1. A 6-year-old girl is brought to your office
A 6-year-old girl is brought to your office
with her parents. Her parents are worried
about her pubic hair and early puberty.
She is health otherwise. On examination,
there are tanner stage 1 pubic hair
(villous, absent pigmented or coarse
hair). There is no breast growth and her
height is normal for her age.
Which ONE of the following is the most
appropriate next step in the examination?
a. Follow up visit in 6 months
b. Check serum FSH/LH
c. Bone age X-ray
d. Pelvic CT scan
e. Vaginal examination with the help
of nurse
Answer detail:
The correct answer is a.
This patient has developed isolated
growth of pubic hair before the age of 8
years. It is also called premature
adrenarche.
Usually there is no virilization and there
is no breast development. No
investigations ore required in most of
the cases and only follow up is required
in case child starts developing any
features of congenital adrenal
hyperplasia.
Precocious puberty is characterized by
appearance of following features before
the age of 8 years in girls:
- Development of secondary sexual
characteristics.
- Accelerated growth velocity.
- Inappropriate sexual behavior.
- Mood disorders.
Investigations of suspected precocious
puberty in a child include serum FSH,
LH, testosterone (males), estradiole
(females).
Consider bone age x-ray (left wrist and
elbow) and MRI if FSH and LH arc
increased.
2.
with her parents. Her parents are worried
about her pubic hair and early puberty.
She is health otherwise.
On examination, there are tanner stage 1
pubic hair (villous, absent pigmented or
coarse hair). There is no breast growth
and her height is normal for her age.
Which ONE of the following is the most
appropriate next step in the examination?
a. Follow up visit in 6 months
b. Check serum FSH/LH
c. Bone age X-ray
d. Pelvic CT scan
e. Vaginal examination with the help
of nurse
Answer detail:
The correct answer is a.
This patient has developed isolated
growth of pubic hair before the age of 8
years. It is also called premature
adrenarche.
Usually there is no virilization and there
is no breast development. No
investigations ore required in most of
the cases and only follow up is required
in case child starts developing any
features of congenital adrenal
hyperplasia.
Precocious puberty is characterized by
appearance of following features before
the age of 8 years in girls:
- Development of secondary sexual
characteristics.
- Accelerated growth velocity.
- Inappropriate sexual behavior.
- Mood Disorders.
Investigations of suspected precocious
puberty in a child include serum FSH,
LH, testosterone (males), estradiole
(females).
Consider bone age x-ray (oft wrist and
elbow) and MRI if FSH and LH are
increased.

3. Which of the following is the indication for
prostaglandin E-1 in a neonate?
a. Transposition of great arteries
b. Hyperplastic left heart syndrome
c. Patent ductus aretriosus
d. Renal failure
e. Cardiac failure
Answer detail:
The correct answer is a.
Prostaglandin (PGE-1) is indicated in
cardiac lesions that depend on patent
cactus arteriosus to maintain adequate
pulmonary or systemic blood flow or to
promote adequate mixing.
These include:
1-Pulmonary atresia with intact
ventricular septum.
2-Tricuspid atresia with intact
ventricular septum.
3-Critical coarctation of aorta.
4-Hypoplastic left heart syndrome.
5-Transposition of great arteries.
PGE-1 is riot indicated in hyper-plastic
left ventricular syndrome, patent ductus
arteriosus, renal failure and heart
failure.
4. You are working in a neonatal unit as an
intern. One of your patients developed
hypoglycemia, and you have given
2m1/kg of 10% dextrose.
Which one of the following is not
associated with neonatal hypoglycemia?
a. Hepatomegaly
b. Micropenis
c. Mid-line defects
d. Macrosomia
e. Undescended testes
Answer detail:
The correct answer is e.
Undescended testes are not associated
with syndromes causing hypoglycemia.
Hepatomegaly is associated with
glycogen storage diseases and fatty acid
oxidation disorders. It can cause
hypoglycemia.
Micropenis shows congenital
gonadotropin deficiency and possible
pituitary abnormalities. This may result
in cortisol deficiency. This may result in
hypoglycemia.
Congenital pituitary deficiency can be
associated with midline defects such as
cleft lip, cleft palate, single central
incisor, and micro-ophthalmia.
Hypoglycemia may be seen in these
children as well due to pituitary failure.
Macrosomia occurs in infants of diabetic
mothers and infants with severe
congenital hyperinsulinism.
Hypoglycemia is seen very commonly in
neonates with a maternal history of
gestational diabetes and macrosomia.
5. A 10-year-old male child is brought in by
his mother for ongoing exercised-induced
asthma despite being on maximum dose
of inhaled corticosteroids.
What would be next step in his
management?
a. Refer to respiratory physician
b. Add leukotriene receptor antagonist
c. Cease inhaled steroids and start
intravenous steroids
d. Add long acting beta2 agonist
e. Add short acting beta2 agonist
Answer detail:
The correct answer is b.
Children with ongoing exercise-induced
asthma despite being on maximum dose
of inhaled steroids, should be given
leukotriene receptor antagonists as
these are superior and more effective
than long-acting beta-2 agonists.
Long acting beta-2 agonists induce
tolerance to short acting beta-2
agonists in children with asthma and
result in exacerbation of asthma
symptoms.
Adding short-acting beta-2 agonist is
not correct as it is not preventer
medication for asthma.
Intravenous steroids are required only
in hospital settings for severe asthma
symptoms. Refer to respiratory
physician is required if there is any
doubt in diagnosis or symptoms remain
uncontrolled despite all step-up therapy
6. A 2-year-old male child is brought to your
clinic with a 3 day history of fever,
occasional cough and coryza. Upper
respiratory tract infection of viral
aetiology is suspected on clinical history.
On physical examination, patient is noted
having down-slanting of palpebral
fissures, widespread eyes, and low-set
ears. Patient was also noted having short
stature.
All of the following are consistent with
this condition except?
a. Pulmonary valve stenosis
b. Myopia and ectopic ocular lens
c. An autosomal disorder involving
mutation in chromosome 11
d. Webbed neck
e. Abnormalities in cardiac conduction
and rhythm
Answer detail:
The correct answer is b.
This clinical picture is suggestive of
Noonan syndrome. This is an autosomal
dominant disorder with mutation of
chromosome 11. It -as deep described
as a male Turner's syndrome but affects
both sexes. Clinical features include the
following:
1- Characteristic faces - down-slanting
palpebral fissures, widespread eyes,
low-set ears + ptosis.
2- Short stature
3- Pulmonary valve stenosis.
4- Webbed neck.
5- Failure to thrive, usually mild.
6- Abnormalities of cardiac conduction
and rhythm.
7- Intellectual disability.
Myopia and ectopic ocular lens is
consistent with Marfan syndrome and
these are not associated with Noonan
syndrome.
7. A 2-year old girl presented with fever,
neck stiffness, lethargy, and rhinorrhea
for last two days. She has a history of
meningococcal vaccine as part of routine
childhood immunization.
On examination, she is febrile with
positive Kernig's sign.
What is the most likely diagnosis?
a. Bacterial meningitis
b. Viral meningitis
c. Subarachnoid hemorrhage
d. Meningioma
e. Atypical viral illness
Answer detail:
The correct answer is a.
The most likely clinical diagnosis is
meningitis. This child has all the clinical
features suggestive of bacterial
meningitis including fever, neck
stiffness and positive kernig's sign.
The bacterial meningitis should be
assumed until proven otherwise and
emergency treatment should be
commenced as soon as possible without
waiting for investigations.
The history of meningococcal vaccine
does not provide 100% immunity and
does not exclude the possibility of
bacterial meningitis.
Meningococcal bacteria (Neisseria
meningitides types A, B, C, Y and W135)
are responsible for most meningococcal
diseases worldwide.

Groups B and C are the most important
groups in Australia. There is vaccine
available in Australia against group C
meningococcal bacterial but not against
group B meningococcal bacteria.
Although vaccine reduced incidence of
meningococcal disease in the
individuals who are vaccinated it does
not provide herd immunity.
So this child can still have bacterial
meningitis despite having been
vaccinated.
Also, it is mandatory to have
cerebrospinal fluid analysis to exclude
bacterial meningitis.
All other options are incorrect.
8. A mother brings her 2-week-old male
child with noisy breathing which gets
worse when the baby is lying on his back.
The child is well otherwise.
What is the most likely cause of this
presentation?
a. Acute asthma
b. Laryngomalacia
c. Croup
d. Acute bronchiolitis
e. Acute epiglottitis
Answer detail:
The correct answer is b.
Laryngomalacia is a congenital
softening of the tissues of the larynx
above the vocal cords. This is the most
common cause of noisy breathing in
infancy. The laryngeal structure is
malformed and floppy, causing the
tissues to fall over the airway opening
and partially block it.
Laryngomalacia symptoms are usually
present at bill, and can become more
obvious within the first few weeks of
life.
Most children outgrow laryngomalacia
by 18 to 20 months of age. Symptoms of
laryngomalacia include:
1- Noisy breathing-an audible wheeze
when a baby inhale. It is aften worse
when the baby is agitated, feeding,
crying or sleeping on his back.
2- High pitched sound
3- Difficulty feeding.
4- Poor weight gain.
5- Choking while feeding.
Acute asthma makes breathing difficult
and wheeze is audible in any position
baby adopts. The child usually looks
unwell and it is uncommon before 6
months of age
Croup is acute inflammation of the
upper and lower respiratory tracts most
commonly caused by parainfluenza
virus type 1 infect on. It is characterized
by a barking cough and inspiratory
stridor. Croup affects mainly children
aged 6 months to 3 years.
Bronchiolitis is an acute viral infection
of the lower respiratory tract affecting
infants less than 24 months and is
characterized by respiratory distress,
wheezing, and crackles. It is primarily
caused by the respiratory syncytia virus.
Treatment is supportive with 02 and
hydration. Prognosis is generally
excellent, but some patients develop
apnea or respiratory failure. This baby
does not have these symptoms.
9. What would be the most ominous sign in
a child with croup?
a. Degree of stridor
b. Increase in temperature
c. Subcostal retraction and use of
accessory muscles
d. Loudness of stridor
e. Low oxygen saturation
Answer detail:
The correct answer is c.
The croup is a viral illness and is
characterized by following symptoms:
- Barking cough
- Inspiratory stridor
- Widespread wheeze
- Work of breathing is increased
- Fever with no signs of toxicity
The loudness of the stridor is not a good
guide to the severity of the obstruction.
Hypoxemia is a late sign of significant
upper airways obstruction.
It is most common in 1 to 3-year-old
children and has the duration of 2 to 5
days. Parainfluenza viruses are the
most common cause of croup, and
antibiotics are not indicated.
The severity of croup is defined in
research studies by the Westley score
but key features are:
1-Mild airway obstruction: mild chest
wall retractions and tachycardia, but no
stridor at rest.
2-Moderate airway obstruction: stridor
at rest, chest wall retractions, use of
accessory respiratory muscles and
tachycardia.
3-Severe airway obstruction: persistent
stridor at rest, increasing fatigue,
markedly decreased air entry, marked
tachycardia.
10.Which of the following is a risk factor for
early onset neonatal sepsis?
a. Artificial ventilation with an
endotracheal tube
b. Previous baby with GBS infection
c. Extreme prematurity
d. Total parenteral nutrition
Answer detail:
The correct answer is b.
Neonatal sepsis is categorized as either
early onset defined as up to 48 hours
after birth and late onset sepsis if it
happens after 48 hours of birth.
