PEDIATRIC

Model paper - 02

2 hours

Single Best Response

1. A 10-year-old girl is brought to the office because of sudden-onset swelling of her eyelids that was noted by her parents the day before. The morning of the visit, she had noticed that her urine was very dark, the color of cola. She also complained of feeling very tired and having a headache. She had just recovered from a sore throat 2 weeks earlier that was treated with antibiotics and antipyretics for 10 days. Her past medical history is unremarkable and she is no longer on any medication. She has an older brother who experienced a similar upper respiratory tract infection before her and recovered without problems. On physical examination the patient is pale, diaphoretic, and complains of a headache. Her temperature is 38.1 C (100.6 F), blood pressure is 180/100 mm Hg, pulse is 100/min, and respirations are 22/min. A urine sample is obtained for analysis and is noted to be smoky brown in color. A urine dipstick is 3+ for blood and protein, and microscopic examination confirms the presence of red blood cell and hyaline casts. Total hemolytic complement and C3 are markedly low. Chest and abdominal radiographs are unremarkable. The most appropriate study that is most likely to confirm the etiology of her disease is(A) antideoxyribonuclease B antibody titer(B) complete blood count with differential(C) pharyngeal swab(D) renal biopsy(E) renal ultrasound

# PSGN: antideoxyribonuclease B antibody titer, then ASO titre

2. A 6-year-old boy is brought to the office by his pregnant mother, who is at 12 weeks’ gestation. The boy currently is receiving chemotherapy for treatment of acute lymphoblastic leukemia (ALL) and his hematologist has recommended that he see you for general health care maintenance. He has no complaints today. You learn from the mother that his medical history is significant for being diagnosed with ALL 2 weeks ago and combination chemotherapy was started last week. She reports that he has no known drug allergies, but he did once develop “hives” after she fed him eggs several years ago. On review of his immunization record you notice that he has never received the varicella vaccine and the mother states that the patient has never had chickenpox. It is noted that the boy’s father has Guillain-Barré syndrome (GBS). A review of systems reveals occasional fever, fatigue, and joint pain. Physical examination is remarkable for pallor and mild hepatosplenomegaly only. At this time the mother tells you that she is eager to bring her son’s immunization status up to date and she asks you to administer the varicella vaccine. You tell the mother that the reason her son should not receivethe vaccine is the patient’s(A) age greater than 18 months(B) diagnosis of acute lymphoblastic leukemia (ALL)(C) egg allergy(D) family history of Guillain-Barré syndrome (GBS)(E) mother being 12 weeks pregnant

3. After a prolonged labor and delivery, a full-term baby boy is delivered. Over the next 36 hours, he becomes progressively jaundiced, with progression of the jaundice occurring in a cephalocaudal direction. His neurologic and new-baby physical examination is, aside from the jaundice, normal. Laboratory studies reveal an elevated total bilirubin of 16 mg/dL, the majority of which is unconjugated. A complete blood count with peripheral smear is normal. During the next 24 hours, the neonate receives intensive phototherapy. Despite this treatment, he still has an elevated total bilirubin, now at 21 mg/dL, and much of it still unconjugated. His

1

physical and neurologic examinations are unchanged. At this point, the most appropriate next step in the management of this child’s hyperbilirubinemia is to(A) administer intravenous immunoglobulin (IVIg)(B) begin treatment with phenobarbital(C) continue phototherapy; recheck level in 6 hours(D) start exchange transfusion immediately(E) stop phototherapy; no additional treatment needed

4. A 7-year-old boy is brought to the emergency department because of vomiting for the past 4 hours. He was well in the morning and had gone to school in the usual manner. At 2 PM the mother received a telephone call from the school stating that the child had been vomiting. At least four other children had also developed vomiting at the same time, and the suspicion was of food poisoning arising from the school lunch that day. All of the affected children had the same dessert at lunch. Upon examination in the hospital, the child is vomiting frequently. The vomitus contains no blood or bile. His temperature is 36.7 C (98.0 F) and pulse is 11/min. There is normal skin turgor and the extremities are warm. There is no abdominal tenderness or distension. Bowel sounds are normal and there is no sign of hernia. The most likely etiologic agent responsible for the patient’s symptoms is(A) Campylobacter(B) Clostridium(C) Salmonella(D) Shigella(E) Staphylococcus

5. A 2-year-old Asian girl is being evaluated for persistent fevers and a rash. Before this illness, now in its tenth day, the child has been healthy and is up to date on all her childhood immunizations. There are no known sick contacts and the family medical history is unremarkable. Physical examination is remarkable for severe bilateral conjunctivitis and dry mucous membranes. Her lips are cracked and her tongue is erythematous and swollen. She has marked cervical lymphadenopathy with at least one tender node of approximately 2 cm. Additionally, across her chest is a pleomorphic, erythematous rash. Her hands and feet are swollen and there are areas of desquamation on her palms and soles. Based on these findings, the patient is treated with a combination of aspirin and intravenous immunoglobulin,and she slowly improves. One month after treatment,the patient’s symptoms have improved dramatically. The most appropriate outpatient monitoring includes(A) electrocardiograms at each visit until adolescence(B) following the erythrocyte sedimentation rate (ESR)(C) no additional specific monitoring, follow clinically(D) one set of blood cultures after symptomaticimprovement(E) serial echocardiograms for at least the first year

