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Question 1
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A 10-year-old girl was brought to the hospital following a seizure episode. On examination, hypopigmented macules were found on her abdomen with acne-like eruptions on her face. Also, her fingers show small periungual fibrous papules. Her parents said that she has learning disabilities. What is the most probable diagnosis?
Your Answer: Tuberous sclerosis (Bourneville's disease)
Explanation:The most probable diagnosis for this patient, according to the clinical scenario provided is tuberous sclerosis. It is an autosomal-dominant disorder characterised by hamartomas located throughout the body, often prominently involving the central nervous system and skin. Two loci on chromosomes 9 and 16 have been identified to be associated with this condition. The condition has a variable expression and penetrance and is further characterised by:- Seizures (usually infantile spasms)- Developmental delay- Facial/cutaneous angiofibromas (adenoma sebaceum)- Periungual fibromas (pink projections from the nail folds)- Shagreen patches (leathery thickenings of the skin usually on the back) – Ash leaf macules (areas of depigmentation that become visible under a Wood’s light)- Fundoscopy may reveal white streaks along the fundal vessels.
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This question is part of the following fields:
- Dermatology
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Question 2
Correct
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A 30-day-old female was diagnosed with a case of breast milk jaundice. She has no other symptoms. Which is the most suitable next step of management?
Your Answer: Continue breastfeeding
Explanation:Breast feeding should be continued for babies with breast milk jaundice as this is a benign condition.
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This question is part of the following fields:
- Gastroenterology And Hepatology
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Question 3
Incorrect
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Which of the following is used to diagnose Infective endocarditis using the Duke criteria?
Your Answer: 1 major and 2 minor criteria
Correct Answer: 1 major criteria and 3 minor criteria
Explanation:Infective endocarditis (IE) is caused by a bacterial, or fungal infection which damages the heart’s endothelium and can thus lead to changes in heart function, valve incompetencies, possible cardiac failure, as well other associated skin and organ changes. Organisms common in IE include Staphylococcus aureus and Streptococcus viridians. The HACEK organisms (Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, and Kingella species) are common in neonates. The Duke criteria uses 2 major, or 1 major and 3 minor criteria, or 5 minor criteria to diagnose infective endocarditis. Major criteria include:- a positive blood culture and evidence of endocardial involvement. Minor criteria include: – evidence of predisposition (a heart condition of injection drug use)- a fever- vascular phenomena such as Janeway lesions- immunologic phenomena such as Osler’s nodes and Roth’s spots; and- microbiological or serological evidence of active infection.
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This question is part of the following fields:
- Cardiovascular
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Question 4
Incorrect
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A 2 year old boy is brought by his mother to the emergency department with colicky pain. The boy has experienced such episodes of pain in the past, which radiates from his loin to the groin. After clinical examination and investigations, a 7mm stone has been found in his ureter. What is the single most appropriate next step?
Your Answer: ESWL
Correct Answer: Conservative treatment
Explanation:Renal stones < 5mm generally pass spontaneously with adequate fluid intake. Stones 5mm-10mm with pain not resolving, require medical expulsive therapy with Nifedipine or Tamsulosin. For stones larger than 10mm, ESWL or Ureteroscopy is indicated. For stones as big as 2cm, percutaneous nephrolithotomy should be applied.
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This question is part of the following fields:
- Renal
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Question 5
Incorrect
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Georgie is a bright 3 year old girl whose development seems to be ahead of her preschool classmates. Which of the following should a typical 3 year old be able to do?
Your Answer: Count to 10
Correct Answer: Match 2 colours
Explanation:A 3 year old should be able to match two colours, copy a circle, walk up and down the stairs, and jump up and down. By the time they are 4 they can copy a cross, draw a person with three parts, count to 10, stand on one foot.
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This question is part of the following fields:
- Child Development
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Question 6
Incorrect
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The positive likelihood ratio for a diagnostic test is 3. A patient, whose pre-test odds were 2 tests positive.The following is most accurate:
Your Answer: The negative likelihood ratio for the test must be known to interpret the results in this patient.
Correct Answer: Their prior odds of having the disease are now 6
Explanation:Before the test, the patient was likely to have the disease being tested for. Their pre test odds were 2, making them twice as likely to have the disease. After testing positive, their pretest odds of 2 and the likelihood ratio of 3 are multiplied to produce 6 as the post test odds. The patient is now 6 times as likely to have the disease after the test. Likelihood ratios above 10 or below 0.1 are strong evidence to rule in and rule out a diagnosis. The negative likelihood ratio is not known here, but does not subtract from the interpretation of the outcomes in this patient.
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This question is part of the following fields:
- Epidemiology And Statistics
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Question 7
Correct
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Which of the following does not cause painless gastrointestinal bleeding?