Risk factors for early onset sepsis
include:
- Maternal group B streptococcus
colonization in current pregnancy.
- A previous baby with GBS infection.
Risk factors for late-onset sepsis:
- Artificial ventilation with an
endotracheal tube.
- Extreme prematurity.
- Total parenteral nutrition.
Central catheter if present also becomes
a reason for late-onset neonatal sepsis
11.An 8-year-old boy is brought to the
emergency department with photophobia,
irritability and neck stiffness.
Lumbar puncture was performed and
cerebrospinal fluid analysis show 50
neutrophils, 100 lymphocytes, normal
proteins and normal glucose.
Which of the following is the most likely
diagnosis?
a. Tuberculosis meningitis
b. Bacterial meningitis
c. Viral meningitis
d. Normal CSF findings
e. Encephalitis
Answer detail:
The correct answer is c.
This patient has developed clinical
symptoms of meningitis and CSF
analysis shows it to be most likely a
viral meningitis.
Please click on the image attached to
find out diagnostics of CSF analysis.
12.A 15-year-old child has recently been
diagnosed with type I diabetes mellitus.
She is very motivated to learn about her
 diet changes, to help her managing her
diabetes.
What is the most appropriate advice?
a. Avoid high protein diet
b. Avoid low carbohydrate diet
c. Take foods with high glycemic index
d. Increase intake of saturated fats
e. Avoid mono-unsaturated fats
Answer detail:
The correct answer is a.
The patients with type 1 diabetes
mellitus should avoid high protein and
should consider low carbohydrate diet.
She should consider reducing intake of
saturated fats and substitution of
saturated fats with monounsaturated
and polyunsaturated fats.
13.A mother of one week old neonate is on
methadone programed. She is concerned
about the risk of methadone to her baby
as she plans to breast-feed her baby.
Which of the following is the most
appropriate advice?
a. Breast feeding is contraindicated
b. She should breastfeed the baby
before taking methadone dose
c. She should use formula milk mixed
with breast milk
d. Leave methadone program for four
months and then rejoin
e. Continue methadone program and
continue breastfeeding
Answer detail:
The correct answer is e.
Various studies have shown that the
amount of methadone transferred
through milk is low even at higher doses
of methadone.
So it is unlikely to result in toxicity to
infant. Also it may help to lessen the
symptoms of neonatal abstinence if
mother was on methadone before
delivery of the baby.
14.A mother brings her 3 weeks old son with
history of excessive clear discharge from
both eyes and crusting over the
eyelashes. There is no redness or
irritation around the eyes.
What is the most likely diagnosis?
a. Conjunctivitis
b. Nasolacrimal duct obstruction
c. Glaucoma
d. Allergic reaction
e. Meningitis
Answer detail:
The correct answer is b.
This neonate has symptoms of blocked
or narrow nasolacrimal duct.
Clear eye discharge and occasionally
crusting over the eyelashes without
redness or irritation are commonly seen
in newborn and infants and result from
narrow or obstructed nasolacrimal
ducts.
This condition usually resolves
spontaneously and requires antibiotics
only when complicated by infection
(conjunctivitis or dacryocystitis).
Ophthalmologic consultation for
nasolacrimal duct probing is appropriate
if this problem persists past 12 months
of age or earlier if complicated by
recurrent infection.
15.Bronchiolitis is a viral illness which results
in a variety of respiratory symptoms in
children younger than two years of age.
Which one of the following is considered
to be at high risk of airway compromise if
developed bronchiolitis?
a. Infants younger than three months
of age
b. Term babies
c. Maternal smoking
d. First degree relative with asthma
e. Another sibling with history of
bronchiolitis in past 12 months
Answer detail:
The correct answer is a.
Bronchiolitis is a viral illness caused by
a respiratory syncytial virus.
In the presence of following risk
factors, the risk of airway compromise
goes higher and thus these children
should be admitted to the hospital if
they develop bronchiolitis:
- Infants under three months of age
(risk of apnea).
- Preterm or low birth weight infants
- Infants with chronic lung disease.
- Infants with congenital acyanotic
heart disease.
16.A 6-months-old male child is brought to
the emergency department by his
parents, for assessment of his breathing
difficulty and irritability. On examination,
the temperature is 38.3c, heart rate is
140 beats per minute, oxygen saturation
is 97% on room air and respiratory rate is
24 breaths per minute.
There are bruises on the chest wall and
he is using accessory muscles. The chest
x-ray is done which shows posterior rib
fractures and right middle lobe
pneumonia. The treatment of pneumonia
is carried out as per local protocol.
What is the most common cause of this
type rib fractures?
a. Non-accidental injury
b. Cardiopulmonary resuscitation
c. Birth injuries
d. Osteogenesis imperfect
e. Pneumonia
Answer detail:
The correct answer is a.
The commonest cause of the posterior
rib fractures is a non-accidental injury.
There is usually no history of trauma
under these circumstances or the
history is inconsistent with the
presentation.
There are rare causes of the rib fracture
in children which include
cardiopulmonary resuscitation, birth
injuries and osteogenesis imperfect.
The pneumonia is never a cause of rib
fractures.
The case needs to be notified of the
child protection services. The
notification is a mandatory and legal
requirement.
17.An 11-year-old male child is brought to
emergency following a fall into an unfilled
swimming pool and hit his head on the
concrete surface. Vital signs include heart
rate of 86/min, respiratory rate of 19/min
and is hypotensive (50/30 mmHg)
despite adequate fluid resuscitation. CT
scan of the head is normal. Chest
examination is clear.
What is most likely diagnosis?
a. Neurogenic shock
b. Hypovolemic shock
c. Obstructive shock
d. Cardiogenic shock
e. Inadequate fluid resuscitation
Answer detail:
The correct answer is a.
This patient is most likely suffering from
neurogenic shock. Loss of sympathetic
tone prevents the expected tachycardia
response.
The hallmarks of neurogenic shock are
hypotension with either bradycardia or
normal heart rate despite fluid
resuscitation.
If the hypotension cannot be corrected
with fluids only, vasopressor therapy
may be required.
As chest examination is clear, it is
unlikely obstructive shock (cardiac
tamponade, pneumothorax). Also it is
unlikely to be primary cardiogenic or
hypovolemic shock.
Inadequate resuscitation is not a
correct option as information provided
indicated adequate fluid given.
18.A 6-year-old male Aboriginal child has
ingested 2 lithium batteries 2 hours ago.
Chest and abdominal X-rays confirmed
the position of the batteries in
esophagus. His Parents are quite anxious.
What will you consider next?
a. Emergency endoscopic removal
b. Watch for the passage for 3 days
c. Serial chest and abdominal x-rays
d. Urgent laparotomy
e. Reassure the parents
Answer detail:
The correct answer is a.
If a child is ingested lithium batteries
and if these are 'n esophagus, it
requires emergency endoscopic removal
within 6 hours (as soon as possible).
Otherwise electrical current generate by
these batteries can lead to destruction
of mucus membrane and perforation of
the esophagus in less than 6 hours.
All other options are incorrect.
19.A mother brings her 3 year-old male
Aboriginal child for passing loose stools
over last 2 weeks. The child lost 2 kg
weight after the onset of diarrhea. Child
looks fatigued. Clinical examination is
remarkable for mild dehydration.
What is the most likely diagnosis?
a. Lactose intolerance
b. Food poisoning
c. Coeliac disease
d. Cystic fibrosis
e. Giardiasis
Answer detail:
The correct answer is e.
This child has signs and symptoms
consistent with diagnosis of Giardiasis.
It is caused by a parasite called as
Giardia lamblia.
Symptoms of Giardiasis include:
1. Diarrhea, which may he watery,
usually lasting more than 1-2 weeks.
2. Weight loss.
3. Frequent loose or pale, greasy stools
which may float in the toilet bowl. 4.
Fatigue.
Lactose intolerance may develop in 20-
40% of cases of giardiasis and lost
severer weeks. However it is not
primary diagnosis here.
Coeliac disease presents after
introduction of glutin-containing solid
diet in a child during weaning. It starts
during first year of life.
Cystic fibrosis presents with frequent
respiratory and gastrointestinal
infections from the birth. This child was
previously healthy, so cystic fibrosis is
unlikely diagnosis.
20.A mother calls you on phone about her 8-
year-old son with type 1 diabetes
mellitus. Child is not feeling well and is
still conscious. His blood sugar is 2.1
mmol/L.
What is the immediate next step?
a. Give him insulin
b. High carbohydrate diet
c. Give him glucagon
d. Call ambulance and reach
emergency department as soon as
possible
e. Reassure her that things are still in
control
Answer detail:
The correct answer is b.
Young children with type 1 diabetes are
particularly at risk for severe
hypoglycaemia because their exercise
and food intake are not predictable,
they have increased sensitivity to
insulin, and it may not be possible to
make sufficiently small adjustments to
their insulin regimen.
If the patient is conscious and able to
drink and swallow safely, a rapidly-
absorbed carbohydrate (glucose tablets,
glucose gel, table sugar, fruit juice, or
honey) should be given by mouth.
This process may be repealed in 10 to
15 minutes.
Infants and children with altered
consciousness and inability to swallow
rapidly absorbed carbohydrate safely,
should be treated with intravenous
dextrose.
While placing the intravenous lines,
subcutaneous or intramuscular
glucagon should be considered.
21.A mother of an Aboriginal neonate visited
you for advice about the BCG vaccine and
tuberculosis.
Which of the following is incorrect with
regard to the BCG vaccine and
tuberculosis among Aboriginal and Torres
Strait Islander people?
a. Aboriginal and Torres Strait
Islander people suffered from
tuberculosis 20 times the rate of non-
Indigenous Australian-born people
b. BCG vaccine is found to be effective
in preventing pulmonary tuberculosis
c. BCG vaccine protects against
disseminated tuberculosis in young
children
d. It is usually administered to eligible
infants by trained staff
e. BCG vaccination is administered
intradermal
Answer detail:
The correct answer is b.
In the past, Aboriginal and Torres Strait
Islander people have suffered from
much higher rates of tuberculosis, more
than 20 times the rate of non-
indigenous Australian born people in
some areas.
While there have been substantial
improvements in disease rates in recent
decades, tuberculosis remains more
common in Indigenous than non-
Indigenous Australian born people in
many parts of Australia, particularly
northern and central Australia.
Although there is uncertainty about the
efficacy of BCG in preventing pulmonary
tuberculosis, it provides substantial
protection against disseminated forms
of the disease in young children is not
effective in complete prevention of
pulmonary tuberculosis.
BCG is therefore recommended for
Aboriginal and Torres Strait Islander in
regions of high incidence.
It is usually administered to eligible
infants by hospital staff (midwives or
nurses who have been specially trained)
soon after delivery.
Injection technique is particularly
important for BCG vaccination which
must be administered intradermally.
Adverse events, such as regional
lymphadenitis, are less common when
administration is performed with proper
technique.
22.A 6-year-old girl is accompanied by her
parents. They are worried about her as
she started developing her pubic hair,
breasts and displays inappropriate sexual
behavior.
On examination, She height is more for
her age and she has breast and pubic
hair at Tanner stage 3.
What will do next?
 a. Reassure
b. Follow up in 6 month
c. Serum FSH, LH
d. MRI brain
e. Monitor growth velocity
Answer detail:
The correct answer is c.
This girl has diagnosis of precocious
puberty and needs investigations to find
out the cause.