# Kawasaki: depending on the coronary artery involvement management may vary.

6. A mother brings her 4-year-old child to the clinic for a routine well-child examination. You have not previously seen the child, and unfortunately do not have immediate access to old medical records. However, the mother reports that the child has been relatively healthy, though she hasn’t always been able to bring her child for routine well-child visits and immunizations. She is now seeking help because her child has been complaining of colicky abdominal pain and has been fighting with other children at nursery school. The mother feels the child has been acting strangely, though she has trouble describing how. Focused questioning reveals that the mother and son live in an old house that is undergoing renovation,and that the child has not had routine pediatric screening. Physical examination is remarkable for an ataxic gait but is otherwise within normal limits, though the child does have inappropriate difficulty concentrating on the history and physical. Given this patient’s presentation, an expected laboratory finding is

2

(A) anemia with a mean corpuscular volume ≥100 μm3(B) round, dark-blue granules (basophilic stripping) in the neutrophils(C) elevated serum urea nitrogen (BUN) and creatinine(D) low free erythrocyte protoporphyrin(E) significant eosinophilia

# paint containing lead → lead poisoning

7. A 13-year-old African American boy is brought to the emergency department complaining of severe right groin pain. The patient was playing football with his friends and noted a sudden onset of severe right groin pain. The pain was so severe he was unable to ambulate. Local emergency medical services had to bring the patient from school to the emergency department in a wheelchair. On further history taking, the patient didrecall having some mild right hip pain before this. The patient is lying flat on a stretcher and has stable and normal vital signs. He is moderately obese and unable to flex or extend his hip without severe pain. The most appropriate next step in this patient’s care is to(A) order an anterior-posterior radiograph of the pelvis and lateral radiograph of the right femur(B) order a CT scan of the patient’s pelvis(C) order an MRI of the patient’s pelvis(D) order an ultrasound of the right hip(E) send the patient home with the diagnosis of a hip contusion

# slipped upper femoral epiphysis

8. A 23-month-old girl is brought to the office by her mother to receive the influenza vaccine for the first time.The patient’s father currently has signs and symptoms of the influenza virus and the mother is concerned that her daughter also will become ill. The mother reports that the child is healthy, does not have an allergy to eggs, and is up to date with her immunizations as of her 18- month visit. A thorough review of systems is unremarkable. You examine the child and determine that she is afebrile and not acutely ill. You provide literature about the vaccine to the mother and answer all of her questions. The mother signs a consent form and you then agree to give the vaccine. You administer 0.25 mL of influenza vaccine into the patient’s left deltoid without complications. The patient should return to your office in 1 month, at which time you will(A) administer the next set of recommended childhood vaccinations(B) administer a second dose of influenza vaccine(C) draw a serum influenza viral titer and administer a second dose if low(D) inspect the injection site on the patient’s left deltoid(E) provide post-vaccination counseling

9. A 7-month-old boy is brought to the clinic because of diarrhea for the past 2 days. The infant was born at full term with a birth weight of 7 lb (3.15 kg).At his 6-month well-child visit, his weight was 15 lb. His mother reports that he was well until 2 days ago when he started passing loose, watery stools several times a day. He also vomited 5 to 6 times a day and was unable to tolerate formula feeds.His mother believes he has not passed urine for the past 6 hours. On examination, the infant seems tired and does not smile on interaction. His weight is 14 lb and he is afebrile. The anterior fontanelle is sunken, there are no tears in the eyes, and the oral mucosa is dry. Peripheral pulses are normal volume and the extremities are warm. Lungs are clear and the abdomen is soft and nondistended. He is offered a bottle of formula in the clinic, but he vomits again. The most appropriate management is to(A) admit the infant to the hospital for intravenous hydration(B) prescribe kaolin-pectin to reduce the diarrhea(C) reassure the mother that it is a self-limited condition(D) send the infant home on oral electrolyte solution(E) start trimethoprim-sulfamethoxazole therapy after sending stool culture

3

10. A 1-year-old boy is in the clinic for a well-child examination. He was born at full term with a birth weight of 8 lb and has remained well during the first year. His mother reports that he is very active and is able to pull himself to a standing position and walk by holding onto the furniture. He was breast-fed from birth, and attempts at introducing solid foods were not successful. Examination reveals a well-appearing infant whoweighs 25 lb. Physical examination reveals no pallor or lymphadenopathy. The lungs are clear and the heart sounds are normal. There is no hepatosplenomegaly. The screening hematocrit is found to be 30%. A complete blood count shows:Hemoglobin 10.0 g/dLHematocrit 30%Mean corpuscular volume 67 flRBC distribution width 15.8%WBC count 6700/mm3 with 49% polymorphonuclear neutrophils, 45% lymphocytes, and 6% monocytesPlatelet count 350,000/mm3The most appropriate next step in management is to(A) advise the mother to include iron-rich foods in the infant’s diet(B) advise the mother to include whole cow’s milk in the infant’s diet(C) determine serum ferritin and iron levels(D) explain that no further management is indicated(E) initiate oral iron therapy at 3 mg/kg/day