Your Answer: Intussusception
Explanation:Intussusception causes abdominal pain leading to painful lower GI bleeding. Intussusception is a condition in which part of the intestine folds into the section next to it. It most commonly involves the small bowel and rarely the large bowel. Intussusception doesn’t usually require surgical correction. 80% of cases can be both confirmed and reduced using barium, water-soluble or air-contrast enema.However, up to 10% of cases can experience recurrence within 24 hours after reduction, warranting close monitoring during this period.Most children have self-limiting and minor bleeds. However, children with massive bleeds will need emergency care and stabilisation.The various causes of lower GI bleeding in neonates include:- Anal fissures- Milk protein or soy allergy- Intussusception- Volvulus- Coagulopathies including haemorrhagic disease of the new-born- Arteriovenous malformations- Necrotising enterocolitis- Hirschsprung enterocolitis- Meckel’s diverticulitis- Drugs (NSAIDs, heparin, indomethacin used for patent duct closure, dexamethasone)The various causes of lower GI bleeding in children aged between 1 month to 2 years include:- Infection- Anal fissures- Intussusception- Malrotation with volvulus- Milk protein or soy allergy- Polyp- Meckel’s diverticulum- Duplication cyst- Foreign body- AV malformation- Colitis of immune deficiency- Tumour- HaematomaThe causes of lower GI bleeding in children older than 2 years include:- Polyp- Inflammatory bowel disease (IBD)- Infectious diarrhoea (caused by Escherichia coli and Shigella)- Intussusception- Haemangiomas- Arteriovenous malformations- Vasculitis- Tumour
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This question is part of the following fields:
- Emergency Medicine
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Question 8
Correct
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A 17-year-old boy presents with a concern that he had not attained puberty. He lacks secondary sexual characteristics and has altered smell and reduced testicular size. Which of the following hormone profiles with regard to FSH (follicle-stimulating hormone), LH (luteinizing hormone) and testosterone would fit a diagnosis of Kallman syndrome for this patient?
Your Answer: Reduced testosterone, reduced FSH and reduced LH
Explanation:While the clinical scenario and the anosmic presentation of the child are highly suggestive of Kallmann’s syndrome, reduced testosterone, FSH and LH levels can confirm the diagnosis.Kallman’s syndrome is a recognised cause of delayed puberty secondary to hypogonadotropic hypogonadism. It is usually inherited as an X-linked recessive trait. Kallman’s syndrome is thought to be caused by a failure of GnRH-secreting neurons to migrate to the hypothalamus.Clinical features of Kallmann’s syndrome include:- Delayed puberty- Hypogonadism, cryptorchidism- Anosmia- Low sex hormone levels – Inappropriately low/normal LH and FSH levels- Some patients can present with associated cleft lip/palate and visual/hearing defects.
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This question is part of the following fields:
- Endocrinology
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Question 9
Incorrect
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A 19-year-old girl presents with polydipsia (>3L daily), polyuria, nocturia, and new-onset nocturnal enuresis. A urine dipstick reveals no glucose or ketones, but her pregnancy test is positive.What is the most probable diagnosis?
Your Answer: Gestational diabetes
Correct Answer: Gestational diabetes insipidus
Explanation:The presenting features with the positive pregnancy test are highly suggestive of gestational diabetes mellitus.Diabetes Insipidus:It is much less common than gestational diabetes mellitus. It is characterised by the inability to concentrate urine, with marked thirst.Presenting symptoms include polydipsia (>3L daily), polyuria, nocturia, nocturnal enuresis.Physical examination may reveal features of dehydration and an enlarged bladder.Investigations include biochemical analysis for electrolytes, urine and plasma osmolality, fluid deprivation test, and cranial MRI.The main differential diagnosis is for diabetes insipidus is psychogenic polydipsia.There are three broad categories of diabetes insipidus (DI): – Central (cranial) DI: It is the most common form of diabetes insipidus.It occurs due to decreased secretion of ADH. It usually occurs due to hypothalamic disease and may show response to low-dose desmopressin.- Peripheral (nephrogenic) DI:It is characterised by the resistance of the kidney to ADH.It usually does not respond to low-dose desmopressin.- Gestational DI:It is rare and is mostly seen in teenage pregnancy.It usually presents in the third trimester and often resolves 4-6 weeks post-partum.
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This question is part of the following fields:
- Nephro-urology
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Question 10
Correct
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A 10-year-old asthmatic boy is brought to the emergency department with severe stridor, wheeze, and lip swelling following the ingestion of a cashew nut at a birthday party.Which of the following can be considered an acceptable treatment option for this child?