Precocious puberty is characterized by
appearance of following features before
the age of 8 years in girls:
- Development of secondary sexual
characteristics.
- Accelerated growth velocity.
- Inappropriate sexual behavior.
- Mood disorders.
Investigations of suspected precocious
puberty it this girl, include serum FSH,
LH and estradiol (females).
Consider bone age x-ray (left wrist and
elbow) one MRI if FSH and LH are
increased.
23.Which of the following is the best
screening test for developmental
dysplasia of the hip at 8 months of age?
a. Ultrasound
b. CT
c. MRI
d. X-ray
e. Abnormal hip examination
Answer detail:
The correct answer is d.
The x-ray of the hip is the invest gallon
of choice for screening developmental
dysplasia of the hip in beyond six
months of age.
All babies with risk factors for
developmental dysplasia of the nip
(Breech presentation, Oligohydramnios,
Family history of DDH and Underlying
neuromuscular dysfunction) or with an
abnormal examination of the hip should
undergo a hip ultrasound and referral to
an orthopedic surgeon.
During first six months of age, the
ultrasound of the hip is the
investigation of choice.
24.An 18-year-old girl presented with
delayed puberty. She is at Tanner stage 2
now. Which of the following is the initial
investigation of choice in this situation?
a. Chromosomal analysis
b. Serum FSH and LH level
c. Thyroid function
d. ESR
e. Bone age
Answer detail:
The correct answer is e.
This patient presented with delayed
puberty which is arrested at Tanner
stage 2. Tanner stage 2 is usually seen
in girls between 9 to 13 years of age
and Tanner stage 5 is seen at 16 years
of age. There is 5 year pubertal delay in
this patient and needs to be
investigated.
The most common cause of pubertal
delay is constitutional delay. The initial
choice of investigation is to determine
bone age by doing an X-ray of left wrist
and left hand.
Bone age determines the biological age
instead of actual age. It helps to
determine the remaining growth
potential for the adolescent. Bone age is
useful in conjunction with chronological
age and height/weight.
Bone age is usually delayed in
constitutional delayed puberty and is
normal in Turner's syndrome. Delayed
puberty is defined as lack of pubertal
development by 14 years of age for girls
and 15 years for boys.
As this patient has started pubertal
development and it is arrested at
Tanner stage 2, it is unlikely due to
hormonal disorder.
However if bone age determination is
not helpful, an endocrinologist may
consider doing serum FSH, LH, prolactin,
thyroid function tests and chromosomal
analysis.
25.A 2-week-old Aboriginal child presents
with fever. On examination, you find
bulging fontanelle. On cerebrospinal fluid
culture, streptococcus organism was
isolated.
Which of the following is the cause of this
presentation?
a. Aboriginal background
b. Malnutrition
c. Prematurity
d. Postmaturity
e. IgA deficiency
Answer detail:
The correct answer is c.
Group B Streptococcus is the most
common cause of life threatening
infections in newborn infants. Babies
may be exposed during birth to Group B
Streptococcus found normally it the
vagina.
Babies are at increased risk of
contracting meningitis or septicaemia if
(a) They are low birth weight.
(b) Premature.
(c) Born after prolonged labor.
(d) Premature rupture of membrane.
Currently there is no vaccine for Group
B streptococcus.
IgA deficiency causes increased
frequency bronchitis, chronic diarrhea,
conjunctivitis and otitis media in
children. It cues not increases incidence
of meningitis.
Aboriginal background would have been
an option if there was any vaccine
available for GBS and this child world
have missed that.
Sill it is worth mentioning that incidence
of meningitis in Aboriginal infants is
about 3% higher than rest of the
Australian population.
Similarly malnutrition and post maturity
has no proven association with
increased incidence of neonatal
meningitis.
26.A 13 year-old boy who is currently in a
special school is now at verge of
expulsion due to sudden outbursts of
anger in school and at home over a
period of last three months. What would
be the most appropriate drug
management for this situation?
a. Sodium valproate
b. Lithium
c. Haloperidol
d. Risperidone
e. Olanzapine
Answer detail:
The correct answer is d.
This child is a special child and most
likely suffers from autism considering
his behavior and requirement of special
school. Aggression and irritability can
be a feature of autism especially during
adolescence. Atypical antipsychotics
have been seen to improve behavioral
symptoms such as repetitive behavior,
hyperactivity, irritability and
aggression. Risperidone, an atypical
antipsychotic is the drug of choice for
management of anger outbursts in
children with autism in Australia and is
approved under patient benefit scheme
(PBS). Typical antipsychotics like
haloperidol can cause extra-pyramidal
symptoms and restlessness which can
further exaggerate the symptoms in
children with autism. Long-term use can
result in tardive dyskinesia. Olanzapine
is not considered as first line drug for
management of aggressive behavior in
children with autism due to side-effects
like weight gain and development of
type 2 diabetes mellitus. Lithium and
sodium valproate both are mood
stabilizers and should be used in bipolar
disorder. This patient does not have
signs or symptoms of bipolar disorder.
27.A 20-month-old baby is brought in by his
parents with chronic diarrhea and weight
loss. On examination, the baby has
growth retardation, muscle wasting and
distended abdomen with hyperactive
bowel sounds. Chest examination is clear.
Laboratory investigations show decrease
serum iron or folate levels. Patient has
been on the lactose-free diet for 3 days
without resolution of symptoms.
What is the most likely diagnosis?
a. Primary lactose intolerance
b. Coeliac disease
c. Cystic fibrosis
d. Bacterial over growth
e. Chronic liver disease
Answer detail:
The correct answer is b.
This patient has the clinical diagnosis of
coeliac disease. It presents as severe
malabsorption syndrome in children
with chronic diarrhea, failure to thrive,
muscle wasting and hyperactive bowel
sounds.
Primary lactose tolerance is due to
deficiency of lactase in a small intestine
and is a malabsorpton syndrome
presenting with abdominal rain,
boating, distension, flatulence and
watery diarrhea. It usually resolves
with a lactose-free diet foe about 2
weeks.
Cystic fibrosis is an inherited autosomal
recessive d souse and is trio most
common cause of bronchiectasis and
chronic suppurative lung disease in
Caucasian children.
Bacterial overgrowth in the small bowel
causes diarrhea and nutrient
malabsorption. Most patients with
bacterial overgrowth have intestinal
stasis associated with underlying
anatomical abnormalities including
strictures, jejunal diverticulosis, motility
disorders and various operations that
create blind loops.
Clinical manifestations of bacterial
growth include diarrhea, weight loss
and anaemia due to vitamin B12
deficiency.
28.A mother brings her 12-month old child
with history of loose watery stools for the
past few hours.
Which of the following is the most specific
indicator of severity of dehydration in this
age group?
a. Sunken eyes
b. Irritability and lethargy
c. Increased respiratory rate
d. Urine output
e. Dry mucous membrane
Answer detail:
The correct answer is c.
Specific indicators of severity of
dehydration include:
- Percentage of weight loss.
- Prolonged capillary refill time.
- Abnormal skin turgor
- Increased respiratory rate.
Following signs considered for
assessment of dehydration however
these are less reliable:
- Sunken eves.
- Lethargy
- Dry mucous membranes.
- Irritability and lethargy.
Urine output is measured to monitor the
response to fluid therapy in
dehydration.
29.A mother brings her 3-year old child with
history of uncomfortable defecation and
minimal bright bleeding on toilet paper
after defecation. On rectal examination
 with mother's consent, hard stools and
painful anal fissure noticed.
What is the immediate next step?
a. Laxatives and high fiber diet
b. Reassurance as it is normal variant
c. Apply anusol cream on the fissure
d. Abdominal X-ray
e. Abdominal ultrasound
Answer detail:
The correct answer is c.
Anal fissures are often seen in infants
and toddlers with uncomfortable
defecation and minimal bright red
bleeding. The anal mucosa is split in the
midline either anteriorly or posteriorly.
It is caused by passage of hard stools.
The fissure usually heals within few
days after application of topical anusol
cream.
Topical anusol cream is effective in
healing anal fissures in children. It
contains zinc oxide, benzyl benzoate
and balsam. Once the pain for anal
fissure is under control) advise using
laxatives and fiber diet.
No further investigations needed.
30.A one week old neonate developed severe
jaundice and mother is quite concerned
about the long term risk of severe
hyperbilirubinemia.
Which of the following is not a possible
consequence of kernicterus in this baby?
a. Hearing deficit
b. Athetoid cerebral palsy
c. Paralysis of upward gaze
d. Hypothyroidism
e. Dental dysplasia
Answer detail:
The correct answer is d.
Kernicterus is the pathogenic sign or
bilirubin staining of the brain stem
nuclei and cerebellum.
Clinical findings include:
- Athetoid cerebral palsy with or
without seizures.
- Developmental delay.
- Hearing deficit.
- Oculomotor disturbances including
paralysis of upward gaze.
- Dental dysplasia.
- Intellectual impairment.
Kernicterus does not cause
hypothyroidism in long term.
31.Which one of the following can be an
alarming sign in a 2 month old infant?
a. Inability to smile at people
b. Inability to hold neck
c. Inability to explore things by
holding, feeling and looking at them in
their hands and putting them in their
mouths
d. Does not appear to recognize their
mother
e. Does not appear interested in
activities around them
Answer detail:
The correct answer is a.
It is an alarming sign when a 2-months
old child is unable to do following
things:
1. Does not respond to loud sounds.
2. Does not watch things as they move.
3. Does not smile at people
4. Does not bring hands to mouth.
5. Cannot hold head up when pushing
up when or tummy.
So if a child at 2 months of age does not
smile at people-it is a concerning thing
for a mom and needs thorough
evaluation.
Neck holding is achieved by 3-months.
Ability to explore things by holding,
feeling and looking at them in their
hands and putting them in their mouths
is achieved by 6 months of age.
A skill to recognize mother's face is
achieved by 9 months of age.
If a child by 9 months of age, does not
appear interested in activities around
them, it is abnormal and requires
further evaluation.
32.An 18-month-old baby is brought by her
mother with a long history of vomiting
after every feed. The baby has a poor
appetite and does not eat much. Her
weight is at the 40th percentile. The rest
of the physical examination is normal.
What will be the next step in
management?
a. Intraesophageal pH probe
monitoring
b. Reassurance
c. Esophagogastroduodenoscopy
d. Intraluminal esophageal electrical
impedance
e. Start treatment and give a trial of
proton pump inhibitor
Answer detail:
The correct answer is a.
This child has a clinical diagnosis of
gastro esophageal reflux disease.
Vomiting could be cue to motility
disorder as well.
So intraesophageal monitoring of pH is
considered the next best step in
management of such cases to confirm
the diagnosis.
Reassurance is not enough as baby has
lost weight and this requires further
assessment.
Esophagogastroduodenoscopy allows
visualization of the mucosa for
diagnosis of peptic ulcer disease. It also
helps to find out H. pylori infection,
strictures, and peptic esophagitis. It
provides access to obtain biopsies for
histopathology examination. However,
this is not the required for diagnosis of
gastro-esophageal reflux disease.
Intraluminal esophageal electrical
impedance has not been thoroughly
validated and normal values have not
been determined in the pediatric age
group.
Starting treatment is an option after
confirmation of diagnosis.
33.A mother brings her 4-week-old child who
vomits after each feed. The child is
lethargic and hungry. On examination, no
epigastria mass is found.
Which of the following investigation will
confirm the diagnosis?
a. Barium meal
b. Ultrasound
c. Urine analysis
d. Abdominal X-ray
e. Stool culture
Answer detail:
The correct answer is b.
