure him that this is normal

• Pubertal gynecomastia is seen in 50-70% of pubertal boys

• Typically resolves without treatment in a few months

40) Epidural hematoma • Head injury over parietal bone → pterion skull fracture → middle meningeal artery rupture → lens-shaped hyper-density that doesn’t cross suture lines

41) Malabsorption of fats and carbohydrates

• Giardiasis disrupts microvilli on enterocytes in the small intestine → malabsorption and loose oily foul-smelling stools

• If untreated → severe weight loss and vitamin deficiency

42) Congenital melanocytic nevus Benign melanocyte proliferation with ↑ density of hair follicles

43) Increased vascular permeability

• Sepsis status post mechanical ventilation → ↑ vascular permeability → ARDS

• Waterhouse-Friderichsen syndrome: Neisseria → vascular collapse and permeability

→ petechiae

44) Fluids

• Give fluids to replace what was lost to the 3rd space

45) Medulloblastoma

• Affects the cerebellum medially (vermis) → truncal ataxia (eg, unsteady gait)

• Pilocytic astrocytoma affects the cerebellum peripherally (hemisphere) → limb ataxia (eg, dysmetria)

• Medullo = Medial, Pilocytic = Peripheral

46) Nonsteroidal anti-inflammatory drug therapy • Primary dysmenorrhea (normal physical exam) first-line treatment is NSAIDs and/or OCP

47) Decreased biliary excretion

• Liver is able to conjugate bilirubin, but cant excrete it → direct hyperbilirubinemia (all other answer choices would lead to indirect hyperbilirubinemia)

• Wouldn’t develop kernicterus because conjugated bilirubin doesn’t cross BBB

48) Ulcerative colitis • Abdominal cramps relieved by passing stool + bloody bowel movements

• Arthritis is the most common non-GI related issue in UC

49) Thyroid dysfunction

Clinical manifestation of congenital hypothyroidism: lethargy, enlarged fontanelle, protruding tongue, hypotonia, umbilical hernia, constipation, jaundice

50) Needle decompression • Hyper-resonance + tracheal deviation = tension pneumothorax • Needle decompression would relieve air pressure surrounding the left lung and allow it to expand

Found a mistake or have a suggestion? Submit errata here

Recent Posts

See All


Unknown member
Jun 02

Where can we find the questions for form 1-4?


Folasade Fakoya
Folasade Fakoya
Feb 29, 2020

Thank you seriously.Can u pls upload form 5 n 6 for peds?


Bilal Saleh Ghaleb
Bilal Saleh Ghaleb
Feb 27, 2020

Thank You


Unknown member
Jan 20, 2020

For number 26. Exchange Transfusion, it is important to now that auditory dysfunction (ie. Hearing loss) can be due to hyperbilirubinemia.


can you please do forms 5 and 6 for peds? my exam is coming up. thank you!

bottom of page