11. A 12-year-old boy is brought to the office by his parents because of repeated nosebleeds that have been happening for the previous several months. He recently joined his school football team and has been returning home with a bloody nose after almost every practice. When asked if his gums bleed, the parents confirm that he has to use a soft toothbrush because the firmer ones cause bleeding from the gums.He is otherwise healthy and has no medical problems. He does not take any medication. The family history is significant for prolonged postpartum bleeding in the mother and menorrhagia in the older sister. On physical examination, the patient is a well-developed and well-nourished young man with normal vital signs. Inspection of the skin and visible mucosa reveals multiple bruises on the arms and legs in various stages of resolution and hemorrhagic crusts onthe distal part of the nasal septum. The laboratory study most likely to be abnormal in this patient is the(A) platelet count(B) platelet morphology(C) prothrombin time(D) red blood cell count(E) bleeding time

12. A physician has been called to the labor and delivery floor to evaluate a newborn full-term infant with respiratory depression. The infant has been dried, placed on a radiant warmer, mouth and nose have been suctioned, and tactile stimulation has been applied. At 1 minute of age, the infant’s color remains dusky and he has gasping respiratory effort. Pulse is 60/min. Muscle tone is noted to have some flexion, but the infant does not cry or grimace when irritated. Bag and mask ventilation is performed for 30 seconds with 100% oxygen. The pulse increases to 110/min, and color becomes pink. The most appropriate next step in management is to(A) administer sodium bicarbonate(B) begin chest compressions(C) continue bag and mask ventilation for another 60 seconds(D) discontinue bag and mask ventilation and observe for spontaneous respirations(E) perform endotracheal intubation

13. An international medical relief team is sent to a remote part of central Africa to provide medical aid for a period of 2 weeks. Individual doctors are assigned to examine the children first. A young mother brings her 16-month-old son for evaluation because of poor feeding, irritability, and easy fatigability. The interpreter translates the mother’s complaints, saying that the child was doing quite well until several months earlier when he stopped growing at the expected rate and began sleeping a lot. Now he refuses to eat on a daily basis, is

4

always sleepy and tired, and easily bursts into crying spells. This is her first and only child. The family is poor and cannot afford regular medical care. His diet consists mainly of cow’s milk with the addition of some rice and an occasional piece of fruit. On physical examination, the child is in no acute distress but is very pale. His temperature is 36.7 C (98.0 F), pulse is 110/min, and respirations are 20/min. Inspection of the nails reveals koilonychia. A complete blood count shows:Erythrocyte count 2.5 × 1012/LLeukocyte count 4000/mm3Platelets 460,000/mm3Hemoglobin 6.1 g/dLHematocrit 28%Adequate treatment is initiated and the patient isscheduled for follow-up blood work. The laboratory study that is most likely to respond first to adequate replacement therapy is(A) hematocrit(B) hemoglobin level(C) reticulocyte count(D) serum ferritin level(E) serum iron level

# within 1st 24-48h of Rx, clinical response improves. Indices↑ → ferritin↑

14. A 7-year-old boy is brought to the pediatric emergency department because of an acute onset rash on his buttocks and legs that was noticed by his parents when he got up in the morning. The rash was rapidly spreading from the ankles up and they were concerned that waiting for a regular appointment with the pediatrician would be too long. The child had a sore throat about a week earlier that resolved with over-the-counter cold and cough medication. He is otherwise in good health and has no allergies to medications that they are aware of. They also have two younger daughters who are in good health. On physical examination, the patient is in no acute distress. His vital signs are within normal limits. Inspection of the skin reveals multiple, 1- to 3-mmpetechiae on the buttocks and lower legs. There are also palpable purpuric papules present around the ankles that seem moderately edematous. Palpation of the abdomen does not reveal any tenderness. Auscultation of the chest is unremarkable. The diagnostic study that is indicated in this patient is(A) a chest x-ray(B) a pharyngeal swab for culture and sensitivity studies(C) a plain abdominal radiograph(D) none; this is a clinical diagnosis, and no additional tests are indicated(E) a urinalysis