This child has provisional diagnosis of
hypertrophic pyloric stenosis. the
investigation of choice in this situation
is abdominal ultrasound.
Hypertrophic pyloric stenosis is more
common among males by a 4:1 ratio,
particularly first born males. It occurs
most often between 3 to 5 weeks of age
and rarely after 12 weeks.
Symptoms car develop between 2 sic 6
weeks of life. Projectile vomiting
(without bile) occurs shortly after
eating. Until dehydration sets in. the
child feeds avidly and otherwise
appears well, unlike many of those with
vomiting caused by systemic illness.
Gastric peristaltic waves may be visible,
crossing the epigastrium from left to
right. A discrete, 2- to 3-cm, firm,
movable, and olive-like pyloric mass is
sometimes palpable deep in the right
side of the epigastrium.
However these classic findings are not
present in every case and diagnosis
should still be suspected based on
history.
Diagnosis is confirmed by abdominal
ultrasonography showing increased
thickness of the pylorus along with an
elongated pylorus. The classic
electrolyte pattern of an infant with
pyloric stenosis is that of hypochloremic
metabolic alkalosis.
34.A newborn baby of a diabetic mother was
born with 4500 g with normal vaginal
delivery without any complication. APGAR
score at one minute was 5 and at 5
minutes, APGAR score 7.Peripheral
cyanosis was present. After few hours,
the baby was found to be jittery.
What is the investigation of choice?
a. Scalp pH
b. CT head
c. Blood sugar level
d. Electrocardiography
e. Full blood count
Answer detail:
The correct answer is c.
The 5 minute APGAR score is regarded
as more important and reflective of the
baby's overall health, than the 1 minute
APGAR score.
A total APGAR score of B-10 is regarded
as good, 5-1 can indicate that the baby
is mildly unwell, 3-4 reflects moderate
poor health and 0-2 is very poor health.
This baby has developed hypoglycemia
most likely considering the history of
maternal diabetes and macrosomia.
Maternal hyperglycemia can result in
fetal hyperglycemia and then secondary
fetal hyperinsulinism. Insulin is the
main 'growth hormone' of the fetus and
therefore infants of diabetic mothers
are often macrosomic (more than 4000
g) o large for gestational age (more
than 90th percentile).
Indication to check fetal scalp pH is to
assess degree of fetal hypoxia during
fetal distress. ECG, CT head and full
blood count are not the primarily
required investigations in this baby.
35.A 2-week-old neonate is found to have
discharge and redness in both eyes. On
examination, there is mild hyperemia
with a thick mucopurulent discharge.
What is the most likely diagnosis?
a. Chemical conjunctivitis
b. Chlamydia conjunctivitis
c. Gonococci conjunctivitis
d. Meningitis
e. Viral infection
Answer detail:
The correct answer is b.
Chemical conjunctivitis due to ocular
prophylaxis usually occurs on the first
day of life. Gonococci conjunctivitis
generally has its peak time of onset
between 3 and 7 days after birth.
By the end of the first week of life and
throughout the first month of life,
Chlamydia becomes the most frequent
cause of conjunctivitis.
So at 2 weeks of life, this neonate has
developed signs and symptoms of
chlamydia conjunctivitis.
Chlamydial conjunctivitis can vary in
severity, ranging from mild to severe
hyperemia with a thick mucopurulent
discharge and pseudo membrane
formation.
Gonococci conjunctivitis usually
presents at 2 to I days of life with
intense bilateral bulbar conjunctiva
erythema, chemosis, and a copious
purulent discharge.
All infants with gonococci conjunctivitis
require admission and evaluation for
disseminated disease.
Intravenous third generation
cephalosporin antibiotics are first lire of
management.
36.A 6-month-old male infant is brought to
the hospital by his parents. He has been
having bilious vomiting, cramp abdominal
pain, mild abdominal distension and
passing blood and mucus in the stool
over last 3 hours.
What is the most appropriate diagnosis?
a. Intestinal malrotation with midgut
volvulus
b. Congenital hypertrophic pyloric
stenosis
c. Urinary tract infection
d. Small intestinal atresia
e. Raised intracranial pressure
Answer detail:
The correct answer is a.
This clinical diagnosis in this situation is
intestinal malrotation with volvulus.
Infants often present acutely with
midgut volvulus, manifested by bilious
vomiting, cramp abdominal pain,
abdominal distention, and the passage
of blood and mucus in their stool.
Patients with chronic, uncorrected
malrotation can have recurrent
abdominal pain and vomiting.
Malrotation can also be entirely
asymptomatic.
With acutely ill patients, consider
emergency surgery laparotomy if there
is a high index of suspicion. So urgent
surgical referral should be considered to
prevent bowel gangrene.
All other options are incorrect.
37.A mother brings her 8-year old daughter
with history of truancy. The girl avoids
school and goes to games and parlors.
Her parents were advised by her teachers
to seek medical help. When you talk to
the girl, she becomes tearful and looks
withdrawn.
What do you suspect from this story?
a. Separation anxiety
b. Truancy
c. Depression
d. Conduct disorder
e. ADHD
Answer detail:
The correct answer is b.
This child has clinical features
suggestive of diagnosis of truancy.
Escaping the school and going to games
and parlors on one hand and being
tearful and withdrawn on other hand
does not fit into diagnosis of
depression.
Truancy is any intentional unauthorized
or illegal absence from compulsory
schooling. Children who run away from
school to do other things (truancy)
rather than stay home usually have
different problems from those who don't
want to go to school.
They may be wanting to get attention,
trying to impress their friends or they
may be angry because of school or
home problems. Truancy may happen
when there are learning problems.
Children who truant a lot sometimes go
on to break the law as they get older.
Children who truant usually try not to
let their parents find out truancy
sometimes happens when parents are
not very interested in the child getting a
good education, and perhaps don't get
on very well with the school
themselves.
Schools usually expect parents to
inform the school in advance if their
child will be absent through the student
diary, or by phoning the school on the
day of absence. It is a good way of
ensuring child's safety.

After 3 days of unexplained absence the
school will usually contact the parent,
as schools are required to report
student absences.
Children with depressive disorders feel
sad, lack interest in activities they
previously enjoyed, criticize
themselves„ and are pessimistic or
hopeless about the future. Thinking that
life is not worth living, they may
contemplate suicide. They may also be
irritable ant aggressive. They may
indecisive, and lave problems
concentrating. They tend to lack energy
and to have problems sleeping.
The typical behavior of those with
conduct Disorder involves bullying,
frequent physical fights, Deliberate
destruction of other people’s property.
Breaking into houses or cars, staying
out late at night despite parental
prohibition, running away from home,
or frequent truancy from school.
This child does not meet the criteria for
conduct disorder, ADHD, depression and
separation anxiety.
38.What is the risk for prenatal viral
transmission in infants born to a mother
who is positive for both HbsAg and
HBeAg?
a. 85%
b. 25%
c. 5%
d. 3%
e. No risk of transmission present
Answer detail:
The correct answer is a.
If a mother is HBsAg and HBeAg
positive, the risk for transmission of
hepatitis B to baby is 70 to 90%.
The risk is lowered significantly to 8 to
15% if mother is HBsAg positive and
HBeAg negative.
Any infant who contracts hepatitis B
during this period has more than 90%
chance developing chronic hepatitis B
infection with increasing the risk of
hepatocellular carcinoma latter in the
life.
39.A 12-year-old child has history of
recurrent urinary tract infections since
the age of 3 years. Which ONE of the
following is the investigation of choice to
rule out renal scarring?
a. Renal biopsy
b. Renal ultrasound
c. Serum urea and creatinine
d. DMSA scan
e. CT scan of abdomen
Answer detail:
The correct answer is d.
Recurrent urinary tract infection (more
than two times during childhood) can
lead to renal scarring, hypertension, and
end-stage renal dysfunction.
Vesicoureteral reflux is the usual
etiology leading to these complications.
Vesicoureteral reflux (VUR) is the
retrograde passage of urine from the
bladder into the upper urinary tract.
The dirnercaptosuccinic acid
scintography scan (DMSA) is the gold
standard for diagnosis of kidney
scarring and measurement of
differential renal functions.
Ultrasound is generally requested after
first urinary tract infection to rule out
any anatomic abnormality. It is not the
gold standard investigation to diagnose
kidney scarring.
40.A 14-year-old boy is brought to the
emergency department with fever and
painful, tender and warm knee joint. He
would not move his limb and does not
allow anyone to touch it.
a. Osteomyelitis
b. Septic arthritis
 c. Perthe's disease
d. Traumatic injury
e. Osteonecrosis
Answer detail:
The correct answer is b.
This child has a clinical diagnosis of
septic arthritis. Septic arthritis is
characterized by following main
features:
- Fever
- Acute onset of limp or refusal to use
the limb.
- Pain on movement and al rest.
- Limited range or loss of movement.
- Soft tissue redness and swelling often
present.
The child with osteomyelitis the lower
extremity is characterized by following
features:
- Sub-acute onset of limp
- Localized pain and pain on movement.
- Tenderness.
- Soft tissue redness and swelling may
be absent.
-Fever may be absent.
Referral to orthopedic surgeon is
required based on clinical diagnosis of
septic arthritis or osteomyelitis in
children.
41.A 4-year-old child is being seen in your
office with a history of 5 days of ongoing
fever and rash. On examination, his temp
is 38.2. Also, there are red injected
conjunctiva red cracked lips,
maculopapular rash, redness of palms
and soles and cervical lymphadenopathy.
What is the most likely diagnosis?
a. Scarlet fever
b. Kawasaki disease
c. Respiratory tract infection
d. Tonsillitis
e. Non-specific viral illness
Answer detail:
The correct answer is b.
This child has developed clinical
features of Kawasaki disease. It is self-
limited vacuities of unknown etiology.
Around 80% cases occur before the age
of 5 years.
The diagnosis of Kawasaki should be
considered in any child who continues
to have fever beyond five days. 1 he
other features include bilateral
conjunctivitis, oral mucosal ulcers,
cervical lymphadenopathy, redness of
hands and feet and maculopapular
generalized rash.
The other differential diagnosis is also a
possibility however persistent fever
beyond 5 days along with skin changes
in peripheries suggest Kawasaki disease
as top diagnosis here.
Kawasaki disease is associated with
vacuities which can lead to coronary
artery aneurysm.
42.A 6-year-old child has been brought to
you by parent for nighttime bed-wetting.
He has been hygiene trained and has
been dry during daytime from the age of
4 years.
Which of the following you are most likely
to find in the history?
a. Night terrors
b. History of urinary tract infections
c. History of urinary tract infection in
mother while pregnant
d. Positive family history of similar
complaints
e. Stress
Answer detail:
The correct answer is d.
Primary enuresis is defined as daytime
bed wetting after the age or 4 years or
night time bedwetting after the age of 6
years. It appears to be due to delayed
maturation of achieving bladder
continence.

This child has been dry during daytime
and thus on y suffers from nocturnal
enuresis.
Positive family history with similar
complaints is the most important risk
factor as the condition runs in the
families.
Also nocturnal enuresis is more common
in boys.
Secondary enuresis is wetting after
normal continence of at least 3 months.
It may be caused by psychological
stress-like separation from parents or
arrival of new baby.
Control of urine is usually expected by
the age of 5 in majority of the children.
After the age of 6, invest gallons
including intravenous program or
ultrasound are necessary to exclude
urinary tract abnormality.
