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4th NATIONAL MCQ EXAMINATION NATIONAL BOARD OF EVALUATION, INDONESIAN COLLEGE OF PAEDIATRICS

NOVEMBER 19, 2008

SELECT THE ONE BEST ANSWER, put your answers in the answer sheet Time allocation: 100 minutes

GROWTH AND DEVELOPMENT

A newborn girl named Sitti presents to the evening nurse in the general care nursery with floppy tone and dysmorphic features. She is born full term to a 28 – year – old G2 P1 whose first pregnancy resulted in a healthy daughter. She has delivered a full – term 3 – kg girl. Pregnancy, labor, and delivery were all uncomplicated. The obstetrician has told the parents that all went well.

A. What are the medical examination findings that occur in 50% but not in 90% of individuals with Down syndrome ?

A. Mid – face hypoplasiaB. Excess nuchal skinC. Small earsD. Central hypotoniaE. Wide space between first and second toes

B. Your examination reveals a clustering of craniofacial dysmorphism, central hypotonia, and a strong Moro. When you come in to discuss your concerns with the family, you should :

A. Talk to the father aloneB. Tell the nurse what to say to motherC. Talk to both parents and describe what the process will involveD. Talk to both parents and say that you do not know what to do for children with Down syndromeE. Describe in detail all that children with Down syndrome cannot do

C. What medical concern listed below is not associated with GI malformations ?A. OligohydramnionsB. Vomiting after first feedC. Delayed passage of meconium D. Choking during feedingsE. Double bubble on abdominal radiograph

D. Which of the following cardiac malformations does not commonly occur in infants with Down syndrome ?

A. Atrioventricular canalB. Tetralogy of FallotC. Hypoplastic left heart syndromeD. Atrial septal defectsE. Ventricular septal defects

IMMUNIZATION

A. An outbreak of measles is occurring in a large urban city. Measles vaccine can be administered to children as young as :

A. 4 weeksB. 4 monthsC. 6 monthsD. 9 monthsE. 12 months

B. Compared with natural infection with varicella-zoster-virus, varicella vaccine is more likely to result in: A. Herpes zosterB. Transmission of virus to contactsC. Mild varicella disease if breakthrough varicella occursD. The serious adverse event of encephalitisE. Fever

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ENDOCRINOLOGY

A 10 – year – old boy comes into your office for a routine physical examination. His only complaint is that he is shorter than all of his friends, and that he can’t ride the mega roller coaster at the local amusement park because he is shorter than the requirement. You have followed this child for many years, but most visits have been for illness, and his height has not been measured for the last few years. He is on no medications. He reports occasional fatigue and occasional constipation. On physical examination, his height is less than the 3 rd percentile and he is prepubertal

5. Of the following, which is the least likely to help with his diagnosis ? A. Parental heightsB. Growth velocityC. Actual heightD. Bone ageE. BMI

6. What is the most likely diagnosis if his growth rate is 5 cm/year, height age is 8 years, and bone age is 10 years ?

A. Constitutional delay of growth and pubertyB. Intrinsic short statureC. HypothyroidismD. Growth hormone deficiencyE. Cushing’s syndrome

C. What is the most likely diagnosis if he has abnormal body proportions and a narrow interpedicular distance in the lower lumbosacral area ?

A. Noonan’s syndromeB. AchondroplasiaC. HypochondroplasiaD. Klinefelter’s syndromeE. Exogenous obesity

D. Which of the following is one of the most common causes of short stature in children ? A. Familial intrinsic short statureB. Growth hormone deficiencyC. Poor nutritionD. Chronic illnessE. Hypothyroidism

INFECTIOUS DISEASE

E. An 18-month-old child presents to the emergency center having had a brief, generalized tonic clonic seizure. He is now postictal and has a temperature of 40C. During the lumbar puncture (which proves to be normal), he has a large, watery stool, that has both blood and mucus in it. The most likely diagnosis in this patient is:

A. SalmonellaB. EnterovirusC. RotavirusD. CampylobacterE. Shigella

F. The 3-year-old sister of a newborn baby develops a cough diagnosed as pertussis by nasopharyngeal culture. The mother gives a history of having been immunized as a child. A correct statement regarding this clinical situation is:

A. The mother has no risk of acquiring the disease because she was immunizedB. Hyperimmune globulin is effective in protecting the infantC. The risk to the infant depends on the immune status of the motherD. Erythromycin should be administered to the infantE. The 3-year-old sister should be immediately immunized with an additional dose of pertussis vaccine

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G. A 14-month-old infant suddenly develops a fever of 40.2C. Physical examination shows an alert, active infant who drinks milk eagerly. No physical abnormalities are noted. The white blood cell count is 22.000/mm3 with 78% polymorphonuclear leucocytes, 18% of which are band forms. The most likely diagnosis is:

A. Pneumococcal bacteremiaB. RoseolaC. StreptococcosisD. Typhoid feverE. Diphteria

H. A 4-year-old child presents in the clinic with mumps. Correct statements about this condition include which of the following?

A. Arthritis is a common presenting complaint in childrenB. The disease could have been prevented by prior immunization with killed whole cell vaccineC. Involvement of the CNS may occur 10 days after the resolution of parotitisD. Orchitis occur almost exclusively in prepubertal malesE. Subendocardial fibrolastosis is a common complication in this age child

GASTROENTEROLOGY

I. An awake, alert infant with a 2 day-history of diarrhea presents with a depressed fontanel, tachycardia, sunken eyes, and the loss of skin elasticity. The appropriate percent of dehydration is:

A. Less than 1 percentB. 1 percent to 5 percentC. 5 percent to 9 percentD. 10 percent to 15 percentE. More than 20 percent

J. An 11-year-old child has been diagnosed with hepatitis C infection. Which of the following may be considered in the treatment of chronic hepatitis C infection?

A. Active vaccinationB. InterferonC. Gamma globulinD. ZidovudineE. Low protein diet

K. An 8-month-old child regularly regurgitates a large portion of her feeds. In the diagnostic evaluation of gastroeosophageal reflux for this infant, the least helpful procedure is

A. Barium swallow and upper GI seriesB. Urea breath testC. Esophageal manometryD. Esophageal pH probeE. Technetium 99m scintiscan

L. A 55-day-old former 27-week premature infant is noted by the neonatal nurse to have a swelling in the left groin extending into the scrotum but not involving the testicle. The swelling is not tender, firm, hot or red, and it does not transilluminate. It seems to resolve with pressure, but returns when the infants begin to perform the Valsalva maneuver. The most appropriate course of action at this point is to:

A. Obtain a surgical consultationB. Perform a needle aspirationC. Order a barium enemaD. Order a KUBE. Do nothing, spontaneous resolution will occur

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NUTRITION

19. Syndrome of vitamin A deficiency is as follows: xerophthalmia, keratomalacia, hyperkeratosis, growth failure and death. Which of the following option is most likely a part of the syndrome.

A. ConjunctivitisB. Hordeolum C. Bitot spots D. Subconjunctival bleedingE. Retinal ablation

20. Medium chain triglyceride or MCT is beneficial for certain conditions like cholestasis and premature baby. An explanation for MCT recommendation in

those situations is: A. MCT does not need any lipase for its digestion in gutsB. MCT may directly enter the enterocytes without any support of bile saltC. MCT has a medium length of carbonic chain, therefore gastric juice easily break down it into small

fractionsD. MCT is a polyunsaturated fatty acid which is more accessible in binding bile salt E. MCT stimulates the production of bile salt that promotes the absorption of dietary fats

NEUROLOGY

21. A 15 year- old male with a history of complex partial seizures recently moves into your practice area. He comes into your office for a general physical examination. During the visit, he states that he has been seizure – free for approximately 2 ½ years. His spells consisted of staring with automatisms, but occasionally they would progress to generalized tonic – clonic seizures. As he is concerned about driving next year, he asks you when he can go off his medication. He is currently treated with carbamazepine. The most appropriate response would be which of the following ?

A. “Let’s obtain an EEG. If that test is normal, there is an approximately 70% chance you will be seizure – free”.

B. “Never. Epilepsy is a lifelong condition”. C. :Children with complex partial seizures need to be seizure – free for at least 5 years before a

decision can be made”.D. “It all depends on the epilepsy syndrome or type and complex partial seizures seldom go into

remission”.E. “If a child is seizure-free for two years it may be possible to stop their medication straight away”

22. Which of the following antiepileptic drugs are generally considered the first – and second – line therapies for neonatal seizures ?

A. Diazepam and phenobarbitalB. Phenobarbital and phenytoinC. Phenytoin and midazolamD. Phenobarbital and lorazepamE. Phenobarbital and valproic acid

22. Which of the following is the most common form of childhood seizures ? A. Complex partial seizuresB. Absence seizuresC. Infantile spasmsD. Benign rolandic epilepsyE. Febrile seizures

23. Which of the following statements is not true about febrile seizures ? A. A febrile seizure is considered “complex” if it is prolonged, focal, or occurs multiple times per

febrile illnessB. A family history of febrile seizures in a first – or second – degree relative is a risk factor for the

development of febrile seizuresC. Developmental delay is a risk factor for the development of a first febrile seizureD. Up to 10 % of patients with febrile seizures develop epilepsyE. Carbamazepine and phenytoin are equally effective in the treatment of febrile seizures should one

consider treatment

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RESPIROLOGY

25. A 2 year old female child developed fever, cough and respiratory distress. On chest x-ray consolidation is seen in right lower lobe. She improved with antibiotics but on follow up at 8 weeks was again found to have increasing consolidation in right lower lobe and fever. Your next investigation would be ?

A. BronchoscopyB. Bacterial culture of the nasopharynxC. CT scan of the chestD. Allergen sensitivity testE. Mantoux test

26. The new mother of a 3 week-old infant is concerned that her child is having breathing difficulty. She states he is a noisy breather but has remained afebrile and sleeps/feeds well. After a history/physical exam, it would be prudent to:

A. Begin iv antibioticsB. Prescribe a decongestantC. Reassure mom and send home with saline nasal sprayD. Begin albuterol nebulizerE. Begin a bronchodilator

27. A patient comes into your office in severe respiratory distress with a deep barky cough and stridor. You diagnose the child with croup and decide to admit the child.

Along with securing an airway what are other treatment options? A. Albuterol jet nebulizerB. Ice cream POC. Racemic epinephrine and steroidsD. No treatment options are availableE. Bronchodilator nebulizer

28. A 15 year old boy comes to your office for follow up of his reactive airway disease. He describes his symptoms as daily and also experiencing nocturnal symptoms approximately 2x per week. Spirometry performed in your office reveal that his FEV1/ PEFR is 75% of his predicted value.

These results classify his severity of asthma as: A. Severe persistentB. Moderate persistentC. Mild persistentD. Mild intermittentE. Moderate intermittent

GENERAL PAEDIATRICS

49. A 15 year- old comes to you for a football physical. Which finding below in this child’s history would preclude him from a contact sport?