15. A 2-year-old boy is brought to the emergency department on a Saturday morning because of rectal bleeding. He has had several maroon-colored stools the previous 2 days and the parents scheduled an appointment with the pediatrician for Monday. But this gross bleeding started suddenly and was massive. The child had his diapers soaked with blood and gelatinous stool. He has no significant medical problems in his history and has not taken any medication recently. The family history is significant for high blood pressure and heart disease on the mother’s side. On physical examination the patient does not seem to be in any acute distress. His temperature is 36.7 C (98.0 F), blood pressure is 90/60 mm Hg, pulse is 100/min, and respirations are 20/min. The abdomen is nontender to palpation and there is no guarding. Rectal examination yields bright red blood mixed with stool containing red blood and mucus. A complete blood count reveals hemoglobin of 8 g/dL with other results within normal limits. A plain abdominal radiograph reveals no abnormality. The most appropriate next diagnostic study is(A) barium enema(B) barium swallow(C) computerized tomography scan of the abdomen(D) 99m Technetium-pertechnetate scintiscan

5

(E) selective arteriography# this is meckels Generally very ill in intususseption

16. A 5-year-old Caucasian boy is complaining of groin pain. He has been limping for approximately 1 month and it has gotten progressively worse over the past week. He has not had any recent infectious contacts or any known trauma. On physical examination, the boy is in the fifteenth percentile for height and the tenth percentile for weight. He has a Trendelenburg gait and decreased right hip internal rotation and abduction.The patient’s knee examination is normal. The most likely cause of his limp is(A) developmental dysplasia of the hip(B) juvenile rheumatoid arthritis(C) Legg-Calve-Perthes disease(D) septic arthritis(E) slipped capital femoral epiphysis

17. A 3-week-old girl is brought to the emergency department because of a “high fever.” She was born full-term by normal spontaneous vaginal delivery without complications and her mother was group B streptococcus positive. She had been feeding well until this morning when she was noted to have decreased oral intake and“felt warm” to her mother. Her temperature was taken rectally and it was 38.9 C (102.0 F). No antipyretics were given and they came to the hospital. Now the baby appears awake and alert with a normal physical examination and a temperature of 37.0 C (98.6 F). The most appropriate next step in management is to

(A) obtain cultures of the urine and blood and administer intramuscular ceftriaxone and send patient home with follow up with pediatrician the next day(B) obtain cultures of the urine and blood and sendthe patient home with good follow-up with herpediatrician(C) obtain cultures of the urine, blood, and cerebral spinal fluid, treat with intravenous antibiotics, and admit to the hospital for 48- to 72-hour culture results(D) reassure the parents and discuss fever phobia and send them home(E) send the patient home with no testing because she is afebrile in the emergency department and the fever at home cannot be trusted

18. A 7-day-old boy is brought to the emergency department because of two episodes of vomiting over the past 24 hours.Yesterday he had an episode of yellowish-green emesis. He otherwise seemed well, so the parent did not seek medical advice.He slept well overnight. This morning, however, he vomited his entire feeding and again the color is described as being yellowish-green.He was born at term and discharged from the hospital at 2 days of life. He has been feeding 2 to 3 ounces of an infant formula every 3 to 4 hours. In the emergency department, the baby is crying but consolable. His vital signs and physical examination are normal. He has guaiac-negative stool. During the examination, he has an episode of nonbloody, yellowish-green emesis. The diagnostic study that is most likely yield the correct diagnosis is(A) abdominal x-ray(B) barium enema(C) pH probe(D) ultrasound of the abdomen(E) upper gastrointestinal series with small bowel followthrough

19. Nine days after discharge, a young mother and father bring their first and only child back to the hospital for further evaluation. They are concerned about the color of the baby boy’s eyes. Over the last week, his eyes seem to have developed a yellowish tint, with some mild discoloration of the skin of his face. This was not present at birth, and really did not seem to develop until 48 to 72 hours after he was delivered. The pregnancy and delivery were uneventful, the mother received good prenatal care, and the child was full-term. Routine newborn screening tests were normal.Aside from some grey stools, the family reports that the child has been

6

acting as expected of a 9-day-old infant. Physical examination, aside from scleral icterus, is unremarkable. A complete blood count and differential is within normal limits, though a stat bilirubin level is elevated at 9 mg/dL. The majority of the bilirubin is conjugated. The most likely cause of this infant’s conjugated hyperbilirubinemia is(A) deficiency of uridine-diphosphoglucuronate glucuronosyltransferase(B) inflammation and obliteration of bile duct architecture(C) physiologic jaundice of the newborn(D) reduced bilirubin clearance due to hypothyroidism(E) undiagnosed ABO or Rh blood-group incompatibility

20. A frantic mother calls her your office on a Friday afternoon because her 2-year-old son is unable to bear weight on his right leg. The patient’s mother states that he looks very ill and will not move his right leg.When the patient’smother moves the right leg, the boy screams and cries incessantly. On further history taking, the patient’s mother states that he was playing in the barn and sustained a puncture wound to his right leg 3 days ago and has been having low-grade fevers ever since. The most appropriatemanagement at this time is to tell the patient’s mother(A) that the boy has likely strained his hip while playing in the barn and he will be fine(B) to bring the child immediately to the emergency department(C) to call an orthopedic surgeon’s office on Monday morning(D) to elevate and ice the child’s leg overnight and if the child does not feel better to bring him to theemergency department in the morning(E) to give the child some acetaminophen and visit the office on Monday morning if his symptoms do not improve