43.A 12-year-old male child is brought in
hospital by his mother with acute
shortness of breath and wheeze. He has
background history of asthma and uses
inhalers as required.
Which of the following is the best bed-
side measure to assess the severity of
asthma?
a. Severity of wheezing
b. Response to inhalers
c. Degree of dyspnea
d. Peak expiratory flow rate
e. Pulmonary function tests
Answer detail:
The correct answer is d.
The peak expiratory flow rate (PEFR,
also known as a peak flow) is the
maximal rate that a person can exhale
during a short maximal expiratory effort
after a full inspiration.
In patients with asthma, the PEFR
percent predicted correlates reasonably
well with the percent predicted value
for the forced expiratory volume in one
second (FEV1).
Peak flow meters have a limited role in
establishing the diagnosis of asthma in
the office. However, they are very
useful in measuring the severity of
asthma exacerbation.
Peak flow readings are higher when
patients are well, and lower when the
airways are constricted
Seventy of wheeze is not reliable sign of
severity of asthma. Severe asthma
usually presents with silent chest and
low grade wheeze.
Response to inhalers and degree of
dyspnea are also very unreliable signs
to assess the severity of asthma. A
patient with mild asthma may be
equally breathless as with severe
asthma.
Pulmonary function testing is done at
specialized centers and is required to
diagnose asthma. However peak flow
measurement is quick and useful in
emergency situation to assess the
severity of asthma.
44.A 4-year-old male child is brought to the
emergency department by an ambulance
with 3 days history of fever, associated
altered consciousness. There has been
progressive personality changes and
occasional drowsiness.
An emergency lumbar puncture is done
which confirms the diagnosis of viral
meningitis.
Which of the following is the best choice
for this condition?
a. Ceftriaxone intravenously (IV)
b. Benzyl penicillin IV
c. Ciprofloxacin IV
d. Acyclovir IV
e. Cefuroxime IV
Answer detail:
The correct answer is d.
This case is suggestive of viral
encephalitis. Encephalitis is an
inflammation of brain parenchyma. It is
mainly caused by viruses although other
organism’s including bacteria,
mycoplasma, rickettsia and Histoplasma
can cause encephalitis.
Suspect it when a viral prodrome is
followed by irrational behavior, altered
consciousness and possibly cranial
nerve lesions.
In this case, the cerebrospinal fluid
analysis reveals viral meningitis thus
viral etiology is entertained.
This patient should he hospitalized and
treatment will be supportive Suspected
herpes simplex encephalitis should be
treated with intravenous acyclovir
immediately.
45.Which of the following statement is true
regarding asthma in children?
a. Inhaled bronchodilators are very
effective under age of 12 months
b. Oral bronchodilators are very
effective under age of 12 months
c. Use a spacer with face mask for
children age between 1 to 2 years
d. Most of the children do not grow
out of asthma when they become
adults e. Giving more than 6 inhaled
doses of beta-2 agonist can be life
threatening in severe asthma
Answer detail:
The correct answer is c.
Bronchodilators inhaled or oral, both are
ineffective under 12 months.
Use spacer with face mask in children
age between 1-2 years for adequate
delivery of medication.
Most of the children grow out of asthma
when they become adults and very few
continue to be adult asthmatics.
Giving 6 to 10 inhaled doses of beta-2
agonist are very safe and appropriate if
used in severe asthma.
46.What is the treatment for a child with an
altered level of consciousness who is
found to have hypoglycemia?
a. 2ml/kg of 50% dextrose IV
b. 5ml/kg of 10% dextrose IV
c. 2ml/kg of 10% dextrose IV
d. 1ml/kg of 25% dextrose IV
e. 2ml/kg of 4% dextrose IV
Answer detail:
The correct answer is c.
Any child who presents with altered
level of consciousness must have blood
glucose tested in the emergency
department.
The current treatment of hypoglycemia
in the child is 2 ml/kg 10% dextrose.
47.A 12-year-old male child is brought into
emergency department with loss of
consciousness and low blood glucose level
is 2.5 mmol/L. He has past medical
history of type 1 diabetes mellitus and is
on insulin.
What is the most appropriate
management?
a. 10% glucose intravenously
b. 5% glucose intravenously
c. 50% glucose intravenously
d. Normal saline
e. Oral sweet juice
Answer detail:
The correct answer is a.
In children with type 1 diabetes
mellitus, hypoglycemia can lead to
seizures and loss of consciousness.
The most appropriate treatment of
severe hypoglycemia (associated with
seizures, loss of consciousness) in
hospital settings include 10% glucose
intravenously 2 ml/Kg bolus followed by
sodium chloride 0.45% with glucose 5%
intravenously as maintenance fluid.
In adults with hypoglycemia, 50%
glucose solution is used for treatment of
severe hypoglycemia however in
children it is not recommended as it can
lead to death due to hyper osmolality.
Oral sweeteners are given to a child
with hypoglycemia if child is conscious
and cooperative.
All other options are incorrect.
48.A 5-year-old child with a history of
asthma is brought to your office by his
parents for advice. He had 2 episodes of
asthma since last 6 weeks and he has
been well in between the asthma
episodes. The asthma symptoms respond
to salbutamol inhaler.
What is the next step in his
management?
a. Fluticasone
b. Sodium cromoglycate
c. Salmeterol
d. Oral Montelukast
e. Keep using salbutamol as needed
Answer detail:
The correct answer is d.
This child is suffering from frequent
intermittent asthma. Frequent
intermittent asthma is a class of asthma
when the child gets more than one
episode of asthma in 6 weeks and no
symptoms in between the flare-ups.
Consider regular treatment with
Montelukast 4 mg once daily and review
response in 2-4 week. If symptoms do
not respond, consider regular treatment
with a low dose of an inhaled
corticosteroid and review response in 4
weeks.
49.A 4-week old infant was brought to your
clinic for well-baby checkup. The baby is
feeding well and gaining weight, but the
mother said she notices a bulge in his
inguinal area every time he cries. You
examined the boy but found no
abnormality.
What is the most appropriate step?
a. Refer for the surgical consult
b. Reassure the mother
c. Ask her to come back when the
bulge occurs
d. Admit to hospital
e. Request for an ultrasound
Answer detail:
The correct answer is a.
The diagnosis is an inguinal hernia. It
follows the '6-2' rule:
For reducible hernia diagnosed between
births to 6 weeks, surgery is
recommended within 2 days, 6 weeks to
6 months-surgery within 2 weeks and
over 6 months surgery within 2 months.
50.A 6-month-old male infant was brought
to your clinic due to characteristic cough
of pertussis.
What is the best advice for the patient's
parents to reduce their risk of infection?
a. Commence a 3-dose pertussis
revaccination schedule
b. Immediate booster immunizations
for pertussis
c. A 10-day course of erythromycin
d. Arrange nasopharyngeal swabs
e. Immediate immunization with
pertussis immunoglobulin
Answer detail:
The correct answer is c.
Pertussis is a respiratory infection with
an incubation period of 7 to 20 days.
In unvaccinated persons, B. pertussis is
highly infectious; spreading by aerosols
to 90% of susceptible household
contacts.
Natural infection does not provide long-
term protection and repeat infection can
occur.
Pertussis-containing vaccine is
recommended in a 3-dose primary
schedule for infants at 2, 4 and 6
months of age.
All household contacts of patients with
pertussis should receive erythromycin
for 10 days to prevent further spread of
the disease.
Cotrimoxazole is recommended for
those intolerant of erythromycin.
Since a primary vaccination course
requires three or more injections to
protect against pertussis, infant
vaccination cannot be effectively used
to protect unimmunized infants.
A booster dose of pertussis vaccine
should be considered for children aged
up to 8 years who has a contact with a
patient with pertussis however it’s
effectively is questionable and
chemoprophylaxis should be considered
for all cases.
Passive immunization with pertussis
immunoglobulin is not effective in the
prevention of pertussis.
51.What is the treatment of choice for an 8
year-old child who suffers from wolf white
Parkinson syndrome and supraventricular
tachycardia?
a. Digoxin
b. Propranolol
c. Verapamil
d. Losartan
e. Warfarin
Answer detail:
The correct answer is b.
Propranolol has replaced digoxin as the
drug of choice for treatment of children
with supraventricular tachycardia and
WPW.
Digoxin can enhance conduction
through a bypass tract while slowing
down conduction through AV node.
Ventricular fibrillation has been
reported in patients with WPW
syndrome when treated with digoxin.
Verapamil can both shorten the
effective refractory period for accessory
pathway and raise the risk of sudden
death in WPW patients should they
develop atrial fibrillation.
So in this case, both digoxin and
verapamil are contraindicated.
Losartan is angiotensin receptor blocker
and has no clinical use in SVT.
Warfarin, an oral anticoagulant is also
not used in patients with SVT. It is used
in atrial fibrillation for prevention of
thromboembolic events usually.
52.Which of the following is correct about
combination of long acting beta 2 agonist
with an inhaled corticosteroids in children
with asthma?
a. Reduces severe exacerbations
b. Increases severe exacerbations
c. No effect on asthma overall
d. Excellent for exercise induced
asthma
e. Long acting beta2 agonists
decrease the need for inhaled steroids
Answer detail:
The correct answer is b.
Combination of long acting beta 2
agonist with an inhaled corticosteroid
significantly increases the risk of
asthma exacerbations in children.
The possible mechanism by which this
happens is thought that long acting beta
2 agonists induces tolerance to short
acting beta2 agonists. This results in
diminished response to child Norma
rescue therapy with salbutamol.
Leukotriene receptor antagonists are
superior to long acting beta 2 receptor
agonists for step-up therapy in exercise
induced asthma.
Long acting beta 2 agonists increase the
need of inhaled corticosteroids in
children and child is required to be on
inhaled steroids continuously.
53.A mother brings her 2-year old child with
an episode of tonic-clonic seizure lasting
for one minute. The child also has a
history of fever with coryza for past three
days.
How will you treat?
a. Oral paracetamol
b. Reassurance
c. EEG
d. Sodium valproate
e. Rectal diazepam
Answer detail:
The correct answer is b.
This child had a simple febrile seizure
which lasted for one minute. No
treatment of seizure is required if it has
stopped itself.
Reassurance is necessary for simple
febrile convulsions. The onset of the
seizure. The convulsion may be a
terrifying experience for the parents to
observe.
Paracetamol has not been shown to
reduce the risk of further febrile
convulsions.
An electroencephalogram (EEG) is not
indicated for simple febrile seizure.
The rate of postictal EEG abnormalities
in children with complex febrile seizure
is low, and studies that have shown an
EEG abnormality have been unable to
translate this into a long term predictor
for future febrile seizure and afebrile
seizures.
Rectal diazepam is useful in the acute
management of seizures and is
indicated in following situations:
1-A child with a pattern of prolonged
seizures (usually longer than ten mins.)
which have previously responded to
intravenous or rectal diazepam. 2-A
child with clusters of repeated seizures
in whom oral treatment is inappropriate
3-A child with severe epilepsy who is
remote from emergency services.
Rectal diazepam is not necessary for
children with mild or well-controlled
forms of epilepsy. The seizure, in this
case, has resolved in less than one
minute, so rectal diazepam is not
required.
54.Which of the following is an alarming sign
in a four month old baby?
a. Inability to follow activities with
eyes
b. Inability to roll over
c. Inability to sit without support
d. Child does not show pleasure when
seeing familiar people
e. Do not recognize parent
Answer detail:
The correct answer is a.