A. Sickle cell diseaseB. AsthmaC. Anemia D. Patient has one kidneyE. Myalgia

HEMATOLOGY

29. A 5 year-old boy is brought for evaluation during winter by his mother because of recurrent nosebleeds. They happen between one and three times a week, last 2 minutes, and are difficult to stop. This has been going on for about 6 weeks.All of the following would prompt you to explore the etiology of this boy’s nosebleeds except :

A. Nosebleeds that don’t stop within 2 minutes or more as a cut-off B. Family history of bleeding disorderC. Nosebleeds associated with fever and anemiaD. Nosebleeds with low thrombocyte on screeningE. Evidence of gum bleeding

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30 A 5 year-old boy awoke this morning covered in “red dots”. He had a “cold” approximately 2 weeks previously, but otherwise has been well. The family history is noncontributory. On physical exam, the child is well-appearing and afebrile. He has diffuse petechiae covering his face, neck, chest, back, stomach, arms and legs. He has no palpable lymphadenopathy or hepatosplenomegaly. A complete blood count done in the emergency room is within normal except for a platelet count of 8,000/L.Which of the following laboratory abnormalities is most commonly associated with the development of petechiae?

A. ThrombocytopeniaB. Prolonged prothrombin timeC. Elevated fibrin degradation productsD. Low factor VIII levelE. Clotting time

NEFROLOGY

31. A mother of a 4 yr-old child noticed that there is a solid mass in the right area of her child which she noticed for the first time with occasional blood in urine. What is your initial diagnosis ?

A. Neuroblastoma B. Wilms tumour C. Hydronephrosis D. Polycystic kidney E. Hepatoblastoma

32. A 71/2 year old child presents with non-blanching rash over the extensor aspect of arm with swelling over knee. Urine analysis shows proteinurea + and hematuria +++. On kidney biopsy which finding will be most commonly seen ?

A. Fusion of podocytesB. Acute tubular necrosisC. Deposition of IgAD. Thickened basement membrane

E. Deposition of IgG and complement

33. A child has a history of repaired high imperforate anus. He now has a urinary tract infection. What is the most likely cause?

A. Vesicoureteral refluxB. Rectourethral fistulaC. Neurogenic bladderD. Posterior urethral valves.E. Vesicorectal fistula

34. A 15 year- old girl presents after referral to you for proteinuria. Urinalysis (U/A) shows 1+ proteinuria (no other abnormalities), no edema, normal cholesterol, and no significant Past Medical History / Family History (PMH/FH). Urine protein/creatinine ratio is 0.148 and quantitative protein is 25 (normal 2-10). What is the most likely diagnosis?

A. Minimal change B. Post streptococcal GNC. Benign orthostatic proteinuriaD. Membranous GNE. Lupus nephritis

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GENERAL PAEDIATRICS

50. A 10 year-old boy presents for a pre-participation sports physical examination. He has previously been well with no significant past medical history. His vital signs demonstrate a heart rate of 101 bpm and a blood pressure of 130/85 mm Hg (greater than the 95th percentile for age). The remainder of his exam is normal. What is the most appropriate next step?

A. Recheck the blood pressure with a smaller blood pressure cuffB. Recheck the blood pressure on at least two other separate occasions before beginning further

evaluationC. Begin medical therapy with antihypertensive medicationsD. Order a renal ultrasoundE. Order an ECG

CARDIOLOGY

35. A 2 year-old child presents with a 10 day-history of fever, a heart murmur, bilateral nonexudative conjunctivitis, swollen and erythematous lips and strawberry tongue with erythematous and edematous hands and feet and a polymorphous rash on the face, trunks, and extremities. The most likely diagnosis in this patient is:

A. Kawasaki diseaseB. MeaslesC. Viral upper respiratory tract infectionD. Group A beta hemolytic streptococcal pharyngitisE. Infective endocarditis

36. What acute finding would not be expected to be associated with this 2 year-old’s diagnosis ? A. Sterile pyuriaB. Hydrops of the gallbladderC. Cervical adenopathy greater than 1,5 cm D. Thrombocytosis is associated with myocardial infarction.E. Anterior uveitis in 70% cases

37. Which of the following statements is true regarding coronary artery involvement with this 2 year -old’s disease ?

A. There is a 50% incidence of coronary artery aneurysms if untreatedB. The peak incidence for coronary artery aneurysms is 6 to 12 months following the onset of feverC. Patients with giant coronary artery aneurysms greater than 8 mm in diameter are at highest risk

for late stenosis and myocardial infarctionD. Coronary artery rupture is the most common cause of mortality within the first 7 days of the

onset of feverE. Smaller aneurysms mostly do not resolve on their own

38. Name the two drugs most commonly used for acute management of this disease.A. Aspirin and IVIGB. Penicillin and IVIG C. Steroids and aspirinD. Steroids and penicillinE. Steroids and IVIG

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PERINATOLOGY 39. A one day- old neonate presents with bilious vomiting. An abdominal film demonstrates air within the

distended stomach and duodenum with a small amount of air in the distal small bowel. The patient has a normal barium enema (specifically, there is no evidence of microcolon.) Which of the following would be the least likely diagnoses?

A. Duodenal atresiaB. Preduodenal portal veinC. Midgut volvulusD. Duodenal webE. Pyloric stenosis

40. A term infant has not passed meconium for 48 hours. He presents with distension of abdomen and emesis since one day. Next most appropriate investigation would be:

A. Genetic testing for cystic fibrosisB. ManometryC. Lower bowel contrast enemaD. OesophagoscopyE. Abdomen X ray

41. A full-term baby is born to a 16 year-old mother. The prenatal course was notable for suspected intrauterine growth retardation. The birth weight is 2325 g, small for gestational age. In the evaluation of a low-birth-weight, term, small for gestational age (SGA) newborn, which of the following should not be considered in the management of this newborn baby?

A. Maternal vascular diseaseB. Fetal chromosomal disorderC. In utero infectionD. Maternal fibroidsE. Maternal size and parity.

42. The differential diagnosis of a newborn who is SGA with a normal physical examination includes : ? A. HerpesB. RubellaC. ToxoplasmosisD. VaricellaE. Syphilis

EMERGENCY

A 5 year – old boy presents to the emergency room with a 12 – hour history of fever and drooling. He was well previously. His temperature is 39.5oC and he appears toxic. There have been no other symptoms and no sick contacs. He has received immunizations.

On physical exam, the heart rate is 120 bpm, the respiratory rate is 26, and the room air blood oxygen saturation is 92%. The child has marked inspiratory stridor and refuses to swallow. He is sitting, leaning forward slightly and refuses to lie down for the examination.

A chest radiograph is normal. The leukocyte count is 28,000/mm3 with significant left shift.

43. In this case, if the diagnosis is epiglottitis, what is the likely pathogen ? A. Coagulase – negative staphylococcusB. Streptococcus pneumoniaeC. Haemophilus influenzaeD. Parainfluenza virusE. Respiratory syncitial virus

44. If the diagnosis of epiglottitis is confirmed in the operating room by direct visualization by an otolaryngologist, the best next step would be : A. A transfer to the ICU with supplemental humidified oxygenB. A transfer to the ICU with administration of corticosteroidsC. A transfer to the ICU with administration of nebulized salbutamol D. An endotracheal intubation before transfer to the ICUE. A tracheotomy before transfer to the ICU

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45. Differences between viral croup and epiglottitis include : A. The child with viral croup is often older than the patient with epiglottitisB. The child with viral croup always has a more abrupt onset of stridor than the patient with epiglottitisC. The child with viral croup is more likely to present in the middle of an upper respiratory infection

than the patient with epiglottitisD. The child with viral croup clinically looks identical to the child with epiglottitis.E. The child with viral croup never presents with high fever

ALLERGY IMMUNOLOGY

46. For the past few days a 5 – year – old child has been complaining of intermittent abdominal pain. No emesis or diarrhea was reported. Then her mother noted a red rash on her legs, and brought her to your office. Your examination reveals a non – toxic child who is afebrile. She has palpable purpuric lesions, coalescing by the ankles, and ascending up to the buttocks. Her abdominal exam reveals mild diffuse tenderness, but no rebound. You suspect that she has Henoch – Schonlein purpura (HSP). All of the following are true about HSP except :

A. Rash frequently recurs over the first 6 weeks after presentation, often increasing after physical activity

B. Arthritis, especially of ankles and knees, is commonC. In a small percentage of children, the purpuric rash is secondary to thrombocytopeniaD. Edema of the scalp, hands and feet is common in children younger than 4 years oldE. Skin biopsy will show a leukocytoclastic vascultis with IgA deposition.

47. All the following are true about GI involvement in HSP except : A. GI hemorrhage is common, and may be occult or grossB. GI symptoms can present before the rashC. A normal barium enema rules out intussusception in HSPD. Complications include intussusception, bowel infarction and perforationE. Ultrasonography may show edema of bowel wall and may identify an intussusception

48. Which statement is true for renal involvement secondary to HSP ? A. The majority of children who have hematuria during the acute phase of HSP illness have

progression of renal diseaseB. It is associated with a membranous lesion on renal biopsyC. It usually presents shortly after HSP diagnosis with nephritic syndrome and hypertensionD. It may persist in 1% to 5% of children and may progress to end – stage disease in approximately

1%E. It occurs more commonly in patients < 8 years old at the time of HSP diagnosis

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5th NATIONAL MCQ EXAMINATIONNATIONAL BOARD OF EVALUATION

INDONESIAN COLLEGE OF PEDIATRICSJUNE 1, 2009

SELECT THE ONE BEST ANSWER, put your answer in The Answer SheetTIME ALLOCATION : 100 MINUTES

GASTRO-HEPATOLOGY

1. A girl aged 6 years old has experienced recurrent abdominal pain since the last 6 months. No abnormalities are evident on physical examination. She complains of persistent or recurrent pain or discomfort centered in the upper abdomen (cranial to the umbilicus). The pain is not associated with the onset of a change in stool frequency or stool form. She feels also early satiety, bloating and nausea.The most likely diagnosis is:

A. Functional dyspepsiaB. Irritable bowel syndromeC. Abdominal migraineD. Gastroesophageal reflux diseaseE. Functional abdominal pain

2. A baby, 4 months of age has 5 bowel movements a day for the last 3 days, which is soft and contains blood and mucus. She looks healthy, has a good appetite and no signs of dehydration. What is the most likely diagnosis?

A. ShigellosisB. SalmonellosisC. Cow’s milk allergyD. IntussusceptionsE. Amebic colitis

3. A 3-year old girl present to the Emergency Department with fever, vomiting and abdominal pain. She has right upper quadrant tenderness and hepatomegaly. Her serum transaminases are elevated, but her total and direct bilirubin are only slightly above normal. Several other children in her day care are sick with similar symptoms. Which of the following statements is FALSE :

A. Most patients with this illness do not develop fulminant or chronic diseaseB. Jaundice is common in young children with this illnessC. Highly effective vaccines exist against this diseaseD. Most commonly transmitted by fecal-oral contactE. This disease more commonly occur in a crowded community (urban)

4. A 3 week-old baby came to the emergency department with the main complaint of profuse non-bilious vomiting after feeds. He was uneventfully born at term with a birth-weight of 3 kg. on physical examination, the BW was 2.5 kg along with moderate dehydration and hypokalemia. The most probable diagnosis in this case is:

A. Gastroesophageal RefluxB. Atresia DuodenumC. Hirschprung DiseaseD. Hypertrophic Pyloric StenosisE. Pancreas Annulare

5. In any infant or toddler who present with acute abdominal pain, bilious emesis, and guarding, which of the following imaging studies is the initial study of choice most likely to confirm your suspicions?