21. A 2-year-old girl is brought to the emergency department by her parents. They state that the girl has been feeling unwell since earlier today, and roughly 3 hours ago she developed a temperature of 37.8 C (100.0 F) and a loud cough. They describe the cough as loud and hoarse, causing the girl some pain and distress. The mother has been treating the fever at home with acetaminophen. The patient’s past medical history is significant for reflux, tonsillitis, and jaundice at birth. She takes no medications and lives with her parents.After examining the patient, you note a loud cough, after which the patient becomes somewhat frightened and begins to cry. Her vital signs, including pulse oximeter on room air, are normal. She no longer has a fever. Her lungs are clear to auscultation, noting an intermittent inspiratory stridor. A chest x-ray would most likely reveal(A) diffusely thickened prevertebral soft tissues(B) a foreign body below the thoracic inlet(C) nodular, thickened prevertebral soft tissues(D) subglottic narrowing(E) a thickened epiglottis

22. A newborn infant boy is having difficulty breathing. The patient was born 4 hours ago, the result of a spontaneous, vaginal delivery at 32 weeks’ gestation. This was the mother’s first pregnancy, and prenatal care was initiated duringthe third trimester. The documented portion of the pregnancy and labor were uncomplicated. In the chart, there is a note that the mother had asymptomatic bacteruria during the third trimester that was not treated. The neonate has a respiratory rate of 35/min and a pulse oximeter of 90% on 2 L O2 by way of nasal cannula. A chest x-ray is interpreted as “diffuse bilateral infiltrates with effusions, consistent with pneumonia.” The mostlikely etiology of this patient’s pneumonia is(A) Aspergillus(B) Chlamydia(C) Pseudomonas(D) Streptococcus(E) viral

7

23. A 3-week-old male infant is brought to the clinic because his mother is worried about frequent vomiting. She says that the infant was well for the first week, but then started to vomit after breast-feeding. Initially, this was intermittent, but now the vomiting is after nearly every feed. She describes the vomit as forceful and large in volume and consisting entirely of milk from the last feed. The baby is also passing stools less frequently than before. On examination the baby looks active and alert, but his weight is 6 ounces less than the birth weight. The abdomen is not distended, and no masses can be palpated. Laboratory studies show:Hemoglobin 13 g/dLLeukocyte count 9.5 × 109/LPlatelets 275 × 109/LSerum sodium 138 mEq/LSerum potassium 3.2 mEq/LSerum chloride 92 mEq/LSerum bicarbonate 32 mEq/LThe most appropriate next step in management is to(A) change to a soy-based formula(B) elevate the head-end after feeds(C) obtain an abdominal ultrasound(D) obtain an abdominal x-ray(E) start metoclopramide

# pyloric stenosis: measure thickness in USS

24. A premature infant girl is delivered at 24 weeks’ gestational age. During the first 9 days of extrauterine life she is on high-frequency ventilation, receives indomethacin to hasten closure of a patent ductus arteriosus, and is fed parenterally. On day 10 she is switched to regular ventilatory support and is transitioned from parenteral to enteral nutrition. Three days later she develops abdominal distention, greenish vomiting, abdominal wall erythema, metabolic acidosis, and low platelet count. X-rays show dilated loops of small bowel with multiple thin-walled, noncommunicating, gas-filled cysts located in subserosa and air in the portal vein. The most likely diagnosis cause of her current condition is(A) duodenal atresia(B) intussusception(C) meconium ileus(D) necrotizing enterocolitis(E) ventilator-induced pneumoperitoneum

25. Two weeks after birth it was noted that an infant girl was jaundiced. The girl had been born at full term and was apparently healthy, although the mother had not had any prenatal care. Laboratory studies performed at that time showed a total bilirubin of 6 mg/dL, with 4 mg/dL direct and 2 mg/dL indirect, and mild elevations of the alkaline phosphatase and transaminases. A presumptive diagnosis of neonatal hepatitis was made anda follow-up visit was scheduled. The mother does not bring the girl back until she is 6 weeks old, at which time the jaundice is obviously more severe. New laboratory studies show the total bilirubin to be 18 mg/dL, with 12 mg/dL direct and 6 mg/dL indirect. The transaminases remain only modestly elevated, but the alkaline phosphatase is five times the upper limit of normal. A more extensive workup is undertaken. Toxoplasmosis, rubella, cytomegalovirus, and herpes infections are ruled out. A sonogram does not show dilated biliary ducts and is negative for choledochal cyst. The infant is placed on phenobarbital and a week later an IDA scan is done. Radioactive material is detected in the liver but not in the intestine. The most appropriate next step in management is to(A) continue phenobarbital therapy for another month(B) order endoscopic retrograde cholangiopancreatography (ERCP)(C) send her for an exploratory laparotomy(D) send her for a percutaneous transhepatic cholangiogram (PTC)(E) wait list for liver transplant# biliary atresia