Following are the alarming signs in a
four month old child when he/she:
1. Does not make eye contact with
people.
2. Does not turn to look for mother
when she speaks
3. Is unhappy or unsettled most of the
time.
By 5-7 months, a baby can roll from
their back to their abdomen. At four
month-this is not an alarming sign. Also
child is unable to sit without support.
This is also not an alarming sign.
At 6-9 months of age, it is concerning if
child does not show pleasure when
seeing familiar people and does not
recognize his/her parents. So these
findings are not concerning in a four
month old child.
55.A mother brings her 4 months old male
baby with lump on the upper mid-
abdomen and crying. On examination it is
epigastria hernia. Pain is reproducible on
palpation.
What will you advise her?
a. Surgical repair now
b. Surgical repair after 6 months
c. Conservative management until 4
years of age
d. Reassure mother
e. Prescribe paracetamol and review in
4 weeks
Answer detail:
The correct answer is a.
This child has developed epigastria
hernia. Epigastria hernias are a type of
hernia that develop in the upper mid-
abdomen, between the sternum and the
umbilicus.
Epigastria hernia is unlikely to close
naturally and is more likely to
incarcerate and cause pain by
strangulation.
Indications of urgent surgical repair
include pain which is reproducible on
palpation of hernia. If a child presents
with epigastria hernia and without pain,
the surgical repair should be considered
after the age of 6 months of age.
56.A mother brings her 4-week-old child who
vomits after each feed. The child is
lethargic and hungry. On examination, no
epigastria mass is found.
Which of the following investigation will
confirm the diagnosis?
a. Barium meal
b. Ultrasound
c. Urine analysis
d. Abdominal X-ray
e. Stool culture
Answer detail:
The correct answer is b.
This child has provisional diagnosis of
hypertrophic pyloric stenosis. The
investigation of choice in this situation
is abdominal ultrasound.
Hypertrophic pyloric stenosis is more
common among males by a 4:1 ratio,
particularly first born males. It occurs
most often between 3 to 5 weeks of age
and rarely after 12 weeks.
Symptoms can develop between 2 and 6
weeks of Life. Projectile vomiting
(without bile) occurs shortly after
eating. Until dehydration sets in, the
child feeds avidly and otherwise
appears well, unlike many of those with
vomiting caused by systemic illness.
Gastric peristaltic waves may be visible,
crossing the epigastrium from left to
right. A discrete, 2- to 3-cm, firm,
movable, and olive-like pyloric mass is
sometimes palpable deep in the right
side of the epigastrium.
However these classic findings are not
present in every case and diagnosis
should still be suspected based on
history.
Diagnosis is confirmed by abdominal
ultrasonography showing increased
thickness of the pylorus along with an
elongated pylorus. The classic
electrolyte pattern of an infant with
pyloric stenosis is that of hypochloremic
metabolic alkalosis.
57.A-12-year-old boy has BMI of 25. He is
generally healthy and height is normal for
his age. According to BMI chart, where he
stands in obesity classification?
a. Obese
b. Underweight
c. Overweight
d. Normal
e. Need a dietician review
Answer detail:
The correct answer is c.
Body mass index (BMI) is a measure of
general adiposity. Body mass index is
defined as the individual's body mass
divided by the square of their height.
In young children, estimates of BMI
corrected for age percentiles are used
(see Obesity in children).
BMI is classified as follows.
1. Underweight with BMI less than 18.5.
2. Healthy-18.5 to 24.9.
3. Overweight-25 to 29.9.
4. Obese-30 or more
So this child is overweight according to
BMI classification.
58.A 6-year-old girl is accompanied by her
parents. They are worried about her as
she started developing her pubic hair,
breast and displays inappropriate sexual
behavior.
On examination, she height is more for
her age and she has breast and pubic
hair at Tanner stage 3.Serum FSH and LH
both are elevated.
What will do next?
a. Reassure
b. Follow up in 6 month
c. Serum FSH, LH
d. MRI scan of brain
e. Monitor growth velocity
Answer detail:
The correct answer is d.
Precocious puberty is characterized by
appearance of following features before
the age of 8 years in girls:
- Development of secondary sexual
characteristics.
- Accelerated growth velocity.
- Inappropriate sexual behavior.
- Mood disorders.
This girl has diagnosis of precocious
puberty and need investigations to find
out the cause.
Investigations of suspected precocious
puberty in this girl include serum FSH,
LH and estradiol (females).
Consider bone age x-ray (left wrist and
elbow) and MRI if FSH and LH are
increased. So this girl needs MRI scan of
the head to exclude any pituitary or any
other brain tumor.
59.Which of the following is useful in the
management of moderate bronchiolitis?
a. Nebulized Salbutamol
b. Oxygen
c. Inhaled hypertonic saline
d. Inhaled hypotonic saline
e. Oral steroids
Answer detail:
The correct answer is b.
The treatment of bronchiolitis mainly
involved oxygenation and fluid therapy.
In a child with moderate to severe
bronchiolitis, supplemental humidified
oxygen is useful. The oxygen should
only be given to those children who are
hypoxic with oxygen saturation less
than 95%.
There is no role of following treatments
choices in the management of
bronchiolitis:
- Oral steroids.
- Salbutamol.
- Inhaled hypertonic saline.
- Inhaled hypotonic saline.
- Cough suppressants.
Bronchiolitis is a viral illness caused by
a respiratory syncytial virus and it
results in whee7e reduced oral intake
and respiratory distress in children
under two years of age.
60.A 6-weeks old baby is brought to the
hospital with a history of gradually
worsening non-bilious vomiting over last
 2 weeks. It has been becoming more
forcible and the baby is eager to have his
formula feed after each vomiting. There is
no history of diarrhea.
On examination, the capillary refill is 3
seconds. The baby has not gained any
weight over last 2 weeks. There is no
jaundice. On abdominal examination,
there is an olive size mass palpable at
right upper quadrant when the baby is
supine. There is no rash. Rest of the
examination is normal.
Which of the following is the most
sensitive investigation to confirm the
diagnosis?
a. CT abdomen
b. Ultrasound abdomen
c. Urine microscopy
d. Barium swallow
e. Laparotomy
Answer detail:
The correct answer is b.
This child has presented with clinical
features of hypertrophic pyloric
stenosis. Hypertrophic Pyloric Stenosis
is due to progressive thickening of the
circular muscle of the pylorus. This
leads to gastric outlet narrowing. The
condition usually presents between 2
and 6 weeks of age.
Abdominal ultrasound is 95% sensitive
to diagnose the hypertrophic pyloric
stenosis. All other given investigations
are not required except urine
microscopy which might help to rule out
urine tract infection.
61.An 11-year-old male child is brought to
emergency following a fall into an unfilled
swimming pool and hit his head on the
concrete surface. Vital signs include heart
rate of 86/min, respiratory rate of 19/min
and is hypotensive (50/30 mmHg)
despite adequate fluid resuscitation. CT
scan of the head is normal. Chest
examination is clear.
What is most likely diagnosis?
a. Neurogenic shock
b. Hypovolemic shock
c. Obstructive shock
d. Cardiogenic shock
e. Inadequate fluid resuscitation
Answer detail:
The correct answer is a.
This patient is most likely suffering from
neurogenic sock. Loss of sympathetic
lone prevents he expected tachycardia
response.
The hallmarks neurogenic shock are
hypotension with either bradycardia or
normal heart rate despite fluid
resuscitation.
If the hypotension cannot be corrected
with fluids only, vasopressor therapy
may be required.
As chest examination is clear, it is
unlikely obstructive shock (cardiac
tamponade, pneumothorax) also it is
unlikely to be primary cardiogenic or
hypovolemic shock.
Inadequate resuscitation is riot a
correct option as information provided
indicated adequate fluid given.
62.A 14-year-old boy is brought into the
emergency department with GCS of 8/15.
He has been unwell for last 24 hours at
home with respiratory tract infection.
On assessment, his airway is intact and
respiratory rate is 10 breaths per minute.
His oxygen saturation is 85% on room air
and capillary refill is 3 with cold hands.
His heart rate is 126 beats/minutes and
his blood pressure is 80/40 mmHg. His
capillary blood glucose less than 2
mmol/l. He has been given intramuscular
glucagon by the ambulance officer
however his blood sugar has not
improved.
 Urgent investigations shows sodium 130
mmol/l, potassium 5.5 mmol/l, venous
blood glucose 1.6 mmol/l.
Which of the following is the most likely
diagnosis?
a. Septic shock
b. Neuroglycopenic symptoms due to
hypoglycemia
c. Addison's disease
d. Hypovolemic shock
e. Complicated insulin dependent
diabetes mellitus
Answer detail:
The correct answer is c.
This patient has a typical presentation
of acute adrenal Insufficiency. Clinical
findings in favor of this diagnosis
include hypotension, reduced CCS with
altered consciousness.
Laboratory findings include
hypoglycemia, hyperkalemia,
hyponatremia and poor response to
glucagon injection. This is due to
cortisol and aldosterone deficiency. Any
infection like upper respiratory tract
infection car unmask the symptoms.
This patient needs urgent fluid
resuscitation with steroid replacement
therapy.
In the presence of hyperkalemia,
hypoglycemia and hyponatremia any
other option are least likely to cause
this type of presentation.
63.Which of the following is the indication for
prostaglandin E-1 in a neonate?
a. Transposition of great arteries
b. Hyperplastic left heart syndrome
c. Patent ductus aretriosus
d. Renal failure
e. Cardiac failure
Answer detail:
The correct answer is a.
Prostaglandin (PGE-1) is indicated in
cardiac lesions that depend on patent
ductus arteriosus to maintain adequate
pulmonary or systemic blood flow or to
promote adequate mixing.
These include:
1-Pulmonary atresia with intact
ventricular septum.
2-Tricuspid atresia with intact
ventricular septum.
3-Critical coarctation of aorta.
4-Hypoplastic left heart syndrome.
5-Transposition of great arteries.
PGE-1 is not indicated in hyper-plastic
left ventricular syndrome, patent ductus
arteriosus, renal failure and heart
failure.
64.A 2-day old newborn is found to be
irritable, crying all the time and sleeping
very less. On examination he has
increased muscle tone, hyperactive deep
tendon reflexes and exaggerated Moro
reflex. Mother has been taking
methadone daily until day of delivery.
There is on electrolyte abnormality
reported on routine investigations.
What is your next course of action?
a. Give naloxone
b. Give morphine
c. Start 5 percent dextrose infusion
d. Give oral paracetamol
e. Admit in intensive care unit for ten
days
Answer detail:
The correct answer is b.
This baby has developed neonatal
abstinence syndrome.
Do not administer naloxone and
naltrexone to babies of known or
suspected opioid dependent women
during resuscitation or the neonatal
period. Use may precipitate severe rapid
onset of withdrawal associated with
seizures.
Withdrawal from heroin may he
clinically apparent within 24 hours from
birth but is usually observed between
24 and 72 hours.
Withdrawal from methadone and
buprenorphine may be delayed until 3 -
7 days after Birth, or beyond.
National Health and medical Research
Council (NHMRC) recommends all opioid
withdrawal should be treated with
morphine.
There is no evidence of hypoglycemia is
the baby on routine investigations. So it
would be wise not to give any dextrose
infusion.
Oral paracetamol is not helpful to treat
withdrawal symptoms.
This baby needs monitoring however rot
in intensive care for 10 days. General
observation of withdrawal symptoms is
required however baby should not be
discharged until day 7 after delivery.