A. Magnetic resonance imagingB. UltrasonographyC. CT ScanD. Barium enemaE. Upper GI series

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HEMATOLOGY

6. On a routine-screening of complete blood count, a 1 year-old is noted to have a microcytic anemia. Follow-up hemoglobin electrophoresis demonstates an increased concentration of hemoglobin A2. The child is most likely to have

A. Iron deficiencyB. β thalasemia traitC. Sickle cell anemiaD. Chronic systemic illnessE. Lead poisoning

7. A 3 year-old develops pallor and recurrent epistaxis. There is no hepatosplenomegaly or lymphnode enlargement. Laboratory finding shows hemogloblin level 3g/dl, hematocrit 14 %, red blood cell count 2,500.000/mm3, white blood cell count 11.000/mm3, and platelet count 180,00/mm3. The most likely diagnosis of the patient is :A. Hemolytic anemia

B. Aplastic anemiaC. Post-hemorrhagic anemiaD. LeukimiaE. Iron deficiency anemia

8. A 5 year old boy came with rashes like purpura in the lower extremities, lower trunk and buttocks. There was a history of low grade fever for few days. There was no other complaint. Physical examination was unremarkable. Complete blood count reveals slight leukocytosis and normal platelet count. Hemostatic function also reveals normal. What is the most possible diagnosis in this child ?

A. Immune Thrombocytopenic PurpuraB. Secondary Thrombocytopenic PurpuraC. Systemic Lupus ErithematousD. Henoch-Schonlein PurpuraE. Drug Allergy

9. A Patient suffered from fever and chills 30 minutes during Packed Red Cell transfusion. There was no history of transfusion before. In emergency situation like this, what should you do?

A. Give paracetamol and continue transfusionB. Give paracetamol and antihistamin, and then continue transfusionC. Stop the transfusion and change into washed erythrocyte transfusionD. Stop the transfusion and change with another Packed Red Cell bagE. Stop the transfusion, keep the intravenous line open with Psychological Saline until the symptom

resolved

ALLERGY-IMMUNOLOGY

10. A 3 month old boy was admitted because he had red, raised, palpable wheals all over his body, along with cyanosis, tachycardia, and breathing difficulty. He had been breastfed and his mother recently gave him cow’s milk formula 5 days before admission. What is the baby’s diagnosis?

A. UrticariaB. AngloedemaC. AnaphylaxisD. AsthmaE. Heart Problems

11. The drug of choice for this patient is:A. AntihistamineB. EpinephrineC. CorticosteroidD. DigitalisE. Ephedrine

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12. You are a doctor on duty when a pregnant woman visit you and ask if you can do something to avoid her baby from getting allergy after the baby is born. Your immediate management step to the case , is :

A. To do allergy screening by taking both parent and siblings history of allergyB. Suggest parent to give hypoallergenic formula anytime when manifestasion of allergy appearC. Consider long term antihistamine for the baby soon after deliveryD. Treat allergy symptom when it appearsE. Improving quality of life of the allergic baby

13. A 5 years old girl presented to you with purpura that spread over her buttock and lower extremities. You noticed that the purpura was palpable. Assuming this case to be Henoch Schonlein Purpura, you asked for laboratory investigation. What you expected to find is:

A. Prolonged clotting timeB. Prolonged APTTC. Prolonged PTTD. Thrombocyte count below the normal limitE. Thrombocyte count exceeding the normal limit

TROPICAL/INFECTIOUS DISEASE

14. A 10 years old girl present with a history of sore throat for 4 days, along with breathing difficulty of 1 day’s duration. On examination she is very ill-appearing. She has some inspiratory stridor and thick white-gray material covering her tonsils and faucial pillars, and she has swelling of her neck.What kind of treatment will you give for the patient at the time?

A. B2 agonist nebulizationB. CorticosteroidC. Ceftriaxon injectionD. Immunzation with DTE. ADS 40.000 IU

15. A 14 year old girl awakens with a mild sore throat, low-grade fever, and a diffuse maculopapular rash. During the next 24 hours, she develops tender swelling of her wrists and redness of her eyes. In addition, her physician notes mild tenderness and marked swelling of her posterior cervical and occipital lymph nodes. Four days after the onset of illness the rash has vanished. The most likely diagnosis of this girl’s condition is

A. RubellaB. RubeolaC. RoseolaD. Erythema infectiosumE. Erythema multiforme

16. A 20 month-old baby has a three week history of diarrhea and recurrent fever. He is noted to have oral thrush. He was hospitalized 3 times with the same complaint. At the moment he has a body weight of 7 kg, and appears moderately ill. His head, ear, heart and lung exams are normal. His oral exam is significant for thrush. He has liver, spleen enlargement along with anterior/posterior cervical and occipital lymphadenopathies. Which one of the following is used as a screening test in HIV infection diagnosis?

A. Enzyme immunoassayB. Polymerase chain reactionC. Western-blotD. Immune fluorescence assayE. Viral culture

17. Which is the following vaccines is contra-indicated in HIV-infected children?A. IPVB. MMRC. HIBD. PneumococcalE. BCG

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NEUROLOGY

18. A 5-year-old boy present with a limp. This was preceded by a febrile illness, but there has been no preceding trauma. On examination he has weakness of all muscle groups in his right lower limb. The limb is hypotonic, and deep tendon reflexes cannot be elicited. There is no pain on movement of the joints nor is there tenderness. Sensory examination is normal. What would be the most likely diagnosis?

A. Guillain Barre SyndromeB. PoliomyelitisC. Diphtheritic PolyneuropathyD. ChikungunyaE. Spinal tumour

19. What kind of examination would you suggest for the patient?A. Head CT scan

B. Stool cultureC. CK-MB examinationD. Serum electrolyteE. Lumbal puncture

20. A 2 month-old baby came to the Emergency Department with seizures and unconsciousness. There was no history of fever, cough or other illness. The baby was uneventfully born spontaneously with good condition and had only been breastfed. Physical examination showed a very weak baby, along with pallor and bulging fontanella. CBC revealed Hb 7.2 g/dL normal white blood count and platelet count. Haemostatic function revealed PPT 45” (control 11.3”) and APTT 53.1” (control 26.3”).What is the most possible diagnosis of this baby?

A. HemophiliaB. Von Willebrand DiseaseC. Acquired Prothrombin Complex DeficiencyD. DICE. ITP

21. A previously healthy 10 year old girl has developed progressive weakness, areflexia, paresis of extra-ocular muscles and respiratory insufficiency over a 2 week period. The MOST likely diagnosis is

A. PolymyositisB. Myasthenia gravisC. Acute spinal muscular atrophyD. Guillain-Barre syndromeE. Botulism

NEPHROLOGY

22. A 6 year old boy is being evaluated for high fever of unknown etiology, flank pain, vomiting, toxic appearance, haematuria and leucocyturia. Volding cystoureterography reveals findings as a shown below. Which of the following is a working diagnosis option?

A. UrethritisB. CystitisC. PyelonephritisD. EneuresisE. Nephritis

23. Which of the following is an appropriate treatment option?A. Intravenous antibiotics for 3 days

B. Intravenous antibiotics for 7 daysC. Oral antibiotics for 3 daysD. Oral antibiotics for 7 daysE. Oral antibiotics for 10 days

24. A 6 week old child is being evaluated for a fever of unknown etiology. As part of the laboratory evaluation, a urine specimen was obtained that grew Escherichia coli with a colony count of 2000/µL. These findings will be definite evidence of a urinary tract infection if the sampled urine.

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A. Is the first morning sampleB. Is from an ileal loop bagC. Is from a suprapubic tapD. Is from a bag attached to the perineum of uncircumcised boyE. Has a specific gravity of 1.008

ENDOCRINOLOGY

25. A pregnant woman has a low urinary estriol level. At delivery, her male infant develops hyponatermia, hyperkalemia, and hypoglycemia. What diagnosis should you consider?

A. Inappropriate antidiuretic hormoneB. Congenital adrenal hypoplasiaC. Juvenille diabetes mellitusD. PhenylketonuriaE. Hyperthyroid

26. An 8 year old boy has short stature. He has begun to gain quite a bit of weight over the last year, has little or no energy, sleeps more than normal, and complains of feeling cold. His growth demonstrates that he has fallen from 50th to the 5th percentile for height, but his weight has increased to 90 th percentile. On examination, he is obese, has an immature facies, thin hair, and slow reflexes. Which is the following is the most appropriate course of action for this child?

A. Measure thyroid functionB. Determine bone ageC. Order a growth hormone levelD. Reassure the mother that the child has normal prepubertal developmentE. Chromosomal analysis

27. A normal-apperaring 9 month old boy is discovered on routine herniorrhaphy to have bilateral Fallopian tubes and a rudimentary uterus. Biopsy of the gonads performed during this procedure revealed normal testicular tissue. On examination today, his phallus is normal in size and appearance, and his descended testes are both 2 mL in volume. Of the following, the MOST likely sex chromosome complement for this child is:

A. XXB. XX/XYC. XXYD. XO/XYE. XY

PEDIATRIC EMERGENCY

28. A 2 year old girl who having difficulty breathing and a barky cough has had a fever and runny nose for the past 3 days. She is alert and sitting on her mother’s lap. Assessment reveals that she has warm, flushed skin, is using her abdominal muscles to breathe, and has increase work of breathing. She has a blood pressure of 88/66 mm Hg, a pulse of 128 beats/min, and respirations of 48 breaths/min.You should immediately determine whether the patient has:

A. StridorB. Delayed capillary refill timeC. Weak pulsesD. The ability to tolerate oral feedingsE. Cyanosis

29. Abdominal breathing in the patient above should be viewed as a :A. Normal finding for a toddlerB. Sign of impending respiratory failureC. Sign of decreased perfusion to the respiratory centerD. Compensatory mechanism to increase the volume of air inhaledE. Compensatory mechanism to increase the respiratory rate

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30. A 3 month old infant who is extremely lethargic has had a cough, vomiting, and diarrhea for the past 3 days. Assessment reveals that he respond to pain, has mottled skin color, and a capillary refill time of 4 seconds. He has a blood preasure of 74/60 mm Hg, a pulse of 190 beats/min, and rapid, respirations without increased work of breathing at 60 breaths/min. The tachycardia in this infant is most likely due to:

A. AnxietyB. HypovolemiaC. PneumothoraxD. Swelling of the brainE. Pain

31. The appropriate initial treatment in patient above is to A. Administer 100% oxygen by maskB. Administer dopamine intravenousC. Administer epinephrine via an intraosseous needleD. Perform endotracheal intubationE. Administer fluid infusion

NUTRITION

32. A 3 year old boy who suffer from diarrhea more than 6 times a day was brought to the clinic. No bloody stool was found. The boy was slimy, the ribs pronounce, the skin wasting, hyper-pigmented skin and edema on the feet. The boy’s face resembled ‘old man face’, along with ‘flag sign hair’. He had measles two months before. The boy’s weight is 9 kg and his height 90 cm. (using gold standard CDC-2000). What the diagnosis of the child?