8

26. A 10-year-old boy was diagnosed with bilateral paranasal sinusitis 1 week ago and placed on appropriate oral antibiotic therapy. The parents called this morning, reporting that the child woke up with his right eye “swollen shut.” They are asked to bring the patient in for immediate evaluation. Physical examination shows a febrile, somewhat obtunded boy with grossly swollen eyelids, redness, and proptosis on the right side. When the eyelids are pried open, it is ascertained that the ocular surface is also inflamed, he has decreased vision on that side, he cannot move the eye, and his pupil does not react to light. Emergency CT scan confirms the presence of orbital cellulitis. The most appropriate next step in management is(A) a biopsy of the periorbital fat(B) emergency surgical drainage and decompression of the orbit(C) emergency surgical enucleation(D) emergency transnasal drainage of the maxillary sinus(E) a 10-day course of intravenous antibiotics

27. Concerned parents bring their 10-month-old child to the emergency department. The child, who had a respiratory infection last week, has developed fever and lethargy and is constantly crying. The parents have given the child some acetaminophen but it hasn’t seemed to help. Vital signs are remarkable for a hightemperature and heart rate. Examination reveals a bulging fontanelle, marked photophobia, poor muscle tone, and a positive Brudzinski sign.No focal neurologic deficits are present. You are paged while the emergency room attending attempts to perform a lumbar puncture (LP). By the time you arrive, the attending has tried and failed a lumbar puncture, and a nurse has called for another lumbar puncture kit so that you can try. At this point, the most appropriate next step in this patient’s management is to(A) order a stat CT scan before LP, perform LP, then start antibiotics(B) order a stat CT scan before LP, then start antibiotics and perform LP(C) perform LP, begin antibiotics once adequate CSF samples obtained(D) perform LP, treat on the basis of the results of cell count and Gram stain(E) start antibiotics immediately, then attempt to perform LP

28. A 14-year-old boy is brought to the urgent care clinic for evaluation of a painful, red eye. Earlier in the day, while playing Capture the Flag, the young man fell into some bushes, resulting in numerous superficial abrasions on his hands and face.He thinks he may have gotten something in his left eye. All afternoon, the patient has had trouble keeping his left eye open. Light bothers him, and he is constantly tearing. He reports feeling as if sand is in his eye. Vital signs are within normal limits, and visual acuity is 20/20 OD and 20/40 OS. The left eye appears injected but is otherwise grossly normal; a penlight examination reveals that the anterior chamber is of normal depth, and the cornea appears clear. Eversion of the lid reveals the presence of a small foreign body, which is dislodged with vigorous irrigation. Fluorescein is applied to the inferior cul-de-sac of the left eye. After the patient blinks, a small yellowish discoloration is present lateral and superior to the limbus. Appropriate management of this patient is to(A) explain that no further treatment is necessary; follow up if symptoms fail to improve(B) patch the eye and immediately refer to an ophthalmologist(C) place a pressure patch and prescribe topical antibiotics(D) prescribe oral antibiotics; follow up in 2 days with ophthalmology(E) prescribe topical antibiotics, steroids, and analgesics for 2 weeks

29. A 1-year-old girl is recovering in the pediatric intensive care unit. One week earlier, she was admitted after being found to have a high fever, lethargy, and evidence of meningeal inflammation. A lumbar puncture confirmed the diagnosis of bacterial meningitis, and a rapid test revealed the organism to be Haemophilus influenzae type B. The mother and father admit that they have not had their child immunized because they were worried about the risks of immunizations causing autism. The patient was treated with cefotaxime andhas slowly improved. However, the intern taking care of the child has noticed that she is not easily startled. On a hunch, the intern orders a formal audiometry evaluation, which reveals bilateral sensorineural hearing loss.In addition to immunization, a treatment that may have prevented this patient’s hearing loss is(A) acyclovir(B) ampicillin

9

(C) cefuroxime(D) dexamethasone(E) rifampin30. A baby-sitter brings a 4-year-old boy to the emergency department for evaluation of a high fever. About 6 hours ago, she noticed that the boy was drooling and seemed to be having difficulty swallowing. At that time she found that he had a temperature of 39.5 C (103.1F). These symptoms have worsened over the past couple of hours. The family recently immigrated to the United States and the baby-sitter is uncertain of the child’s vaccination history. He does not have a cough. Examination reveals an uncomfortable child leaning forward on the examination table, with inspiratory retractions and soft stridor. Given this child’s presentation and likely condition, an associated finding is(A) a diffuse rash after being given amoxicillin(B) flattened diaphragms on chest radiograph(C) grayish pseudomembrane on pharynx and tonsils(D) subglottic narrowing on lateral radiograph of the neck(E) supraglottic swelling on lateral radiograph of the Neck

True & Faults

1.The following statement/s regarding cytogenic abnormalities is/are true/false?a) In diseases due to an autosomal recessive gene, the risk of having a second child affected is 50%.b) Diseases due to X-linked recessive genes affect only male.c) Diseases due to X-linked dominant genes affect male more seriously than female.d) All daughters of a haemophiliac father will be carriers.e) On nuclear sexing Klinefelter`s syndrome show chromatin pattern seen in female

2.The following can be diagnosed antenatal?a) Diaphragmatic hernia.b) Severe Rhesus incompatibility.c) Severe ABO incompatibility.d) Homozygous Beta Thalassaemia.e) Bilateral hydronephrosis with hydroureters.