65.A mother brings her 3-year old son with
history of loose stools containing peas
and vegetables for last few days. The
child is gaining weight normally and is
otherwise healthy. Past medical history is
insignificant.
What is the most likely diagnosis?
a. Crohn's disease
b. Coeliac disease
c. Toddler's diarrhea
d. Lactose intolerance
e. Acute gastroenteritis
Answer detail:
The correct answer is c.
This child has clinical features
suggestive of Toddler's diarrhea.
It is also known as chronic nonspecific
diarrhea of childhood. It is one of the
most common causes of chronic
diarrhea in otherwise healthy children.
Toddler's diarrhea is suspected in a
child with chronic diarrhea who is age 6
months to 5 years, gaining weight and
developing normally, and otherwise
healthy.
Children with toddler's diarrhea often
have:
- 5-10 episodes of loose, watery, large
stools per day.
- Stools with undigested food particles.
- Diarrhea lasting weeks followed by
weeks of normal stools.
This child does not have symptoms
associated with dairy products and so
unlikely to suffer from lactose
intolerance.
Other options a, b, d and e are incorrect.
66.A mother brings her 18-month old male
child and is concerned as she believes,
her child is not thriving well. On growth
chart, the child is in the 25th percentile of
his weight since last 12 months.
What is the next best step?
a. Lactose free diet
b. Sweat chloride test
c. Gluten free diet
d. Multivitamins
e. Reassure
Answer detail:
The correct answer is e.
Failure to thrive means the inability to
achieve the growth potential expected
for a child.
Clinical features of failure to thrive
include:
- The weight consistently below the 3rd
to 5th percentile for age.
- Progressive decrease in weight to
below the 3rd to the 5th percentile.
- A reduction in the percentile rank of 2
major growth parameters in a short
period.
Growth chart 'percentile' lines show the
reference range of weights and heights
for a particular age and gender.
For example, 50 percent of the
population are expected to be below the
50th percentile. 25 percent below the
25th percentile.
Half of all children at a given age are
usually between the 25th and 75th
percentiles. So reassure the mother that
child is normally thriving and no
investigation needed at this stage.
Parents and doctors should not feel
under any pressure to try that the
baby's weight should be on or near the
50th centile at any age.
67.Absorption of which of the following is
most commonly impaired in untreated
coeliac disease?
a. Vitamin K
b. Iron
c. Vitamin B12
d. Folate
e. Calcium
Answer detail:
The correct answer is b.
Malabsorption in coeliac disease can
result in iron, folic acid and vitamin B12
deficiency.
But iron deficiency is seen more
frequently in patients with coeliac
disease than megaloblastic anemia due
to folic acid and vitamin B12 deficiency.
Absorption of fat-soluble vitamins A, D,
E, and K is also affected resulting in
their deficiency.
Calcium and vitamin D malabsorption
may cause osteopenia (decreased
mineral content of the bone) or
osteoporosis (bone weakening and risk
of fragility fractures).
Iron deficiency anemia is however most
common finding amongst all of these.
68.A 9-year-old child was brought to the
emergency department with altered level
of consciousness and confusion. He has
history of type I diabetes mellitus and is
on insulin. Capillary blood sugar is
14mmol/L. What will you do next?
a. Chest X-ray
b. Urine culture
c. Arterial blood gases
d. Blood culture
e. Give subcutaneous insulin
Answer detail:
The correct answer is c.
Diabetic ketoacidosis is the combination
of hyperglycemia, metabolic acidosis,
and ketonaemia.
Following investigations arc needed
urgently to diagnose diabetic
ketoacidosis:
a. Capillary blood sugar level
b. Venous or arterial blood gases
c. Blood or urinary ketone level
d. Other investigations like chest X-ray,
blood culture, urine culture, full blood
count etc.
All patients presenting with a blood
glucose level more than 11.1mmo1/1
should have blood ketones tested on a
capillary sample.
Urinalysis can be used for initial
assessment if blood ketone testing is
not available.
The biochemical criteria for DKA are:
a. Arterial pH less than 7.3 or
bicarbonate less than 15 mmol/l
b. Presence of blood or urinary ketones
So in this patient is important to know
pH to fulfill the criteria for diagnosis of
diabetic ketoacidosis.

If ketones are negative, or the pH is
normal in the presence of ketones,
patients can be managed with
subcutaneous insulin.
69.A 9-year-old male child is brought in by
his mother with fever, headache and
malaise for last three days. On
examination, you notice facial puffiness
and peripheral edema around both
ankles. Chest examination is significant
for bilateral basal crackles. The rest of
the physical examination is normal.
Blood pressure is 170/90. Heart rate is
90/min. Respiratory rate is 22/min
Oxygen saturation is 98% on room air.
Dipstick urinalysis indicates blood,
proteins. Hospital record shows that he
was seen at an outpatient clinic about
two weeks ago for a viral sore throat.
Which of the following statement is true
regarding this condition?
a. It is less common in Aboriginal and
Torres Strait Islanders
b. It is immune mediated condition
c. Proteinuria if alone is very
significant for diagnosis
d. It is unlikely to be caused by skin
infection
e. Seizures secondary to acute
hypertensive crisis is very common
Answer detail:
The correct answer is b.
This child has developed clinical
features suggestive of acute post-
streptococcal glomerulonephritis
(APGN). APGN is more commonly seen
in Aboriginal and Torres Strait
Islanders.
It is an immune mediated condition
caused by antibodies formed during
streptococcal throat and skin infection if
not treated with antibiotics.
These antibodies cross react against
kidney tissue. Proteinuria alone is very
rare and if present, think of alternative
diagnosis.
Streptococcal skin infection can cause
APGN if not treated with antibiotics.
Seizures secondary to an acute
hypertensive crisis are very rare.
70.A mother brings a 10-year-old male child
to your clinic after a sports injury. She
brought an avulsed tooth wrapped in a
paper fold. On examination, you find the
maxillary central incisor is missing.
What is the most appropriate next
management?
a. Re-implant the tooth under local
anesthesia
b. Immerse the tooth in the milk and
referral to dentist for urgent review
c. Immerse the tooth in the milk and
referral to dentist for review in next
couple of days
d. Throw the tooth into medical waste
e. Reassure the mother that it will
grow back in few weeks
Answer detail:
The correct answer is b.
This patient has presented with
completed disarticulation of the tooth.
From its bony socket. This is called
avulsion of the permanent teeth.
The clinical features of teeth avulsion
includes:
- Pain.
- Displacement of the tooth from the
socket.
- Bleeding.
The fast frequently avulsed tooth in the
permanent dentition is the maxillary
central incisor, which predominantly
presents in the 7-10 years' age group.
The patient should he advised to
immerse the tooth in the milk and
should be seen by the dentist within 2
hours ideally. Other storage options
include Harks' solution and contact lens
solution.
Storage of the avulsed tooth in a
compatible solution will prevent the
periodontal ligament from tying cut and
increases the possibility of successful
replantation.
The tooth should not be exposed to the
dry air, and the water should be avoided
as its osmotic effect causes cell death in
the periodontal ligament.
71.Which one of the following patients with
urinary tract infection will require
hospitalization?
a. An infant less than 12-months
b. A 6-year old male child with family
history of urinary tract infection
c. A 5-year old female child with
family history of urinary tract infection
d. An infant less than 2-month of age
e. A 2-year old child with allergy to
penicillin
Answer detail:
The correct answer is d.
As any infant younger than 2-month of
age is at increased risk of urosepsis or
other serious concomitant infections
and so requires treatment as an
inpatient.
The family history of urinary tract
infection is significant only when there
is suspected urinary tract anatomical
abnormality suspected in a patient and
can be managed in the outpatient
department.
Any allergy to penicillin is not an
indication of hospital admission. It
requires giving the alternative oral
antibiotics as an outpatient.
The patients with UTI who are toxic,
dehydrated and unable to tolerate oral
antibiotics will require admission to
hospital.
72.A 9-year-old boy has just been treated
for an anaphylactic reaction in a rural GP
clinic to which he responded well and is
stable now.
What would be the next step in his
management?
a. Discharge home
b. Observe in GP clinic for one hour
and then send home
c. Refer the child to nearest
emergency department
d. Discharge home with Epipen
e. Organize pediatric immunology
follow up
Answer detail:
The correct answer is c.
Any patient who has been treated for
anaphylaxis at home or in the
community with an adrenaline auto
injector or in general practice should
then be sent to an emergency
department for post-acute treatment
observation.
Current opinion is that a reasonable
minimum length of observation after
symptom resolution is 4-6 hours after
the last dose of adrenaline.
Organizing follow up with immunologist
is essential part of a first episode of
anaphylaxis but it is next best step in
this situation.
73.Which of the following is the risk factor
for the development of infant
hypertrophic pyloric stenosis in a 4 weeks
old infant?
a. Breastfeeding
b. Female
c. Asian background
d. Maternal smoking during pregnancy
e. All of the above
Answer detail:
The correct answer is d.
The infant hypertrophic pyloric stenosis
is more common in maternal smoking
during pregnancy.
Hypertrophic Pyloric Stenosis due to
progressive thickening of the circular
muscle of the pylorus. This leads to
gastric outlet narrowing. The condition
usually presents between 2 and 6 weeks
of age.
The risk factor for the development of
hypertrophic pyloric stenosis include:
-Formula feeding rather than
breastfeeding
-Male
-Caucasian background rather than
Asian background
-Firstborn
-Maternal smoking during pregnancy
-Positive family history
-Both erythromycin and azithromycin
are associated with increased risk of
infant hypertrophic pyloric stenosis
particularly when administered to
infants younger than 2 weeks.
74.An 8-year-old boy is brought to the
emergency department with photophobia,
irritability and neck stiffness.
Lumbar puncture was performed and
cerebrospinal fluid analysis show 50
neutrophils, 100 lymphocytes, normal
proteins and normal glucose.
Which of the following is the most likely
diagnosis?
a. Tuberculosis meningitis
b. Bacterial meningitis
c. Viral meningitis
d. Normal CSF findings
e. Encephalitis
Answer detail:
The correct answer is c.
This patient has developed clinical
symptoms of meningitis and CSF
analysis shows it to be most likely a
viral meningitis.
Please click on the image attached to
find out diagnostics of CSF analysis.
75.Which of the following is the most likely
to increase the risk of developmental
dysplasia of the hip?
a. Being male
b. Breech presentation
c. Maternal smoking during pregnancy
d. Asian origin
e. Iron deficiency
Answer detail:
The correct answer is b.
Developmental dysplasia of the hip is an
abnormal development of the hip joint.
The ball at the femoral head is not
stable within the acetabulum. The
ligaments of the hip joint which hold it
all together may also be stretched and
loose. The hips dislocate after birth and
this may riot be noticed until your child
starts to walk.
The risk factors for the development of
developmental hip dysplasia include
being a girl, breech presentation and
positive family history of hip dysplasia.
Being male, maternal smoking during
pregnancy, being from Asian origin and
iron deficiency has no significant
association with the development of hip
dysplasia.
Let is learn about breech presentation
as well.
Complete breech: Here, the buttocks are
pointing downward with the legs folded
at the knees and feet near the buttocks.
Frank breech: In this position, the
baby's buttocks are aimed at the birth
canal with its legs sticking straight up in
front of his or her body and the feet
near the head.
Footling breech: In this position, one or
both of the baby's feet point downward
and will deliver before the rest of the
body.