A. KwashiorkorB. MarasmusC. Marasmic-KwashiorkorD. Failure to thriveE. Stunting

33. A 2 year old girl came with obvious pallor. On admission the body weight was 6 kg, she did not show any sign of respiratory distress or cardiac emergencies. The hemoglobin level was 6 g/dL. Proper management would be:

A. Blood transfusion given as soon as possibleB. Immediate transfer to intensive or high care wardC. Oral iron supplementation is allowed starting at second week of hospitalizationD. Immediately starting a high calorie diet of 200 KKal/kgE. High protein along with a low fat diet

34. A 3 year old boy came with a history of nausea, vomiting, diarrhea, anorexia, fatigue and headache. He showed confusion and appeared psychotic. Laboratory examination revealed hypercalcuria. This child most probably had a deficiency of

A. Vitamin AB. ThiaminC. Vitamin CD. Vitamin DE. Vitamin E

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35. A 24 month old girl was admitted to the emergency department the main complaint of high fever. Seven days before admission, she got high fever, cough and cold. There was no history of vomiting and diarrhea. On clinical findings, she look weak, the respiratory rate was 54x/minute and Capillary Refill Time 10 seconds. There were fine moist rales on both lungs. The heart and bowel sounds were within normal limits. The body weight was 10 kg, body length 85 cm, and the ideal body weight 11.9 kg; the percent ideal body weight was 84%. When should enteral feeding be given or this patient?

A. As soon as possible after stable conditionB. After 72 hoursC. 48 – 72 hoursD. After the patient was consciousE. As soon as possible after 24 hours

GROWTH AND DEVELOPMENT

36. An infant is brought by his mother to your well-baby clinic. He can move his head from side to side while following a moving object, can lift his head from a prone position 45º off the examining table, smiles when encourage and make cooing sounds. He cannot maintain seated position. The most likely age of the infant is

A. 1 monthB. 3 monthsC. 6 monthsD. 8 monthsE. 10 months

37. The mother has concerns about maintaining a safe environment for her child. In providing age-appropriate anticipatory guidance, you tell her thatA. Pillows in the crib should be soft to provide a comfortable sleeping environment

B. She should set her water heater to 70ºC to ensure the sterility, thereby decreasing the risk of infections

C. She can start to give solid food like pieces of apple or bananaD. Her baby should be placed on his back to sleep, as this decreases the risk of Sudden Infant Death

SyndromeE. She should give him small objects such as round pliable toys, to increase his fine motor

development

38. A 3.5 year old boy says only three single words, and these are poorly articulated. He uses gestures to communicate. There are no other reported problems, gross and fine motor skills are normal for age and physical examination, including tympanography, is normal. Which of the following is the MOST LIKELY explanation?

A. Intellectual disabilityB. DeafnessC. Manipulative behaviourD. DysarthriaE. Autism

PERINATOLOGY

39. A 4.5 kg infant is delivered at 37 weeks of gestation. The mother is a 29 year old juvenile diabetic. A cesarean section is performed when fetal distress is noted. The Apgar scores are 4 and 7 at 1 and 5 minutes respectively. Maternal blood glucose prior to delivery was 320 mg/dl. The infant is lethargic in the nursery and the blood Dextrostix test is found to be undetectable. The next appropriate step is:

A. Obtain serum for blood sugar analysis to confirm the Dextrostix valueB. Administer glucose water by mouthC. Administer 10 ml/kg 50% dextrose intravenouslyD. Administer glucagon intravenouslyE. Administer 2ml/kg 10% dextrose intravenously

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40. A 2 day old is brought to ED after a generalized seizure lasting 3 minutes. If the seizure were related to birth trauma, the most likely finding would be:

A. Subarachnoid hemorrhageB. Epidural hematomaC. Subdural hematomaD. Focal brain contusionE. Concussion

41. A 27 year old gravida 1 para 0 female presents with a history of prolonged rupture of membranes and is presently in active labor. Tocolytics are started, and despite medical intervention, a 30 week gestational infant is delivered. The baby demonstrates nasal flaring, grunting, and intercostal retractions and is intubated. Positive pressure ventilation is initiated. A chest radiograph reveals a fine granular appearance of the lung fields. The baby is hypotensive and poor is noted. Initial arterial blood gas reveals pH 7.16, PCO2 50 mm Hg, PO2 55 mm Hg, and base excess -14.Which of the following is the most appropriate intervention at this time?

A. Administer endotracheal surfactant immediatelyB. Increase the ventilator settings to keep PaCO2 below 40 mm HgC. Administer 10 ml/kg 0.9% sodium chloride IVD. Administer a dopamine infusion at 10 mgm/kg/minE. Administer broad-spectrum antibiotics immediately

42. A patient presents in labour at a level 1 clinic. By her date and abdominal palpation she is 32 weeks pregnant. After a short labour she delivers a male infant weighing 1400 grams. The New Ballard Score confirm the gestational age.How would you classify this infant by weight for gestational age?

A. Low birth weightB. Premature infantC. Appropriate for Gestational Age (AGA)D. Small for Gestational Age (SGA)E. Large for Gestational Age (LGA)

CARDIOLOGY

43. A five year old girl presents with fever for 8 days, weight loss, night sweats, a new heart murmur, splenomegaly, joint pains and a history of having her teeth cleaned by a dentist 1 month prior to this visit. What is the most likely diagnosis for this patient?

A. Kawasaki diseaseB. Juvenile rheumatoid arthritisC. Acute rheumatic feverD. Infective endocarditisE. Systemic Lupus Erythematosus

44. A one month old is seen after turning blue when feeding. Auscultation of the heart reveals a harsh grade ill systolic ejection murmur over the pulmonary area that radiates to the back. Arterial blood gas shows a normal pH, PaCO2, and PaO2 at rest. The ECG demonstrates right axis deviation and right ventricular hypertrophy. The chest x-ray film reveals a large heart with a reduced main pulmonary artery segment. Which of the following congenital heart disorder is consistent with these findings?

A. Atrial septal defectB. Coarctation of the aortaC. Tetralogy of FallotD. Patent ductus arteriousE. Ventricular septal defect

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45. A 4 year old boy was referred for dyspnea on exertion. Poor weight gain, cold sweat on the forehead. There is distended neck veins and tachycardia. The CXR showed cardiomegaly with increased pulomnary vascular marking. The ECG showed LVH. What is the diagnose?

A. Infective endocarditisB. Congestive heart failureC. CardiomyopathyD. Cardiogenic shockE. Septic shock

46. A 6 year old boy was referred for prolonged fever and welling, severe pain and redness of ankles. The precordium is normal except for a mild thrill in the apex. S1 and S2 are normal, but a harsh holosystolic murmur is heard in the apex. The abdomen is soft and there is no organomegaly. What is the diagnosis?

A. Juvenile rematoid arthritisB. Acute rheumatic feverC. MyocarditisD. Infective endocarditisE. Cardiomyopathy

RESPIROLOGY

47. A 7 month old boy was brought to the hospital with the chief complaint of difficulty in breathing since 3 hours prior to admission. He started to have cough, rhinorrhea and fever 2 days before. Physical examination revealed that the baby was alert, appeared distressed, with no evidence of cyanosis. Heart rate was 112 times per minute, respiration rate 60 times per minute, the body temperature was 38.5 C. Lung auscultation appeared wheezing; no rhales or crackels was evident. The patient then underwent Chest X Ray. Peripheral Blood Smear, and Blood Gas Analysis.Working diagnosis of the cas is:

A. PneumoniaB. BronchopneumoniaC. Acute BronchitisD. BronchiolitisE. Acute asthma attack

48. The result of CXR or BGA is predicted as:A. Diffuse infiltrate on CXR and Hypoxemia, Metabolic acodosis on BGAB. Hyperaeration on CXR and Hypercapnia, Respiratory acodosis on BGAC. Emphysematous lung, alveolar infiltrate on CXR and Metabolic acodosis on BGAD. Alveolar infiltrate on CXR and no hypoxemia, only metabolic acodosis on BGAE. Pleural effusion on CXR and Hypoxemia, Respiratory acodosis on BGA

49. A 13 year old girl was admitted to the hospital due to chronic cough and difficulty of breathing since 2 days ago. She complained that this condition recurs almost every month, with each attack typically lasting for 1 or 2 days, especially at night. The mother had a history of having allergic rhinitis, while the father was a heavy smoker. On physical examinantion the child looked slightly dyspneic, with increased expiration time. Diffuse wheeze was heard over both lungs. She was able to communicate to the physician, with clear and uninterrupted sentences. All other vital signs were normal.Proper initial prompt treatment of this case :

A. Administration of broad spectrum antibioticsB. Inhalation therapy with B2 AgonistC. Simultaneous steroid and aminophyllin intravenouslyD. Oral mucolitic to dissolve mucusE. Antitussive to depress coughing

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50. A 3 year old boy was brought to pediatric clinic for consultation. His father suffered from haemopthysis and has been treated with antituberculous drugs since a week ago. The child was symptomless with normal body weight. Tuberculin skin test result was 12 mm, and the chest x-ray doesn’t show any suggestion for tuberculosis. Which of the following answers is the most appropriate management in this child?

A. Primary chemoprophylaxis with isoniazid for 3 monthsB. Primary chemoprophylaxis with isoniazid + rifampin for 3 monthsC. Secondary chemoprophylaxis with isoniazid for 6 monthsD. Secondary chemoprophylaxis with isoniazid + rifampin for 6 monthsE. Give isoniazid, rifampin, and pyrazinamide for 2 months, follow with isoniazid and rifampin for 4

months

NATIONAL MCQ EXAMINATIONNATIONAL BOARD OF EVALUATION

INDONESIAN COLLEGE OF PEDIATRICSDECEMBER , 2009

SELECT THE ONE BEST ANSWER, PUT YOUR ANSWER IN THE ANSWER SHEETTIME ALLOCATION IS 100 MINUTES

GASTRO-HEPATOLOGY

1. A pediatrician received result of fractionated bilirubin on a 1 month old infant. Total bilirubin was 4.6 mg/dl, unconjugated bilirubin was 1.2 mg/dl, conjugated bilirubin was 3.1 mg/dl. The best course of action is to:

A. Repeat blood work in two months since presence of unconjugated bilirubin suggest to breast milk jaundice. B. Inform the family that it must be a lab error since conjugated bilirubin suggests breast milk jaundice.C. Refer the patient for evaluation of neonatal cholestatisD. Inform the family that liver biopsy and cholanglogram are associated with high risk of bleeding and shoud be avoided at all cost.E. Explore the possibility of ABO incompatibility.

2. A 10 day old mate presents with bilious emesis. What is the most likely diagnosis?A. AppendicitisB. Pyloric stenosisC. Malrotation with midgut volvulusD. Feeding intoleranceE. Functional intestinal obstruction

HEMATOLOGY

3. The family of a child just diagnosed with acute lymphoblastic leukemia asks for information about the child’s a prognosis. Included as a poor prognostic sign is which of the following?

A. Presence of a mediastinal massB. Hyperdiploidy with more than 50 chromosomesC. White blood cell count at diagnosis of less than 100,000/µLD. Age between 1and 10 yearsE. Early pre-B-cell variety of the disease

4. A 4 year old child presents a petechial rash but is otherwise well and without physical findings. Platelet count is 20,000/µL, Hemoglobin and WBC are 12,4 g/dl and 7,200/µL respectively.Which of the following laboratory abnormalities is most commonly found in this case?