Your Answer: Nebulised adrenaline 5ml 1:1,000
Explanation:The patient is suffering from an anaphylactic reaction to the cashew nut he consumed.Anaphylaxis:Anaphylaxis is an acute, rapidly progressing, potentially life-threatening IgE mediated Type I hypersensitivity reaction.It involves the release of mediators from mast cells, basophils and inflammatory cells. It is characterised by oedematous swelling of the airway mucosa giving rise to dyspnoea and respiratory distress.The most common cause of anaphylaxis in children is a food allergy.Risk factors for death in patients with anaphylaxis include asthma, age 11+, peanut allergy, and delay in adrenaline administration.Management of anaphylaxis includes:- Resuscitation – ABCD- Remove the allergen- IM adrenaline is given at ten microgram/kg or Nebulised adrenaline 5ml 1:1,000- IV Hydrocortisone is given at 4mg/kg- pro re nata IV fluid support. – Followed by observation.
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This question is part of the following fields:
- Emergency Medicine
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Question 11
Correct
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A 26-year-old doctor who has recently been diagnosed with melanoma asks about survival rates associated with this condition. Which of the following statistical methods is employed to predict the survival rates?
Your Answer: Kaplan-Meier estimator
Explanation:The Kaplan-Meier estimator, also known as the product limit estimator, is a non-parametric statistic used to estimate the survival function from lifetime data. In medical research, it is often used to measure the fraction of patients living for a certain amount of time after treatment.
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This question is part of the following fields:
- Adolescent Health
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Question 12
Correct
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Which is a sign of subacute bacterial endocarditis (SBE)?
Your Answer: Splinter haemorrhages
Explanation:Infective endocarditis (IE) is defined as an infection of the endocardial surface of the heart.Fever, possibly low-grade and intermittent, is present in 90% of patients with IE. Heart murmurs are heard in approximately 85% of patients.One or more classic signs of IE are found in as many as 50% of patients. They include the following:- Petechiae: Common, but nonspecific, finding- Subungual (splinter) haemorrhages: Dark-red, linear lesions in the nail beds -Osler nodes: Tender subcutaneous nodules usually found on the distal pads of the digits- Janeway lesions: Nontender maculae on the palms and soles- Roth spots: Retinal haemorrhages with small, clear centres; rareSigns of neurologic disease, which occur in as many as 40% of patients, include the following:- Embolic stroke with focal neurologic deficits: The most common neurologic sign- Intracerebral haemorrhage- Multiple microabscessesOther signs of IE include the following:- Splenomegaly- Stiff neck- Delirium- Paralysis, hemiparesis, aphasia- Conjunctival haemorrhage- Pallor- Gallops- Rales- Cardiac arrhythmia- Pericardial rub- Pleural friction rub
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This question is part of the following fields:
- Cardiovascular
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Question 13
Correct
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When measuring blood pressure in infants and children, which one of the following statements is accurate?
Your Answer: Doppler methods of auscultation are especially helpful in infants
Explanation:Using a Doppler device, you can estimate systolic BP even when the pulse is inaudible. Handheld and portable, the device uses ultrasound waves to detect the velocity of arterial blood flow. Helpful for patients with traumatic injuries or shock, the Doppler technique is also useful for children and patients whose BP is hard to hear because of oedema, obesity, vasoconstriction, or low cardiac output.
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This question is part of the following fields:
- Nephro-urology
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Question 14
Incorrect
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A 7 year old boy who never had a history of incontinence presented with bed-wetting. Which of the following is the best approach?
Your Answer: Reassure
Correct Answer: Sleep alarms
Explanation:As this boy didn’t have a previous history, a structural abnormality is unlikely. Parents should be asked to take the child to the bathroom to void before bedtime. Either alarm therapy or pharmacologic therapy should be considered if the above method doesn’t work after 3 months. From the above 2 therapies, neither one is superior than the other, so alarm therapy should be tried first.
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This question is part of the following fields:
- Behavioural Medicine And Psychiatry
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Question 15
Correct
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A 6 year old girl with a history of polyuria and polydipsia undergoes a water deprivation test. Previous urine dipstick results were negative for blood, glucose, or protein. The test is started and once the girl loses 3% of her body weight, her serum osmolarity is more than 300 whereas her urine osmolarity is less than 300. Doctors administer desmopressin but osmolarity levels do not change. What is the most likely diagnosis?
Your Answer: Nephrogenic Diabetes Insipidus
Explanation:Nephrogenic Diabetes Insipidus is an acquired or hereditary condition that affects the water balance. It presents with polyuria and polydipsia, leading commonly to dehydration.
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This question is part of the following fields:
- Nephro-urology
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Question 16
Incorrect
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Which is not true relating to growth in the normal child?
