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Written Papers_ Format and Samples

Summer Written Paper (Summer Exam period: End of year):


This will comprise 2 x 2 hour papers

Formal examination: run through examination office.

Each paper will have 4 questions, a variety of essay,


modified essay (MEQ) and short answer questions (SAQ).

Paper 1 = Obstetric and Infant Health (See Table )


Paper 2 = Womens and Childrens Health (See Table )

Paper 1: Obstetric and Paper 2: Womens and


Infant Health Childrens Health

Q1: Obstetric Essay question Q1: Gynaecology Essay


Question

Q2: Neonatal MEQ Q2:Children's Health MEQ


older child

Q3: Obstetric MEQ Q3: SAQs Gynaecology

Q4: Children's Health MEQ Q4: Other Children's Health


involving an infant MEQ/ SAQ

Children's Health MEQ Sample MEQs

If you wish submit answered MEQs to your tutor for correction.

MEQ:

You are asked to assess Michael born 18 hours previously by


normal delivery at 38 weeks gestation. He is jaundiced, not
breast feeding well, and has a slightly elevated temperature.
The membranes had been ruptured for 36 hours prior to
delivery and mother had also been febrile during labour.
(1) What is the most important diagnosis to consider?

_________________________________________________________[ 1 ]

(2) Which single investigation is most important to


perform prior to starting treatment?

________________________________________________________[ 1 ]

List 3 further investigations which should be performed to


help clarify the diagnosis.
(i)__________________________________________________________[
1 ]

(4) What treatment should be given for the jaundice if


bilirubin is significantly raised but not at the level
which could cause permanent damage?

_________________________________________________________[ 1
]

(5) What treatment will need to be considered if the


jaundice reaches the danger level?

_________________________________________________________[ 1
]
(6) What 2 organs are particularly susceptible to
permanent damage from very

high levels of bilirubin?

(i)__________________________________________________________[
1 ]

Following a course of treatment the infant


improves, but it is noted that the jaundice has not
completely cleared after 2 weeks.

(7) What is the commonest cause of prolonged


jaundice in a well infant born at full term?

_________________________________________________________[ 1
]

In a well full term infant, what is the most common cause


to be considered at this

stage?

________________________________________________________[ 1 ]

(9) How would further analysis of bilirubin help


distinguish between these 2 conditions?
_________________________________________________________[ 1
]

(10) Stool examination shows complete absence


of pigment. List 2 further diagnostic investigations.

_________________________________________________________[ 1
]

(11) These results are abnormal. What is the specific


treatment for this condition?

_________________________________________________________[ 1
]

(12) By what age should this be performed to minimise


the risk of permanent damage?

_________________________________________________________[ 1
]

(13) If this is not achieved what condition may result?

_________________________________________________________[ 1
]

(14) Michael remains well and jaundice settles without


treatment. List the diseases for which protection can
be offered by immunisation at 2 months of age.

(i)__________________________________________________________[
1 ]

(15) Give the most common reason for not performing


immunisation at this age.
_________________________________________________________[ 1
]

(16) How should this situation be managed?

_________________________________________________________[ 1
]

End

MEQ:

A 27 year old West African lady presents in advanced


labour at 42 weeks gestation. This is her fourth
pregnancy.

She booked at 36 weeks and routine screening has


revealed that she is both Hepatitis B and HIV positive.
She is not taking any drug treatment.
The liquor is heavily meconium stained and there is
evidence of foetal distress. An emergency caesarean
section is performed.
A male infant weighing 4.5kgs is delivered. He is covered
in meconium.
He has a heart rate of 60, and some tone, is very pale,
has no response to stimulation, and no respiratory
effort. Cord ph, 7.0.

Q1. Outline the immediate priorities in management


of this infant on the labour ward.

(4x 1 marks)

____________________________________________________________
_____

The infant responds and develops spontaneous regular


respirations and a steady heart rate at ten minutes.

Q2. What actions are needed to reduce the risk of


perinatal transmission of: (a) Hepatitis B (3 marks)

____________________________________________________________
_____

(b) HIV infection (3 marks)


____________________________________________________________
_____

____________________________________________________________
_____

Over the next 48 hours the infant is irritable and has


moderate respiratory distress requiring 60% oxygen to
maintain satisfactory blood gases.

At 48 hours of age the child develops a generalised


tonic/clonic seizure. Blood sugar is 4.5 mmol/L. The
seizure stops spontaneously after 5 minutes.

Q3. What is the most likely cause of the seizure? (2


marks)

____________________________________________________________
_____

Q4. Concerning the seizure, list immediate


investigations should be undertaken?

(3 marks)

____________________________________________________________
_____

____________________________________________________________
_____

The infant gradually recovers and establishes a


satisfactory feeding pattern. The infant is ready for
discharge on day of life 10.

Q5. List specific discharge instructions you will give


his parents? (5 x 1 marks)

____________________________________________________________
_________
At one year old the child presents acutely to the
Emergency Department.

He appears pale, is crying and miserable; temperature


normal.
He is noted to have symmetrical painful swelling of the
hands and feet.