3.The following infective agent/s is/are known to cause intrauterine infection of the foetus?a) Clostridium tetanus.b) Chicken pox virus.c) Coxsackie virus.d) Treponema pallidum.e) Neisseria gonorrhoea.

4.The following is/are true/false of immunizations in Sri Lanka?a) Infantile eczema over face is not a contraindication to DPT.b) BCG vaccination should not be given to a healthy 4 months old baby without prior Mantoux test.c) A booster dose of oral polio vaccine should be given before school entry.d) TAB vaccine provides adequate protection from Typhoid fever for at least 2 years.e) Cholera vaccine provides immunity for about 2 years.

5.The following problems are much more common in the small fordates baby born at term then in the pre-term baby?

a) Symptomatic hypoglycaemia.b) Inability to suck and swallow.c) Asphyxia during birth.d) Idiopathic respiratory distress syndrome.

10

e) Apnoeic attacks.

6.WOF is/are true/false of the nutritive value of common foods?a) Cow’s milk contains the same fat content as breast milk.b) Fresh meat and Soya beans contain the same amount of protein.c) The protein of the pulses is deficient in methionine.d) Dried mature Dambala seeds contain more protein than chicken.e) The caseinogens content of breast milk is about one-sixth of cow’s milk.

7.A baby of 7 years is admitted to the hospital with a history of joint pains and fever. The features, if present in this child will favors a diagnosis of RF?

a) An ESR of 35mm.b) A mid diastolic murmur at the apex.c) Erythema marginatum.d) A sleeping rate of 70 per minute.e) A rapid response to Aspirin.

8)WOF is/are known to be risk of developing Hypoglycaemia?a) Infant of a diabetic mother.b) Child on corticosteroid therapy.c) Child admitted with acute alcohol poisoning.d) Child with growth hormone deficiency.e) Term baby with IUGR.

9.WOF is/are true/false of congenital hypothyroidism?a) The transplacental maternal Thyroxine protects the baby from hypothyroidism in the first 3 months of

life.b) If adequate treatment with Thyroxine is started at 6 months of age the child is unlikely to be

intellectually retarded.c) Large doses of KI administered to a pregnant mother will result in hypothyroidism of her baby.d) Treatment can be discontinued once the child has attained his maximal growth potential.e) A bio-chemical screening programme is unlikely to yield a greater number of cases than that of detected

clinically.

10.WOF is/are favour a diagnosis of the minimal lesion type of the NS?a) A persistent haematuria.b) A selective proteinuria.c) A normal creatinine clearance.d) Absence of glomerular changes on light microscopy.e) A raised serum Gamma-globulin level.

11.WOF is/are true/false of Kwashiorkor?a) The age of onset is commonly in the first 6 months of life.b) The skin pigmentation is due to vit-B12 deficiency.c) Hypothermia is a recognized cause of death.d) Blood transfusions are recommended to Hasten recovery.e) In the management of this condition 200killocallories/kg body weight is recommended.

12.A 4 months old baby is referred for investigation of systolic murmur. Her growth and development are normal and there are no symptoms referable to cardiovascular system. On examination, the heart is in normal size clinically. Pulmonary second sound is loud and has a normal split. There is a moderately loud systolic murmur best heard over the second, third and forth left ICS. The ECG shows early biventricular hypertrophy. The X-ray shows an increase in lung vasculature.

11

WOF clinical condition is/are compatible with the above clinical picture?a) ASD.b) Aortic stenosis.c) PDA.d) VSD.e) Physiological murmur.

13.WOF is/are true/false regarding drug therapy in childhood?a) Long-term use of Prednisolone causes sterility.b) Hyperactivity is a known complication of Phenobarbitone administration.c) Patient on Isoniazid therapy are prone to develop an allergic reaction to certain types of fish.d) Use of Cyclophosphamide is associated with occurrence of malignant diseases in later life.e) Optic atrophy is a common complication of Gentamycin therapy.

14.WOF is/are true/false of Ray’s syndrome?a) Chicken pox virus has been illuminated in the aetiology.b) The prothrombin time in these patients is usually prolonged.c) CSF examination characteristically shows an increase in cells.d) Hyperglycaemia is a characteristic feature.e) Intra-venous Manitol is useful in the management.