A. Prolonged bleeding timeB. Prolonged prothrombin time (PT)C. Elevated fibrin degradation productsD. Prolonged APTTE. Prolonged clotting time

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5. A 3 year and 5 month old child presented to the clinic with fever, gum bleeding, melena and purpura. The body temperature was 40ºC and blood culture positive for a pathogenic microorganism. The blood pressure was 90/70 mmHg and peripheral blood count revealed Hemoglobin 7 g/dl, WBC 22,000/µL and platelet count 30,000/µL, APTT and PTT were prolonged.The most likely diagnosis of this case is:

F. Henoch-Schonlein purpuraG. ITPH. HemophiliaI. DICJ. ALL

6. A 5 year old boy came with rashes like purpura in the lower extremities, lower trunk and buttocks. There was history of low grade fever for few days. There was no other complaint. Physical examination was unremarkable. CBC reveals slightly leukocytosis with normal platelet count. Hemostatic function also reveals normal.Which is the most possible diagnosis in this child ?

A. Immune Thrombocytopenic PurpuraB. Secondary Thrombocytopenic PurpuraC. Systemic Lupus ErithematousD. Henoch-Schonlein PurpuraE. Drug Allergy

7. The parents of a previously healthy 3 year old girl bring the children to your office because she is complaining that ther tongue hurts. The parent also report that she has not been eating well. The family usually eats a regular diet including meats and vegetables. On physical examination her tounge is smooth, red, and tender. She is pale and has tachycardia. Her complete blood count reveals a macrocytic anemia. The most likely diagnosis in this child is:

A. Iron deficiencyB. Nutritional deficiencyC. Transcobalamin deficiencyD. Juvenile pernicious anemiaE. Folate deficiency

ALLERGY-IMMUNOLOGY

8. A 15 year old has had persistent year round nasal itching and stuffiness. What is the most likely allergen responsible for the symptoms?

A. Dust miteB. WeedC. TreeD. GrassE. Mold

9. A mother of a children with multiple allergic disease asks you for allergy prevention advice for her next child. What would you recommend?

A. Germ free environmentB. Breast feeding at least 4 monthsC. Diet control during pregnancyD. Using HEPA air filter and vacuumE. Immunotherapy during pregnancy

10. Two weeks following a viral illness, a teenage boy breaks out in an evolving rash that is remarkable for target lesions. What is the primary treatment?

A. EpinephrineB. GlucagonC. CorticosteroidsD. AntihistaminesE. Symptomatic or supportive therapy depending on severity

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11. You are seeing a 4 year old girl in the emergency department for treatment of an episode of anaphylaxis. She is currently taking amoxicillin for treatment of otitis media. She had just finished lunch today and taken her medication when she experienced respiratory difficulties, urticaria, and general discomfort. Lunch included foods she normally eats, except for a new brand of chicken noodle soup and shrimp salad for dessert. She does not like eggs, and when she has eaten them in the past, she spat them out.Of the following, the MOST likely cause of her reaction is:

A. Drug allergyB. Food allergyC. Food poisoningD. Serum sicknessE. Viral urticaria

TROPICAL / INFECTIOUS DISEASE

12. An 8 month old boy born from a HIV infected mother had failure to thrive, prolonged fever, chronic cough, oral candidiasis, and popular eruption. From all the above mentioned symptoms, the most likely that indicate cellular immunodeficiency is

A. Failure to thriveB. Prolonged feverC. Chronic coughD. Oral candidiasisE. Popular pruritic eruption

13. A 5 years old boy presents to the clinic with a history of low grade fever for 3 days, along with, tender swelling of both of his mandibula. There was no evidence of cough or coryza. Mother says that there were 2 other children in her neighborhood presenting similar symptoms. The most likely diagnosis of the boy’s condition is :

A. DiphteriaB. Mononucleosis infectionC. MumpsD. Drug allergyE. Lymphadenopathy tuberculosis

14. A 3 year old is very fussy, febrile and has profuse rhinorrhea. On exam, shallow ulcers are noted on the soft palate and vesicles are noted on one plam and both soles of the feet. The etiology of this infection is likely:

A. Group A streptococciB. Arcanobacterium haemolyticumC. CoronavirusD. CoxsacklevirusE. Corynebacterium diphtheria

15. A 6 year old child complains of sore throat and is noted by the parens to have a lot of “grayish junk” in his mouth and nose. Exam shows an adherent grayish white membrane over both tonsils and the soft palate that, when removed, leaves an edematous, bleeding area of tissue. After calling your state health department, you initiate therapy with:

A. Intravenous erythromycin or penicillin GB. The above antibiotics plus antitoxinC. The above antibiotics plus antitoxin plus active immunizationD. Antitoxin aloneE. IVIG

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NEUROLOGY

16. A child presents in a coma. There is central hyperventilation. Pupils are mid-position and irregular 3-5 mm and fixed. The vestibule-ocular reflex is intact. He shows bilateral decerebration posturing to noxious stimuli. What is MOST likely to be the position/location of the transtentorial herniation?

A. Reticular formationB. DiencephalonC. Mid-brain-upper ponsD. Low pons-upper medullaE. medulla

17. A previously healthy 3 year old child has a single generalized convulsion lasting 5 min. she is found to have a reddened throat and a rectal temperature of 39.7ºC, from which she recovers uneventfully in 5 days. Three months later she again becomes febrile with an upper respiratory tract infection. Which of the following is CORRECT?

A. She should be started on oral phenobarbitoneB. She should be put in a bath of cold waterC. 600 mg aspirin should be administeredD. An antibiotic should be administered promptlyE. Most such children will not have a further seizure

18. A 7 year old girl develops behavioral changes, and her performance in school begins to deteriorate. Several months later she develops a seizure disorder, ataxia, and focal neurologic symptoms. She is eventually quadriparetic, spastic, and unresponsive. Death occurs within a year. This patient may have had which of the following viral disease at 1 year of age?

A. ChickenpoxB. German measlesC. MeaslesD. MumpsE. Parvovirus B19

19. A 20 month old child was seen at a well baby visit for routine examination. On physical examination you found that he still has a palpable anterior fontanel. A condition unlikely to cause this problem is :

A. RicketsB. HypothyroidismC. HydrocephalusD. UndernutritionE. Hypophosphatemia

NEPHROLOGY

20. A 6 year old boy has brown urine and healing impetigo lesions. He present with hypertension, dyspnea, periorbital edema, and hepatomegaly. The most likely cause of this problem is:

A. Postsreptococcal glomerulonephritisB. lgA nephropathyC. Nephritic syndromeD. PyelonephritisE. Idiopathic hypercalciuria

21. After a urinary tract infection, a 1 year old boy is diagnosed with grade 2 vesicourethral reflux. Which of the following is an appropriate treatment option?

A. Low doses antibioticB. Immediate surgical reimplantation of the uretersC. Weekly urinalyses and cultureD. Diet low in proteinE. Early toilet training

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22. A 2 year old boy developed bloody diarrhea shortly after eating a fast food restaurant. A few days later, he develops pailor and lethargy, his face looks swollen and his mother reports that he has been urinating very little. Laboratory evaluation reveals low hematocrit and platelet count and positive blood and protein in the urine. Which of the following diagnoses is likely to explain this symptoms?

A. lg A nephropathyB. Henoch Schenloin PurpuraC. IntussusceptionsD. Poststreptococcal glomerulonephritisE. Hemolytic uremic syndrome

ENDOCRINOLOGY

23. A short 16 year old girl presents with primary amenorrhea. Laboratory studies show how low estradiol and elevated follicle-stimulating hormone (FSH) levels. Which of the following conditions is the most likely cause of primary ovarian failure?

A. Turner syndromeB. Congenital adrenal hyperplasiaC. Autoimmune ovarian failureD. Hypogonadotropic hypogonadismE. Androgen insensitivity syndrome

24. A girl aged 10 years with diabetes type 1 developes polyuria and polydipsia in the course of an eposide of bronchopneumonia. Her urine test have become positive for ketones, and blood glucose is 360 mg/dl. Which of the following approaches is appropriate?

A. Wait for improvement of her diabetes over the next 1-2 days, followed by the introduction of antibiotics

B. Increase her insulin doses the next day by 30%C. Ask her to recheck her urine ketones again every dayD. Advise her to drink clear non-caloric fluids only and stop all solid foodE. Admit her to hospital for stabilization

25. An 8 year old girl has a 2 year decline in growth velocity, as determined by plotting her height on a standard growth curve. At age 6 years, her height was at the 60 th percentile; at age 7 years, it was the 40 th

percentile; and ate age 8 years, it was at the 10 th percentile. Her parents are of average height. Her history is otherwise unremarkable, and physical examination reveals no abnormalities, although the thyroid gland cannot be palpated. The pair of laboratory test that would best help explain the cause of this patient’s recent growth retardation is:

A. Free T4 and T3B. Growth hormone and blood urea nitrogenC. Thyroid ultrasonography and technetium pertechnetate scanD. T4 and free T3E. TSH amd free T4

26. A 15 year old boy is evaluated by a clinician for failure to develop normal male secondary sexual characteristics. Physical examination reveals small testes, a small penis, and gynecomastia. The boy has had some difficulties in school, and the parents say that according to the school psychometrist he had an IQ of 90. This patient’s condition is most likely to be related to which of the following?

A. DeletionB. Nondisjunction of an autosomal chromosomeC. Nondisjunction of a sex chromosomeD. Non-Robertsonian translocationE. Robertsonian translocation

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27. A baby is born with small head, small eyes and 6 fingers on each hand. Tow dimensional echocardiography reveals congenital heart defects. Which of the following genetic conditions is most likely to be the cause of this child’s presentation?

A. Trisomy 13B. Trisomy 18C. Trisomy 21D. XXYE. XYY

PEDIATRIC EMERGENCY

28. A 3 year old boy who has a tracheostomy has had difficulty in breathing and coughing for 2 days because of increased secretions. He is on continuous oxygen. His mother states that his breathing is getting much worse. Assessment reveals that he is lethargic, has cool, mottled skin, and has copious secretions in the tracheostomy tube. Which of the following signs suggest significant obstruction of the tracheostomy tube?

A. A slow heart rate and poor air movementB. Irregular respiration and wheezingC. Crackles and feverD. Unequal chest rise and wheezingE. No breathing

29. A child with a suspected ingestion presents to the emergency department with delirium, tachycardia, mydriasis, dry mucus membranes and warm/dry skin. This child exhibits signs and symptoms of which toxidrome?

A. AnticholinergicB. SympathomimeticC. CholinergicD. OpioidE. Sedative hypnotic

NUTRITION

30. Breast milk is the natural food for full term and premature infants during the first months of life. There are nutritional, practical, psychological, immunological and physiological benefits to breastfeeding. Which is the following is NOT true about breast feeding?

A. Recommended food for infants both term and pretermB. Fifty percent of energy are from proteinsC. Contains immunological benefits (i.e. lgA, active lymphocytes)D. Promotes growth of lactobacillus in GIE. Decreases incidence of allergic disorders

PERINATOLOGY

31. A one week old newborn is irritable and has several episodes of bilious emesis after the most recent feeding. You are called to ask for new feeding orders. The baby has tachycardia but otherwise the vital signs are stable. On physical examination the abdomen was “full” without marked abnormalities. What would be the next step in this case?