Q6. What is the most likely diagnosis? (4 marks)

____________________________________________________________
________Q7. Outline your:

Immediate investigations (3 x 1 marks)

____________________________________________________________
_________

Q8: Outline your: Immediate management (3


x 1 marks)

_____________________________________________________________________

End

MEQ:
Peter is a previously healthy 4 year old. He presents to his
GP with a fever, sore neck and will not eat but is managing
to drink. There is no meningism but he does have tender
cervical lymphadenopathy. He has a diffuse sandpaper-like
erythematous rash on his face, neck, trunk and especially in
his axilla. There is peri-oral pallor, a strawberry tongue and
marked tonsillitis.

(1) What is the most likely clinical diagnosis?

_________________________________________________________[ 1
]

(2) What organism is this condition usually due to?

_________________________________________________________[ 1
]

1. What is the most specific treatment?

__________________________________________________________[ 1
]

1. For how long is this treatment required? (state a single


figure in days)

_________________________________________________________[ 1
]

Peter rapidly recovers but 2 weeks later he is


brought back to his GP because he has suddenly
developed puffiness around his eyes. His mother
has noticed that he has not passed much urine in
the last 24 hours and the urine he passed was
smokey in appearance.

1. What is the most likely diagnosis?


_________________________________________________________[ 1 ]

(6) Peter is referred to A&E. List 2 simple urine tests


that would help you

confirm this diagnosis.

(i)____________________________________________________[ ]

(7) State the expected results of the 2 tests requested

(i)____________________________________________________[ ]

8) List 4 important immediate blood investigations

(i)_______________________________________________________[
]

(9) State the expected results of the 4 tests


requested
(i)_______________________________________________________[
]

(10) While in the A&E Department Peter has a generalised


seizure. What is the most likely reason?

_________________________________________________________[ 1
]

How is it treated?
_________________________________________________________[ ]

(11) What is the prognosis for a complete


recovery (state a single percentage figure,

not a range)?

_________________________________________________________[ 1
]

Peter completely recovers from this illness. Several


years later Peter, now aged 6 years and weighing 20
kg, is admitted to the Surgical Ward and has his
perforated appendix removed. Peter returns to the
ward at 11 pm and is warm, well perfused and
appears correctly hydrated. He is keen just to sleep
and not be disturbed. As he will receive nothing
orally overnight the nurse requests you to prescribe
IV fluids.

(12) What IV fluid should be prescribed?

_________________________________________________________[ 1
]

(13) If you were prescribing full maintenance


fluids, what should the hourly

rate be?

_________________________________________________________[ 1
]

(14) Given Peters current clinical situation


(currently well hydrated and no vomiting but in immediate
post-operative state) what adjustment should be made to
this rate of fluid administration?

_________________________________________________________[ 1
]

End

MEQ:

You are called to see a 9-month old boy in the emergency


department. He became limp and unresponsive ten
minutes ago and has been having generalised rhythmic
jerking of all four limbs and his face since that time.

List your priorities in initial urgent emergency


management. (5 marks)

____________________________________________________________
_________

It is noted that he has a temperature of 40 oC. His vital


signs are otherwise stable.

Outline your priorities in management and clinical


evaluation (3 marks)
____________________________________________________________
_________

There is no clear focus for his fever on clinical


examination. Temperature has now come down to 38oC
and he is conscious and alert. Mother says that he was well
until 15 minutes ago.

Which items are important in history at this point?


(2 marks 4 x 0.5)

History discloses no relevant findings. He is now becoming


more alert and oriented but remains febrile.

What immediate investigations should be carried


out? (3 marks)

____________________________________________________________
_________

Investigations reveal an elevated white cell count. The


urine is cloudy and is positive for nitrates, leucocytes and
protein on dip testing and shows heavy pyuria on
microscopy.

What is the likely diagnosis? (1 mark)

What further investigations should be undertaken


before treatment is commenced? (1 mark)

____________________________________________________________
_________

What is the initial treatment that you would


recommend? (2 marks)

____________________________________________________________
_________

Should imaging be carried out? If so, which test or


tests? (2 marks)

____________________________________________________________
_________

Subsequently, the child is found to have Grade 3 Vescico-


ureteric reflux on the left with a scarred, shrunken left
kidney (with 20% of renal function). Another doctor has
recommended daily prophylactic trimethoprim for 2 years.
The parents are worried about side effects and are
reluctant to treat him with antibiotics long term.

What is your advice and how do you justify this


advice? (2 marks)

What are the long term risk of a scarred kidney? (2


marks)

____________________________________________________________
_________

____________________________________________________________
_________

The parents are worried that the unconsciousness and


jerking may happen again.

What advice do you give them on discharge as


regards management of fever (2 marks)or fitting (2
marks) ?

____________________________________________________________
_________

Over the next year, he has 3 further similar episodes, all


lasting less than 5 minutes, not associated with urine
infection.

Parents are concerned that these may lead to brain


damage, and someone has told them that he should be on
regular anti-convulsant treatment.