15.The likely cause/s of short stature in a 6 years old girl is/are?a) Severe chronic bronchial asthma.b) Congenital adrenal hyperplasia.c) Emotional deprivation.d) Juvenile hypothyroidism.e) Turner’s syndrome.

16.WOF is/are known to cause non-infective diarrhoea?a) Coeliac disease.b) Lactase insufficiency.c) Koshiorkor.d) Lead poisoning.e) Cyclophosphamide therapy.

17.WOF is/are true of Thalassaemia major?a) The manifestation of the disease is usually present in the neonate.b) There is a michrocytic hypo chromic anaemia.c) There is an increase of Hb-E.d) The serum iron is characteristically low.e) The daily administration of folic acid is useful.

18.WOF is/are true/false regarding breast milk and feeding in the newborn?a) colostrum contains high concentrations of secretary IgA.b) the protein concentration of breast milk in a preterm baby’s mother is higher than that of a term

baby’s mothers.c) Mother who is on intravenous Heperine therapy should not breast feed her baby.d) An asymptomatic mother who is positive for hepatitis B virus should not breast feed her baby.e) Babies fed only on large amount of breast milk are liable to get hypocalcaemic fits about the fifth day

of life.

19.WOF is/are true/false regarding growth of the children?a) Weight for age less than the 3rd centile is an indicator of acute but not chronic malnutrition.

12

b) Height for age less than the 3rd centile is an indicator of chronic malnutrition.c) An occipito-frontal-circumference on the 50th centile rules out malnutrition.d) A chest circumference less than the head circumference at two years of age is an indicator of

malnutrition.e) 3 years old child has 3 carpal bones on x-ray .

20.WOF statement/s is/are true/false?a) Around 90% of births take place in institution in Sri Lanka.b) The present population growth rate for Sri Lanka is more than 2%.c) The infant mortality rate is the number of death in the first year of life per 1000 live births.d) The current infant mortality rate for Sri Lanka is around 35.e) The perinatal mortality rate is the number of still births plus first week deaths per 1000 live births.

21.WOF is/are true of cerebral palsy?a) It is usually a hereditary disorder.b) The pathological lesion gets worse with the passage of time.c) Some patients with cerebral palsy are known to have IQ over 110.d) Hypotonia does not exclude it.e) Involuntary movements occur in some patients.

22. WOF conditions would you consider to be true/false as neonatal surgical emergencies?a) Meningocoele.b) Cleft palate.c) Bilateral cloacal atrisia.d) Congenital laryngeal stridor.e) Tracheo-oesophageal fistular

23. WOF is/are true/false of mature baby?a) Thick, long lanugo hairb) A closed posterior frontenella.c) A dry parchment like skin.d) An abundance of scalp hair.e) A cushinoid facies

24. WOF statement is/are true of Thalassaemia major?a) Anaemia is hypochromic, microcytic.b) The blood picture improves with iron therapy.c) Splenectomy is the treatment of choice.d) The scalp hair is short and stiff giving a hair end appearance.e) It is inherited as a x-linked recessive trait.

25. WOF statement is/are true/false regarding cretinism?a) They have microglossia at birth.b) They have prolonged neonatal jaundice.c) They have high-pitched cry.d) Antereal frontanelle close earlier than usuale) In 3 years of age, an x-ray of the wrist show one center of ossification

26. WOF is/are true/false regarding to Hb/haematological system?a) Newborn baby’s Hb level is 20g %.b) Physiological jaundice of newborn is due to increase haemolytic activity.

13

c) The reticulocyte count during first fortnight is 5-10%.d) Foetal Hb disappears by 6 weeks.e) Adult Hb levels are reached by 6 months.

27. WOF statement is/are true of Hirsch sprung disease?a) They have constipation from birth.b) Both sexes are equally affected.c) A rectal examination yield grossly foecal-contaminated finger.d) A rectal biopsy is useful in diagnosis.e) A grossly distended segment of bowel as seen in x-ray with Barium enema, will have to be resected.

28. WOF statement is/are true of normal baby?a) The head circumference is larger than the chest circumference at birth.b) The chest circumference is same as head circumference at 2 years.c) The main reflexes should disappear at 6/52.d) The posterior frontanelle usually closes after 3/12.e) The ---- reflex of --------up to one year.

29. WOF is/are true of congenital heart disease?a) Fallot’s tetralogy is the commonest cyanotic congenital heart disease seen in childhood.b) ASD is the commonest cyanotic heart disease.c) Rubella in 2nd trimester is known cause of CHD.d) Mid systolic murmur and thrill in the 2nd left ICS is suggestive of pulmonary stenosis.e) Spontaneous closure may occur in VSD.

30. WOF are true/false of fluid in the pleural space in 3 years old child?a) Tuberculosis effusion fluids are sterile.b) The commonest cause of empyema is Staphylococcal Pneumonia.c) Pneumococcal pneumonia is often asso. With a small sterile effusion.d) Tuberculosis effusion must not be tapped as they have a therapeutic effect in resting the disease lung.

A suctions splash is an invariable sign.

14