A. Consider the possibility of gastro-esophageal refluxB. Start a proton pump inhibitorC. Perform ultrasound examination of the pylorusD. Perform an upper gastrointestinal contrast studyE. Change oral feeding to a soy-based formula

32. A newborn infant presents with the following clinical picture: coughing and cyanosis immediately after ingesting fluids, no difficulty in swallowing, coarse rhonchi and rales after swallowing, gastric distension after crying, no symptoms after gavage feeding. The most likely diagnosis is:

A. Tracheo-esophageal fistula with esophageal atresiaB. Tracheo-esophageal fistula without esophageal atresiaC. Isolated esophageal atresiaD. Pyloric stenosisE. Achalasia

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33. A baby who was apparently normal at birth, develops persistent regurgitation and vomiting in the second and third weeks of life. No fever is present and hematologic studies and blood chemistries are normal. Which of the following therapies is most likely to be effective in this case?

A. AntacidsB. Barium enemaC. Gastric resectionD. Oral antibioticsE. Pyloromyotomy

34. A 12 year old girl presents with poor feeding, vomiting nd lethargy. She was born uneventfully at 37 weeks gestation with a body weight of 2900 grams, and there were no neonatal problems. No drugs or other medications were given. On examination she is thin and wasted. She has lost weight <3%, the temperature is 36,5 5ºC, RR 40/min, and HR 150/min. the chest is clear with no evidence of murmur. There is no organomegaly, no rash or dysmorphic features.What is the most likely diagnosis?

A. Congenital adrenal hyperplasiaB. Congenital heart diseaseC. Inborn errors of metabolismD. SepsisE. Congenital hypothyroid

35. When evaluating a hypoglycemic infant, the first thing to assess is:A. Ballard examB. Presence or absence of symptomsC. Airway, breathing, circulationD. Presence or absence of a suck reflexE. Apgar score

36. Which of the following conditions is LEAST likely to be associated with neonatal seizures?A. E. Coli meningitisB. Syndrome of inappropriate diuretic hormoneC. Neonatal hypoglycemiaD. Transient tachypnea of the newbornE. Umbilical cord prolapse

GROWTH AND DEVELOPMENT

37. A baby boy was born at 32 weeks gestation. He smiled at 6 weeks and could pick up a small object with his finger and thumb at 10 months. He is not yet walking at the age of 16 months. His speech is normal. Likely diagnoses is:

A. Mental subnormalityB. Gross motor delayC. Muscular dystrophyD. Spina bifida occultaE. phenylketonuria

38. A child is brought to your clinic for routine examination. She can dress with help, can ride a tricycle, kows her own age, and can speak in short sentences. She had difficulty in copying a square. The age of this child is most likely

A. 1 yearB. 2 yearsC. 3 yearsD. 4 yearsE. 5 years

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39. A 3.5 year old boy says only three single words, and thes are poorly articulated. He uses gestures to communicate. There are no other reported problems, gross and fine motor skills are normal for age and physical examination, including tympanigraphy, is normal. Which of the following is the MOST LIKELY explanation?

A. Intellectual disabilityB. DeafnessC. Manipulative behaviorD. DysarthriaE. Autism

40. A 2 year old girl comes in for a well baby check up. She should be able to do all of the following except:A. Turn pages one at a timeB. Use 2-3 word phrasesC. Follow two step commandsD. Participate in group playE. Walk unsupported

CARDIOLOGY

41. A 7 years old girl is referred for chronic recurrent cough. She shows normal vital signs, pulses, and abdomen. The RV impulse is accentuated. S2 is fixed and widely split. A nonspecific 2/6 almost vibratory systolic ejection murmur is best heard at the left sterna border, and there is also a 2/6 middiastolic murmur at the lowest left sterna border, what is the lesion?

A. VSD (Ventricular Septal Defect)B. ASD (Atrium Septal Defect)C. PDA (Patent Ductus Arteriosus)D. AVSD (Atrio-Ventricular Septal Defect)E. PS (Pulmonal Stenosis)

42. A 6 year old boy was referred for prolonged fever and swelling, severe pain and redness of his ankles. The precordium is normal except for a mild thrill in the apex. S1 and S2 are normal, but harsh holosystolic murmur is heard at the apex. The abdomen is soft and there is no organomegaly. What is the diagnosis?

A. Juvenile rematoid arthritisB. Acute rheumatic feverC. MyocarditisD. Infective endocarditisE. Cardiomyopathy

43. An eight year old boy with known diagnosis of unrepaired tetralogy of Fallot becomes severely cyanotic while crying. Which of the following is NOT indicated for acute management of this situation?

A. Placing in knee chest positionB. OxygenC. Morphine sulfateD. PropranololE. Insert rectal tube

44. A patient presents with cyanosis and clubbing of the toes with sparing of the fingers. A rough murmur is heard at the left upper sternal border. What is the most likely diagnosis?

A. Atrial septal defectB. Sinus of valsava fistulaC. Common atrioventricular canal defectD. Patent ductus arteriousE. Ventricular septal defect

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RESPIROLOGY

45. A healthy 15 year old complains of swollen glands in his neck and groin for the last 6 months along with an increasing cough over the previous 2 weeks. He also reports some fevers, especially at night, and possibly some weight loss. On examination, you notice that he has nontender cervical, supraclavicular, axillary, and inguinal nodes. No hepatosplenomegaly, and otherwise looks to be fairly healthy. Which of the following would be the appropriate next step?

A. Biopsy of a nodeB. Complete blood count and differentialC. Trial of antituberculos drugsD. Chest radiographE. Cat-scratch titers

46. A 3 year old boy was brought to a pediatric clinic for consultation. His father suffered from haemopthysis and had been treated with antituberculous drugs since the week before. The child was symptomless and had a normal body weight. Tuberculin skin test result was 12 mm, and the chest x-ray didn’t show any suggestion for tuberculosis. Which of the following answers is the most appropriate management in this child?

A. Primary chemoprophylaxis with isoniazid for 3 monthsB. Primary chemoprophylaxis with isoniazid for + rifampin for 3 monthsC. Secondary chemoprophylaxis with isoniazid for 6 monthsD. Secondary chemoprophylaxis with isoniazid + rifampin for 6 monthsE. Give isoniazid, rifampin, and pyrazinamide for 2 months, follow with isoniazid and

rifampin for 4 months

47. A 3 month old girl has suffered from dyspnea since 2 days befor admission. She also complains of rhinorrhea, cough, fever, and vomiting. There is no family history of atopy. On physical examination fever, tachypnea, nasal flaring, chest indrawing, crackles, and wheezing were evident. Her laboratory result are

WBC: 4000/ with a preponderance of polymorphonuclear. What is the most likely diagnosis for this patient?

A. Severe asthma exacerbationB. Severe pneumoniaC. Pneumonia with asthma exacerbationD. Pneumonia with GERE. Bronchiolitis

48. A 10 year old girl came to the outpatient clinic with the chief complaint of cough for 3 weeks. She had no fever, no dyspnea and no TB contact. On physical examination she had good nutritional status, no abnormalities were found except for a slight decrease of her right field breath sound. The Tuberculin SkinTest resulted in a 5 mm induration and the Chest X-Ray was as attached below.The most appropriate assessment and management of choice would be:

A. Pertussis, aminoglycosideB. Atypical pneumonia, macrolideC. Pneumococcal pneumonia, cephalosporinD. Tuberculosis, rifampicinE. Asthma, salbutamol nebulizer

49. A 2 year old boy suffer of inspiratory stridor. On the physical examination revealed suprasternal and intercostals retractions, nasal flaring, and barking cough. He has ha a mild upper respiratory tract infection for 3 days. The most likely diagnosis in the patient is:

A. Foreign body aspirationB. Acute laryngitisC. Acute epiglottitisD. Papilloma of larynxE. Viral croup

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50. A patient with tuberculosis develops bright orange-red urine. His mother was in a panic because she is afraid he is bleeding into the urine. The patient has no other urinary tract symptoms. Which of the following medications is most likely to procedure this side effect?

A. EthambutolB. IsoniazidC. PyridoxineD. RifampinE. Streptomycin

7th NATIONAL MCQ EXAMINATION

NATIONAL BOARD OF EVALUATIONINDONESIAN COLLEGE OF PEDIATRICS

JULY 14, 2010SELECT THE ONE BEST ANSWER, PUT YOUR ANSWERS IN THE ANSWER SHEETTIME ALLOCATION : 100 MINUTE

GASTRO-HEPATOLOGY

1. A 7-week-old,full-term girl has worsening jaundice that the parents first noticed 10 days ago. On her examination, she is well appearing and is noted to have a liver edge 4 cm below her costal margin. Her direct bilirubin is 9.The most likely cause of her direct hyperbilirubinemia is which of the following :

A. Billiary atresiaB. CholecystitisC. SepsisD. Acetaminophen toxicityE. Chollytiasis

F. An 8-year-old girl presents to your office with a 3 day-history of decreased appetite and abdominal pain. She denies fever or diarrhea but has nausea and intermittent vomitting. Physical examination reveals a jaundiced girl with a height and weight at the 50 percentile for age. The abdomen is soft and nondistended with positive bowel sounds, but the patient has diffuse right upper quadrant pain and enlargement of the liver without splenomegaly.Your initial evaluation includes

A. Hepatitis A antibodyB. MonospotC. Hepatitis B surface antigenD. Hepatitis B antibodyE. Hepatitis B e antigen

3. A 5-year-old girl has had intermittent, painless, bright red colored bleeding from the rectum in association with bowel movements for the past 3 months. Inspection of the anus reveals no fissures, but blood is present on the examiner’s finger following digital examination of the rectum. Of the following, the most likely cause of this patient’s rectal bleeding is :

A. IntussusceptionB. Juvenile polypC. Meckel’s diverticulumD. Peptic ulcer diseaseE. Ulcerative colitis

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PERINATOLOGY

4. A newborn male spits up his first feeding and subsequently develops bilious emesis following further feddings. On physical examination, he appears ill, has a scaphoid abdomen, and has absent bowel sounds. A plain radiograph reveals air in the proximal small bowel but a paucity of air in the distal digestive tract. Of the following, the most likely cause for this infant’s vomiting and clinical findings is :

A. Antral webB. Choledochal cystC. Hirschsprung diseaseD. Tracheoesophageal fistulaE. Volvulus

5. A baby boy was born from a mother who had positive AFB from her sputum. His mother was on antituberculosis treatment since 1 month before the baby was born. The baby was doing well with 9/10 Apgar Score. His Birth Weight was 3100 gram and his placenta didn’t show any tubercle. He also had two siblings. His 8 years old sister was well nourished and had no complaints. His 3 years old brother was also in a good condition.The most appropriate time for BCG immunization would be :

A. Immediately after BirthB. At the age of 2 months as a routine immunization scheduleC. At the age of 1 months, when the clinical condition is good and tuberculin test negativeD. At the age of 3 months, when the clinical condition is good and tuberculin test negativeE. There is no need for giving BCG immunization

6. A 19 year-old primiparous woman developed toxemia in her trimester of pregnancy and during the course of her labor was treated with magnesium sulfate. At 38 weeks’ gestation, she delivered a 2100 grams-infant with an Apgar score of 1 at 1 minute and 5 at 5 minutes. Laboratory studies at 18 hours of age revealed a hematocrit of 79 %, platetet count of 100,000/micro, glucose 41 mg/dl, magnesium 2,5 mEg/l, and calcium 8,7 mg/dl. Soon after, the infant had a generalized convulsion.Of the following the infant’s seizure was most likely caused by

A. PolycythemiaB. HypoglycemiaC. HypocalcemiaD. HypermagnesemiaE. Thrombocytopenia

7. A premature infant had been fed 10 ml for orogastric tube. The gastric residual before feeding is 2 ml which contained digested formula. The physical examination and vital signs are normal. What should you do to the infant?