How do you advise, justify your advice? (3 marks)

____________________________________________________________
_________
End

MEQ:

Helen, a 13 year old with a six year history of hay fever, is taken by
ambulance to her local hospital with sudden onset of shortness of
breath and wheeze following a game of hockey at her school. When
she arrives, she is struggling to speak and looks centrally cyanosed.
A pulse oximeter reads 87%. A medical colleague suggests doing an
arterial blood gas to check if she is hypoxic and what amount of
oxygen to give.

Why would a blood gas be unhelpful in this situation? (2 marks)

A staff nurse gives Helen some oxygen through a mask and sits her
on an examination bed.

What treatment would you administer immediately? (2 marks)

Helen responds well to this treatment and is now able to speak but
has a loud wheeze heard throughout her chest. She still needs
oxygen to maintain her peripheral saturations above 93%.

What information from the brief history above would support the
diagnosis of an acute asthma attack in Helen and why?(2 marks)

In A&E, Helen is given further treatments including some soluble


prednisolone. Her condition continues to improve, she no longer
needs the oxygen to maintain her saturations and she is transferred
to the ward. Further history reveals that Helen has had a blue
inhaler from her GP for six months to take for recurrent wheeze. The
doctors decide to start her on some long term preventative
treatment for her asthma.
What type of inhaler would they prescribe?

How does this work?

Helen is taking her blue reliever inhaler directly into her mouth.

Who can give Helen advice about her inhaler technique?(1 mark)

What is the most appropriate way for her to take her inhalers?(1
mark)

End

MEQ:
Six year old Bradley arrived in outpatients unable to move. For the
last 10 months he been increasingly immobile and had seen his GP,
gone to A&E, and seen an Orthopaedics doctor who had diagnosed
irritable hip, viral infections and growing pains. He was now being
carried everywhere and had fixed flexion deformities in his knees
and elbows. He wasnt gaining weight and had stopped growing

1. Give three symptoms which may help distinguish inflammatory


from mechanical joint pain
3 points

2. What non-articular symptoms are important to ask about in a


child with joint symptoms?Having taken a full history, the doctor
went on to examine Bradleys joints.

3. What are the main actions the doctor did when examining his
joints?2 points

Almost all of Bradleys joints including his elbows, wrists, fingers,


knees, ankles and toes were found to be warm, swollen, and very
painful and restricted to move
4. What is the most likely clinical diagnosis for Bradleys problem?2
points

5. Bradley was treated initially with intra-articular steroid injections of


the large joints affected and commenced on a disease-
modifying agent. Which drug would be the first line treatment
of choice for Bradley? 1 point

Having made a diagnosis and started treatment, his family had


many questions as to what would happen next. They were worried
about starting back at school, his lack of mobility and getting him
walking again, side effects of his medication, impact of his disease
on the rest of his family, and so forth.

6. What is the best approach to managing a patient like Bradley to


optimise his disease control, maximise function, and address
the needs of the family? 1 point
End

MEQ:
Dean is six years of age. He was born at 28 weeks gestation and
was in hospital for the first 4 months of his life. At eighteen
months, he is diagnosed with cerebral palsy.

1. What is the definition of cerebral palsy? 2 marks

There are concerns about his motor skills.

2) What gross motor skills would you expect an average 18


month old to achieve? (2 marks)

He was found at assessment to have markedly increased adductor


tone in his legs and to have brisk knee jerk reflexes.

3. What do these clinical signs suggest? (2 marks)


4. What type of cerebral palsy is a sequelae of pre-term birth and
would be consistent with his bilateral signs. (2 marks)

With support from the child development unit, Dean has made
excellent progress. Dean can now walk but occasionally needs
support. He has excellent understanding but his speech is poor.
When Dean is five years old the family move and he attends a new
school. The school feel that although Dean is able to do the work
given, he has a limited attention span and is very disruptive in class.

5. What can the school apply for to help with Deans education (2
marks)

MEQ:

A mother brings her 10 month old son to the GP, because she is
worried about his weight. Jake was born at term and is her first
child. She is a single parent but gets good support from her family,
in particular her elder sister, who has three children. She works full-
time and Jake is looked after by another sister during the day. He
has always been a vomiting baby but this improved when he was
weaned onto solid food. Over the past month however the vomiting
has worsened and is three or four times a day (particularly after a
bottle of milk).

He weighs 7.5 kg and the Practice Nurse measures his length which
is 73 cm. His birth weight was 3.9 kg.

1. On what centile was his birth weight? (1 mark)


2. On what centile is his current weight? (1 mark)

3. On what centile is his height? (1 mark)

4. How would you describe this pattern of weight gain? (1 mark)

5. What can the GP ask for that might contain more information on
his weight pattern?

(1 mark)

The GP feels Jake is very pale and organises for him to have some
blood tests. The results show a haemoglobin of 7.2 G/dL and a MCV
of 72

6. What is the most likely diagnosis? (2 marks)

The GP refers Jake and his mother to a Paediatrician, who sees them
the following week. The Paediatrician is worried about the mothers
relationship with Jake and feels that she handles him roughly.

7. Who, aside from the GP, could the Paediatrician contact to gain
more information on the family situation (1 mark)

The Paediatrician organises an investigation to exclude gastro-


oesophageal reflux

8. What investigation would be appropriate in this age group (2


marks)

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