Your Answer: Growth continues past the pubertal growth spurt
Correct Answer: Full growth hormone responsiveness develops in puberty
Explanation:Most healthy infants and children grow predictably, following a typical pattern of progression in weight, length, and head circumference. Normal human growth is pulsatile; periods of rapid growth (growth spurts) are separated by periods of no measurable growth Growth hormone levels and responsiveness’ develop in late infancy, increase during childhood and peak during puberty.Typical milestones – General guidelines regarding length or height gain during infancy and childhood include the following:- The average length at birth for a term infant is 20 inches (50 cm)- Infants grow 10 inches (25 cm) during the first year of life- Toddlers grow 4 inches (10 cm) between 12 and 24 months, 3 inches (7.5 cm) between 24 and 36 months, and 3 inches (7.5 cm) between 36 and 48 months- Children reach one-half of their adult height by 24 to 30 months- Children grow 2 inches per year (5 cm per year) between age four years and puberty- There is a normal deceleration of height velocity before the pubertal growth spurt.Growth continues past pubertal growth spurt as there is increase in spinal length.
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This question is part of the following fields:
- Endocrinology
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Question 17
Incorrect
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A baby is delivered at 26 weeks. Full course of antenatal steroids was administered. There was a delay in clamping the cord. No respiratory effort is observed, and the heart rate is slow. What should be the next step in management of this case?
Your Answer: Dry and wrap baby
Correct Answer: 5 inflation breaths
Explanation:Most infants have a good heart rate after birth and establish breathing by about 90 s. If the infant is not breathing adequately aerate the lungs by giving 5 inflation breaths, preferably using air. Until now the infant’s lungs will have been filled with fluid.
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This question is part of the following fields:
- Neonatology
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Question 18
Correct
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A 5-year-old child was found to have orchidomegaly and splenomegaly. Blood tests show a WBC = 1.7 X 104/L, Hb = 7.1 g/dl and platelets = 44 X 104g/dl. His parents mention that he suffers from fatigue while at presentation he looks pale and has a fever. What is the most likely diagnosis?
Your Answer: Acute lymphoblastic leukaemia
Explanation:Acute lymphoblastic leukaemia (ALL) is an aggressive type of blood and bone marrow cancer which can appear in childhood. Signs of childhood ALL include: Fever, Easy bruising, Petechiae, Bone or joint pain, Painless lumps in multiple areas of the body, Weakness, fatigue or paleness, and Loss of appetite. Blood tests may show elevated white blood cells, decreased values of red blood cells and low platelet count.
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This question is part of the following fields:
- Haematology And Oncology
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Question 19
Correct
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Which of the following statements is true regarding Bell's palsy in childhood?
Your Answer: Commonly preceded by a viral infection
Explanation:While the cause for Bell’s palsy is still under debate, it is observed that Bell’s palsy is often preceded by a viral infection. Bell’s Palsy:Bell’s palsy (idiopathic facial palsy) is an acute unilateral lower motor neurone palsy. It typically occurs two weeks after viral infection such as Epstein-Barr, herpes simplex, herpes zoster or mumps. A careful assessment may suggest an alternative aetiology for the acute onset of weakness, e.g. acute otitis media, Lyme disease, hypertension. Causes:In childhood, Bell’s palsy is probably a post-infectious (i.e. immune-mediated) phenomenon, while in adults, there is increasing evidence that the majority of cases follow reactivation of previous HSV infection. Management:The prognosis is generally good in childhood with full recovery in the majority. However, permanent weakness is observed in around 5%. Steroids and acyclovir may have some benefit in adults with recent onset of weakness, but the evidence of the treatment benefit is much less convincing in childhood. Exposure keratitis is an important complication and children should be managed with eye drops and taping of the eyelid at night until recovery is complete.
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This question is part of the following fields:
- Neurology And Neurodisability
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Question 20
Correct
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A 14-year-old girl with HIV develops jaundice while being treated for overwhelming sepsis. Blood investigations reveal:ALT: 50 IU/L (0-45) Alkaline phosphatase (ALP): 505 IU/L (0-105)Which of the following medications has she most likely been administered in the course of her treatment?
Your Answer: Co-amoxiclav
Explanation:Based on the presentation, she probably was administered co-amoxiclav.The liver function tests are highly suggestive of cholestatic jaundice, which is a classic adverse dug reaction related to co-amoxiclav use.Other options:- Erythromycin is more commonly associated with gastrointestinal (GI) disturbance.- Gentamicin is more commonly associated with renal impairment.- Meropenem does not commonly cause cholestasis but is associated with transaminitis.- Vancomycin is associated with red man syndrome on fast administration.
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This question is part of the following fields:
- HIV
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