A. FastingB. Discard the aspirate and continue the feedingsC. Take an abdominal radiographD. Increase the interval of feedingE. Replace the volume

B. The examination of a newborn’s back reveals a quarter-size “lump” of the soft tissue overlying the lower spine. Evaluation with ultrasound of this lesion may demonstrate :

A. Ebstein pearlB. Mongolian spotC. CephalohematomaD. OmphaloceleE. Occult spina bifida

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TROPICAL/INFECTION DISEASE

9. A 6 year-old boy has a bright, red, punctate, erythematous rash which blanches on pressure, beginning in the axilar along with some perioral pallor and relative facial sparing. The skin feels like “sandpaper”. The rash fades and desquamates on the hands and feet. A thick white exuadate develops on the tongue which peels off leaving a “stawberry tongue” with prominent papillae. This description is typical of :

A. Scarlet feverB. Kawasaki’s diseaseC. Infectious mononucleosisD. Staphylococcal scalded skin syndromeE. Measles

10. A 7 year and 6 months-old girl with a body weight and length of 24 kg and 125 cm respectively, was hospitalized because of dengue virus infection. The patient presented with fever for 5 days, abdominal pain, and vomiting. Caough and cold were not noted. Petechia and echymosis was found on her skin. Blood pressure was 100/70 mmHg, pulse 100/min, body temperature 39°C, Hematocrit 47 % and platelet count 90.000/cmm. The most likely diagnosis would be

A. Dengue FeverB. Dengue Hemorrhagic Fever grade IC. Dengue Hemorrhagic Fever grade IID. Dengue Hemorrhagic Fever grade IIIE. Dengue Hemorrhagic Fever grade IV

11 A 9-year-old boy presents with fever >39°C for 4 days, watery diarrhea, conjunctival injection, diffuse erythroderma, strawberry tongue, blood pressure of 80/40 mm Hg, and moderately elevated hepatic transaminases. The most likely diagnosis is :

A. Staphylococcal scalded skin syndromeB. Kawasaki diseaseC. Toxic shock syndromeD. Stevens-Johnson syndromeE. Toxic epidermal necrolysis

PEDIATRIC EMERGENCY

14. A 5-year-old boy came to the emmergency departement because of clammy hands. The mother told the doctor that her son had had fever for 4 days. The temperature bacame normal the night before; however a few hours later, she felt that her son’s hand got clammy. There were some small red dots on the face and feet, noticed by his parents since the afternoon. There were no history of bleeding, vomiting and diarrhea. His appetite was decreased. Defecation was nornal. Based only on that story, the most likely diagnosis is :

A. Septic shockB. Cardiogenic shockC. Dengue shock syndromeD. Hypoglicemia shockE. Anaphylactic shock

15. You are informed that a 6 year-old girl is being transported to your ED following a drowning incident at a nearby pool. The patient is unconscious and total submersion time is unknown. Which of the following would be the most important priority in the prehospital setting?

A. Attempts to evacuate aspirated fluid by performing Heimlich maneuverB. Cervical spine immobilizationC. Wrap the patient in warm blanketsD. Do nothing and continur rapid transportE. Initiate cardiopulmonary resuscitation if the patient is pulseless

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A. A 5 year-old boy is brought to your emergency departement (ED) for evaluation of scalding burns to face, arms, and torso from hot water. On examination yo note that the burns to the hands and face seem qiute extensive. There is marked edema, erythema, and some blistering present. Which of the following is a management priority in this child?

A. Estimate the percentage surface area involved in the burn. If the burn involved more than 15 % body surface area (BSA), begin agressive fluid administration.B. Assess the child’s airway and oxygenation statusC. Begin humidified oxygen and prepare for intubationD. Determine the circulation statusE. Nebulize respiratory treatments to prevent bronchospasm

17. You are at a restaurant when you observe a child apparently choking, the child is not able to cough and is unconscious. Which of the following describes the most appropriate intervention?

A. Active emergency medical service (EMS)B. Attempt to remove the foreign body if visualized in oropharynxC. Administer a combination of back blows and chest thrustD. If the cough becomes ineffective, perform the Heimlich manouverE. Place the child on the floor and administer five abdominal thrust

RESPIROLOGY

18. A 5 month-old girl came to Emergency Room with difficulty in breathing. Three days prior to admission she suffered from fever and cough. Her physical examination showed increased respiratotory rate along with a chest indrawing. Auscultation revealed crackles without any evidence of whezzing. Her CBC showed a leucocyte count of 27,00 cell/ul and chest X-ray showed multiple blebs in right hemithorax.The possible causative agent of pneumoniae in this baby girl would be :

A. Streptococcus pneumoniaeB. Staphylococcus aureusC. Haemophylus influenzaeD. Staphylococcus epidermidisE. Chlamydia trachomatis

NEUROLOGY

19. An 11-month-old presents to your emergency departement with irritability, fever, and stiff neck. When performing the lumbar puncture in this child, you should

A. Quickly push the needle in all the way until a pop is leftB. Push the needle in until resistance is left and then withdraw the styletC. Use a needle without a styletD. Twirl the needle repeatedlyE. Advance the needle by small increments and remove the stylet after each advance to see if

cerebrospinal fluid (CSF) comes out

20. A 4 year-old boy was admitted to the hospital with alteration of consciousness since 2 days prior of hospitalization. He has had fever for 3 days, along with headache and projectile vomiting. Seizures developed 2 days before admission, which was of a general type, lasting for 5 minutes and recurred. His bowelmovement and urination were normal. He never received basic immunization, and never got severe disease since birth, except for swollen cheek about 2 weeks before, which resolved by itself. Physical examinations revealed GCS 8 (E2M4V2), hyperthermia, neck stiffness and spasm. His physiological reflexes were increased ang pathological reflexes were present. Laboratory examinations revealed WBC 5,500/mm³, Hemoglobin 12.1 g/dl, Platelet count 540,000/cmm.The most reasonable examination which should be perfomed is :

A. Head CT-scanB. MRIC. EEGD. Blood cultureE. Spinal tap

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21. A 13-year-old boy admitted for complaints of lower extremity weakness niticed that his legs were weak when getting out of bed. His symptoms seem to be getting worse because now he is having difficulty in walking. He contracted an upper respiratory tract infection about 2 weeks ago but did not experience any fever. He plays football but denies any recent trauma. Physical examination : afebrile, cranial nerves normal, upper extremities is 5/5, no pronator drift and lower extermity strength is 3/5. Sensory normal, gait : unable to walk unassisted. Relfexes are absent in the lower extremities. Give the most likely diagnosis :

A. Transverse myelitisB. PoliomyelitisC. Guillain Barre SyndromeD. MyositisE. Myastenia gravis

22. A six year-old boy was brought to the emergency departement because of seizure since one hour before admission. Physical examination revealed an unconcious boy, body temperature was 41,5 ° C, respiration rate 40/m deep, pulse rate 144 m, BP 130/90, Hb 13 g %, PCV 40 %, leucocyte 18000. His body weight was 33 kg.

The working diagnosis of this boy is :A. Encephalitis + obesity + bronchopneumoniaB. status epilepticus + hyperpyrexia + obesityC. tuberculosis meningitisD. bacterial meningitisE. complex febrile seizure + hyperpyrexia

23. A mother in the predecing question delivered a 4000 g- baby by a difficult forceps delivery. The baby was alert and active. She did not more her left arm, however, which she kept internally rotated by her side with the forearm extended and pronated; she also did not move it during a Moro reflex. The rest of her physical examination was normal.

This clinical picture most likely indicatesA. Fracture of the left clavicleB. Fracture of the left humerusC. Left-sided Erb-Duchenne paralysisD. Left-sided Klumpke paralysisE. Spinal injury with left hemiparesis

HEMATOLOGY

24. A12 year-old boy, 20 kg,ith lung TB was consulted to you because of pallor. The patient suffered from lung TB since 4 months ago and now was in 2nd month of TB treatment. The history and physical examination was unremarkable. Laboratory findings revealed Hb 8,9 g/Dl, WBC 7400/cmm, Platelet 176000/cmm, Reticulocyte 1,2 %, differential count 1/-/8/16/54/21, Serum Iron 35 (N 60-90) Total Iron Binding Capacity 275 (N 250-400).

A. Iron deficiencyB. Chronic diseaseC. MalnutritionD. HemoglobinopathyE. Hypoplastic anemia

25. The best management in this patient isA. Give PRC transfusion until Hb 10 g/Dl to increase blood oxygenationB. Give Iron orallyC. Give erythropoietin injectionD. Continue TB treatmentE. Give high calorie diet

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26. A 3 year-old boy develops pallor, purpura on the skin and recurrent epistaxis. There is no evidence of hepatosplenomegaly or lymphnode enlargement. Laboratory findings reveals a hemoglobin level of 3 g/dl, hematocrit 9,3%, red blood cell count 1,500.000/mm³, white blood cell count 1,500/mm³ and platelet count 55,000/mm³. The most likely diagnosis of the patient is :A. Hemolytic anemiaB. Aplastic anemiaC. Post-hemorrhagic anemiaD. LeukimiaE. Iron deficiency anemia

27. A 5 year-old has had recurrent hematoma on both his arms and legs since the age of one year. platelet count is 200,000/µL, Hb and WBC are 11,1 g/dl and 5,500//µL respectively, and bleeding ime is 2 minutes. There is no hepatosplenomegaly or lymphnode enlargement. which of the following is most likely to explain this child’s condition?

A. Disturbance of thrombocyte functionB. Disturbance of synthesis in Von Wiillebrand factorC. Disturbance of vascularD. Disturbance of fibrinolytic systemE. Disturbance of coagulation system

28. A 3 year-old boy with ALL (L3 type) suddenly experienced low urine output. The total urine output was 0.3 ml/kg BW/h. The patient was diagnosed as ALL (L type) since 2 weeks before and started induction phase of chemotherapy since 8 days before.The most possible reason for this condition is :

A. Acute Kidney InjuryB. Tumor Lysis SyndromeC. Not adequate hydrationD. Syndrome of Inappropriate Anti Diuretic Hormone (SIADH)E. Hyperleukocytosis

29. A 6 year-old child came to the hospital with the chief complaint of nose-bleed a long with red dot spots on his extremities. There was no fever. There aws no history of bleeding beforehand. He had been circumcized without any problem. There was no history of the same symptoms in his family The physical examination revealed no evidence of hepatosplenomegaly.The most likely cause of these symptoms would be

A. Primary TrombocytosisB. Von Willebrand’s DiseaseC. HemophiliaD. Vitamin K deficiencyE. ITP

NEPHROLOGY

30. A 7 year-old Indonesian boy has complaints, pallor and difficulty to gain weight for one year. A thorough physical examination revealed that he was alert, looked ill with a body weight of 18 kg, body height of 104 cm. Blood pressure was 140/100 mmHg. Laboratoryfindings revealed Hb 9 g/dl, ureum 150 mg/dl, plasma creatinine 3.6 mg/dl, Erythroctre cast, leucocyte : 0-1/HPF, erythrocyte : 20-40/HPF.

The most likely diagnosis of this patient is :A. Acute post-streptococcal glomerulonephritisB. Acute pyelonephritisC. Nephrotic syndromeD. Chronic glomerulonephritisE. Chronic pyelonephritis

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31. Which of the following that is NOT the indication for long-term prophylaxis against urinary tract infection :

A. Ureteropelvic junction obstructionB. Posterior urethal valveC. Prune belly syndromeD. Nephrotic syndromeE. Vesico-uretheral reflux

32. A 6 year-old girl with global developmental delay presents with fever and gross haematuria, along with visible pink urine and clots. Birth history revealed full term normal delivery with no neonatal complications. She has been diagnosed as developmental delay at 9 months, and receives spesial schooling. Immunizations are up to date. There is no family or social history of note. On examination she has a temperature of 37.8ºC, respiratory rate of 18/min and heart rate of 90/min. She has suprapubic tenderness. Urine dipstix testing shows 4+ haematuria, 3+ proteinuria and 3+ nitrites.

The most lukely diagnosis isA. Benign familial haematuriaB. GlomerulonephritisC. Haemorrhagic cystitisD. Henoch-Schonlein DiseaseE. Urinany tract infection

33. A 1 year-old male child was brought with fever for 2 days along with decreased appetite. Physical examinations were normal. Urinalysis showed protein +1, abundant leucocytes, erythrocyte 20-30/hpf, bacteria +.

What would be the best therapy for this case?A. Oral antibiotics for Gram-positive bacteriaB. Oral antibiotics for Gram-negative bacteriaC. Intravenous antibiotics for Gram-negative bacteriaD. Intravenous antibiotics for Gram-positive bacteriaE. Intravenous followed by oral antibiotics for Gram-negative bacteria

ENDOCRINOLOGY

34. An eleven year-old boy presented to the clinic because of short stature. Height was much below 3 rd

percentile and weight was on 75th percentile. Which of the following is important in your initial evaluation?

A. Measure parent’s height, calculate mid-parental heightB. Assure him that his short statute is not pathologicalC. Immediately do growth hormone stimulation testD. Start growth hormone tratment, if clinically suggestive of GH deficiencyE. Start short trial of growth hormone and see the response

35. A ten year-old girl presented with obesity, round plethoric face, hirsutism and short stature. On examination her blood pressure was hidh and her obesity was truncal. Which of the following laboratory finding is expected to be present in the child?

A. Metabolic acidosisB. HyperkalemiaC. HypoglycemiaD. Hypokalemia and metabolic alkalosisE. Increased cortisol level

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36. An 8 year-old male has a 3 week-history of weight loss, polyuria and polydipsia. He has been urinating approximately two or three times per hour for the last few weeks.

He has experiended some mild abdominal discomfort but there was no evidence of nausea or vomiting.Taking into consideration that the child has Diabetes, the statements below are true expect

A. A patient with poorly controlled diabetes should not undergo elective surgery until glucose is reasonablyB. Patient undergoing minor surgial procedures may be brought in on the morning of surgeryC. There are only 2 ways of starting insulinD. Lantus is very helpful, as it has a long-acting profile and provides good control of basal hyperglycemicE. Selection and rotation of insulin sites are important

37. A 14 year-old is brought into your office because concerns of lack of pubertal development. The parents report that the child has otherwise been healthy, but the child has been complaining that all of his/her friends seem to be getting much taller than him/her. The child’s father is 180 cm and could not recall when he went through puberty, but did remember being shorter than all his friends in high school. The mother is 165 cm and had menarche at age 14 years. On the physical examination, the child’s height is less than the 5th percentile, and weight is at the 30 th percentile. The child is entirely prepubertal.

What is the most likely diagnosis if this a boy with a bone age of 11 years, and his father grew 10 cm after high school?

A. Hypogonadotropic hypogonadismB. Constitutional delay of pubertyC. Hypogonadotropic hypogonadismD. Klinefelter’s syndromeE. Kallmann syndrome

NUTRITION

38. Infant formula is not a sterile product and may be contamined with pathogens that can cause serious illness. Proper handling and correct preparations will reduce the risk. According to the WHO guidelines it has to be reconstituted with

A. Boottled waterB. Hot boiling water (100°C)C. Water directly from water dispenserD. Boiled water that has been allowed to cool to no less than 70°CE. Mixture of hot boiling water and cool water to achieve temperature of 70°C

39 Nutritional obesity has to be differentiated with obesity as a part of a syndrome. The following feature that is hard to diferentiate between nutritional obesity and syndromic obesity is:

A. Short statureB. Delayed developmentC. Dysmorphic faceD. Familial occurrenceE. Mentally retarded

40 A two year-old boy was diagnosed as hypercarotenemia. Of the following the most important examination is featuring yellow pigmentation

A. in the sclera and oral cavityB. of the skinC. in the sclera and nailD. in the oral cavityE. in the sclera,oral cavity and nail

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41. A 2 years-old boy, Body Weight 6,5 kg, Body Length 80 cm, complains of weight loss for the last 6 months, along with loss of appetite. He has the following anthropometric measures: weight-for-age z-score <-3 SD, weight for height = 59%, height for age= 93%.The diagnosis of this patient is

A. Severe malnutrition marasmic typeB. Severe malnutrition kwarshiorcor typeC. Severe malnutrition marasmic- kwarshiorcor typeD. Failure to thriveE. Short stature

42. A premature baby is presented with apparent Essential Fatty Acid W-6 defyciency due to prolonged parenteral nutrition without proper supplementation. The following statements are appropriate for Essential Fatty Acid W-6:

A. Main source: Deep-sea fist body oilB. Essential for the nervous system and retina developmentC. Arachidonic acid is thebiological active formD. Pharmacologic action of lowering triglyceride blood levelE. Not essential for the healing of skin lesion

GROWTH AND DEVELOPMENT

42 A mother brings her 7 month-old child for a routine check-up. Between the ages of six and eight, children typically become able to participate in a much greater of activities primarily as a result of:

A. A significant increase in fine-motor control.B. A latency period of minimal physical growth and development.C. A sudden,dramatic improvment in gross-motor control.D. The eatablishment of handedness and footedness.E. Change of intelligence

43 An 18 month-old boy comes to clinic with the chief complaint of not being able to walk yet. He was bom at 32 weeks of gestation. He recently understands simple instruktion,can say dada-tata, and can eat using a spoon.The most probable development problem for this child is:

A. Delayed motoric developmentB. Global delayed developmentC. Delayed speechD. Delayed fine motor developmentE. Normal development

44. In his previuos basic immunization,he has got BCG1x, DPT3x, Hepatitis B 3x, Polio 4x, which are appropriate immunization for him now:

A. DPT 4, Hepatitis 4, Polio 5B. MeaslesC. DPT 4, Polio 5, measlesD. DPT 4, Polio 5 E. Hepatitis 4

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CARDIOLOGY

47 A 5 day old infant bom at 31 weeks gestation is on ventilatory support. He has a grade 2 holosystolic murmur that extends past the second heart sound. Pulses are bounding. Precordial palpation is hyperdynamic. Echocardiography reveals a large patent ductus arteriosus. Concentrations of hemoglobin, electrolytes and creatinine are normal. Of the following the most appropriate INITIAL management is to:

A. Administer furosemide intravenouslyB. Administer indomethacin intravenouslyC. Administer indomethacin via nasogastric tube.D. Defer intervention because spontaneous closure is likelyE. Obtain a surgical consultation of ligation of the ductus.

48 A 3-month old boy comes to you with fast breathing occurring mainly during feeding. The mother tells you that her baby often stops every 5 minutes during breast feeding. On physical examination, you find mild respiratory distress. First and second heart sound are normal, but a lound machinery murmur is heard on the upper left sternal border. The most likely diagnosis is:

A. VSDB. ASDC. CAPVDD. PDA E. Tetralogy of Fallot

49 A 1 year-old child is brought to the ER because his parent thought his heart was pounding as they were putting him to bed. EKG reveal a HR of 300/min that spontaneously converts to asinus rate of 100/min. The parents estimate that the tachycardia lasted 20 minutes; the child was asymtomatic throughout. Of the following the MOST appropriate management of this child is;

A. Administration of a beta blockerB. Administration of digoxinC. Administration of procainamideD. Administration of verapamilE. Observation without drug therapy

50. A 7 year-old child returns for follow up. He is pink and healthy looking with normal vital signs, pulses, and precordial activity. However the anteroposterior diameter of her chest is somewhat increased. The lungs are clear. S1 is normal, but S2 is fixed and widely split. A2/6 medium frequency systolic ejection murmur is heard at the upper left sternal border and all along the left ssternal border; it also heard well in the lung fields. There is also an early 2/6 diastolic murmur, almost descrescendo at the lower left sternal border. The liver is 1 cm below the right costal margin.What is the murmur at the upper left sternal border most likely caused by?A. Relative pulmonary stenosisB. Relative tricuspid stenosisC. Relative mitral sttenosisD. Relative aortic stenosisE. Relative mitral insufficiency

ALLERGY-IMMUNOLOGY

1. A 14-year old girl is exposed to roundworm Ascaris but does not develop clinical signs of infection. Which of the following mechanisms is likely to be responsible for his resistance to infection?

A. Antibody-mediated destruction of worm-infected cellsB. CTL-induced apoptosis of worm-infected cellsC. Complement-mediated lysis of worm attached to host tissuesD. IgE-mediated type I hypersensitivity disrupting worm attachmentE. Phagocytosis of worms followed by necrosis of phagocytes

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2. A 15-month old body who has not received any recommended vaccines remains healthy despite his daily assosiation with several other children for the past years in his otherwise well-tended inner city housing area’ Which of the following merchanisms best explains why he has not contracted diphttheria, measles, pertussis, or polio?A. Hard immunityB. Genetic driftC. Genetic shiftD. Immune evasionE. Tolerance

3. A 5-year old, previously healthy boy has had a daily spiking fever up to 40°C in the evening for 4 weeks. His temperature is normal between spikes. When febrile, the child is irritable, has malaise and does not want to play or move. He is often active and playful when afebrile. He appears stiff in the morning. His mother is concernet that his finger and knee joints appear swollen.

This child’s diagnosis is most likelyA. Rheumatic feverB. Systemic arthritisC. Periodic fever syndromeD. Kawasaki diseaseE. Systemic Lupus Erythematosus

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KOLEGIUM ILMU KESEHATAN ANAK INDONESIA8th MCQ Progress Test Nasional, 11 Mei 2011

Nama :.....................................................................

IPDSA : .....................................................................

Tahapan : ..................................................................... (Yunior / Madya / Senior)

Semster : .....................................................................

Petunjuk :

Berilah tanda X pada huruf jawaban yang benar pada lembar jawaban

1. Bayi berusia 2 hari diperiksakan ke ruang gawat darurat karena pendarahan dari dubur dan hidung.