76.A 6-month-old child with Tetralogy of
Fallout is brought to your clinic by his
mother with a history of nasal discharge,
low to high-grade fever, feeding
difficulties and wheezy cough since last
three days. Father of the child smokes
the cigarette a pack per day at home.
Physical examination is significant for
inspiratory crackles with an expiratory
wheeze. Respiratory rate is 60/min and
oxygen saturation is 92 % at room air.
What is next best step in the
management of this patient?
a. Reassure the mother and educate
about minimal handling and frequent
feeds
b. Admit this baby to hospital and
symptomatic care with supplemental
oxygen, minimal handling and use of
intravenous fluids
c. Start corticosteroid therapy
immediately
d. Start nebulized ribavirin and
monitor the response
e. 3 % inhaled normal saline reduces
the hospital stay and should be used
at first thing in hospital
Answer detail:
The correct answer is b.
This patient has a clinical diagnosis of
acute viral bronchiolitis. The diagnosis
of bronchiolitis is clinical and bases on a
typical history of nasal discharge, fever
and wheezy cough, and examination
findings of inspiratory crackles and
expiratory wheeze.
Clinical indications for admission it
hospital in patients wile bronchiolitis
include feeding difficulty, increased
work of breathing, increased respiratory
rate and oxygen saturation less than 94
percent.
This child has Sp02 of 92% and fast
breathing rate (normal respiratory rate
for 6-month baby is 50/min).
Main issues in management are parental
reassurance and education about
minimal handling and frequent feeds.
I he diagnosis is usually limited to the
first 72 months of life.
Steroids have not shown any benefit in
the management of bronchiolitis and,
therefore, are not indicated.
77.You are working in a neonatal unit as an
intern. One of your patients developed
hypoglycemia, and you have given
2ml/kg of 10% dextrose.
Which one of the following is not
associated with neonatal hypoglycemia?
a. Hepatomegaly
b. Micropenis
c. Mid-line defects
d. Macrosomia
e. Undescended testes
Answer detail:
The correct answer is e.
Undescended testes are not associated
with syndromes causing hypoglycemia.
Hepatomegaly is associated with
glycogen storage diseases and fatty acid
oxidation disorders. It can cause
hypoglycemia.
Micropenis shows congenital
gonadotropin deficiency and possible
pituitary abnormalities. This may result
in cortisol deficiency. This may result in
hypoglycemia.
Congenital pituitary deficiency can be
associated with midline defects such as
cleft lip, cleft palate, single central
incisor, and micro-ophthalmic.
Hypoglycemia may be seen in these
children as we I due to pituitary failure.
Macrosomia occurs in infants of diabetic
mothers and infants with severe
congenital hyperinsulinism.
Hypoglycemia is seen very commonly in
neonates with a maternal history of
gestational diabetes and macrosomia.
78.A 4-week-old child is brought to your
clinic by concerned parents. On
examination, baby has ambiguous
genitalia. Gonads are palpable. Karyotype
analysis confirmed 46xy genetic makeup.
Which of the following is the next
appropriate investigation?
a. X- ray abdomen
b. 17 Hydroxy-progesteron
c. CT Scan pelvic region
d. Ultrasound of pelvic region
e. Testosterone level
Answer detail:
The correct answer is d.
This patient has developed palpable
gonads with ambiguous genitalia. On
initial evaluation, a chromosomal
analysis should be performed.
A pelvic ultrasound is performed as a
next step to determine whether
mullerian structures (uterus) are
present.
A biochemical analysis is performed in
311 patients depending on palpability of
gonads.
1-Palpable gonads.
- Testosterone and dihydrotestosterone
(DHT) ratio.
- LH and FSH.
- ACTH stimulation test.
- hCG stimulation test.
2-No palpable gonads:
In the absence of palpable gonads, the
most likely diagnosis is congenital
adrenal hyperplasia secondary to 21
hydroxylase deficiency.
- 17-hytroxyprogesternne.
- Serum electrolytes.
- Plasma resin activity.
79.A 6-year-old male child is observed by
the school teacher to have sudden, brief
lapses of consciousness without loss of
postural control and no confusion after
the episode. The teacher also observed
the child having rapid blinking of the
eyelids, chewing movements and clonic
movements of the hands during the
episodes.
The EEG is done after requesting the child
to hyperventilate. The result shows a
generalized, symmetric, 3-Hz spike-and-
wave discharge that begins and ends
suddenly, superimposed on a normal EEG
background.
Which of the following is the most likely
diagnosis?
a. Absence seizure
b. Complex partial seizure
c. Simple partial seizure
d. Generalized tonic-clonic seizure
e. Atypical absence seizure
Answer detail:
The correct answer is a.
The child has a typical presentation of
absence seizure with typical EEG
findings.
Atypical absence seizure has features
like prolonged lapses of consciousness,
a more complex motor activity that may
include focal or lateralizing features.
Atypical absence seizures are usually
associated with diffuse or multifocal
structural abnormalities of the brain
and, therefore, may accompany other
signs of neurological dysfunction such
as mental retardation.

The atypical absence seizures are less
responsive to anticonvulsants compared
to typical absence seizures.
Complex partial seizure shows focal
seizure activity accompanied by a
transient impairment of the patients
ability to maintain normal contact with
the surrounding environment. The
patient is usually unable to respond to
visual or verbal commands during the
seizure and is accompanied by post-
iotal amnesia about the event.
80.Which of the following organism is the
most common cause of urinary tract
infections in children?
a. Proteus mirabilis
b. E.coli
c. Staph aureus
d. Enterobacter
e. Pseudomonas
Answer detail:
The correct answer is b.
Between 80 to 90% of urinary tract
infections ore caused by E.coli in
children.
Other organisms may include Klebsiella
pneumonia, Proteus mirabilis,
staphylococci species, pseudomonas
and enterobacters.
81.Which of the following is regarded as the
most important clinical examination
finding in a child with acute viral
bronchiolitis?
a. Fever
b. Expiratory wheeze
c. Nasal discharge
d. Inspiratory crackles
e. Cough with productive sputum
Answer detail:
The correct answer is d.
In a patient with acute viral
bronchiolitis, typical history includes
nasal discharge, fever and wheezy
cough, and examination findings show
inspiratory crackles and/or expiratory
wheeze.
In most of Europe and Australasia, the
presence of inspiratory crackles is
regarded as the more important
examination finding, and the diagnosis
is usually limited to the first 12 months
of life.
82.A 12-year-old male presented with
worsening of his asthma. He has past
medical history of asthma and recurrent
chest infections.
Which ONE of the following if present
would indicate life threatening asthma?
a. Wheeze
b. Cyanosis
c. Speaks in sentences
d. Peak expiratory flow more than
75%
e. Oxygen saturation 95%
Answer detail:
The correct answer is b.
Cyanosis if present indicate life
threatening asthma episode. Wheeze is
not a reliable indicator of severity of
asthma and it may be absent in severe
asthma attack.
A patient with mild asthma can talk in
sentences. Peak expiratory flow metre
is usually more than 75% in mild
asthma In between 75-50%, it shows
moderate asthma and if below 50%
shows severe asthma.
Oxygen saturation around 95% is sign
of m Id asthma.
83.An 8-year-old boy is known to have
primary nocturnal enuresis. He is going to
attend a school camp next week and his
mother is worried about his night time
bed-wetting.
What is the most appropriate treatment?

a. Bed alarm
b. Nasal decompressing
c. Night-trainer
d. Planned waking
e. Any of the above
Answer detail:
The correct answer is b.
Decompression acetate is very useful
for children with nocturnal enuresis who
are going for school camps. It can be
used oral or nasal each night.
Also the child should avoid water
loading before bed.
The bed alarm or night trainer is the
treatment of choice for primary
nocturnal enuresis in all other
situations.
Combination of decompression and the
bed alarm can be used in cases with
persistent enuresis.
Decompression is a synthetic analog of
arginine vasopressin. Decompression
works by decreasing urine volume at
night and by decreasing intravascular
pressure.
84.A 14-year old teenager is diagnosed with
a tympanic membrane perforation
secondary to chronic otitis media. Which
of the following conditions will not
progress to significant complications if left
untreated?
a. Perforation associated with a
cholesteatoma
b. Marginal perforation with discharge
c. Continuously discharging central
perforation
d. Perforation that is surrounded by
granulation tissue
e. Large dry central perforation
Answer detail:
The correct answer is e.
A dry central perforation will not
progress to complications, even if it
does not heal. Surgical repair is
therefore elective and not mandatory.
The other types of perforation are not
'safe' and require specialist attention.
A continuously discharging central
perforation indicates granulation and a
risk of osteitis and bone destruction.
Marginal perforation carries the same
risk.
A cholesteatoma is not a neoplasm but a
cystic lesion containing amorphous
debris (and sometimes spicules of
cholesterol).
It is formed through chronic infection
and perforation of the eardrum with
ingrowth of squamous epithelium,
forming a nest which becomes cystic.
By progressive enlargement a
cholesteatoma can erode the ossicles,
labyrinth and adjacent bone and carries
the risk of cerebral abscess formation
and meningitis.
85.An 18-month old female infant is brought
to your clinic due to an onset of red
maculopapular rash on her trunk.
Symptoms reported by mother include
high grade fever and mild coryza for last
3 days however she has still been quite
active. Her temperature has returned to
normal today.
What is the most likely diagnosis?
a. Roseola Infantum
b. Rubella
c. Measles
d. Chicken pox
e. Erythema Infectiosum
Answer detail:
The correct answer is a.
Roseala infantum is a viral infection
usually affecting children between the
ages of 6-18 months.
I he patient typically develops high
fever up to 40 degrees Celsius, but is
otherwise not particularly unwell. There
may be mild cervical lymphadenopathy
and pharyngitis.
After three days, the temperature
usually returns suddenly to normal and
the patient develops a red macular or
maculopapular non-desquamating rash
which is truncal, usually sparing the
'ace and limbs. The rash abates within
Two days.
Rubella (German measles) is a viral
infection typically characterized by rash,
fever, and lymphadenopathy. The rash
is usually an erythematous, discrete
maculopapular exantherra that begins
on the face and spreads caudally. It
usually disappears within three days but
may persist for eight days.
The exanthema of measles is a
maculopapular, blanching rash
beginning or the face and spreading
cephalocaudally and centrifugally to
involve the neck, upper trunk, lower
trunk, and extremities.
The clinical manifestations of varicella
(chicken pox) in healthy children
generally develop within fifteen days
after the exposure and typically include
a prodrome of fever, malaise, or
pharyngitis, loss of appetite, followed
by the development of a generalized
vesicular rash, usually within 24 hours.
The vesicular rash of varicella, which is
usually pruritic, appears in successive
crops over several days. The patient
with varicella typically has lesions in
different stages of development on the
face, trunk and extremities.
86.Which of the following is the best
screening test for developmental
dysplasia of the hip at 8 months of age?
a. Ultrasound
b. CT
c. MRI
d. X-ray
e. Abnormal hip examination
Answer detail:
The correct answer is d.
The x-ray of the hip is the investigation
of choice for screening developmental
dysplasia of the hip in beyond six
months of age.
All babies with risk factors for
developmental dysplasia of the hip
(Breech presentation, Oligohydramnios,
Family history of DDH and underlying
neuromuscular dysfunction) or with an
abnormal examination of the hip should
undergo a hip ultrasound and referral to
an orthopedic surgeon.
During first six months of age, the
ultrasound of the hip is the
investigation of choice.
87.An 18-month-old male child is brought to
the emergency department by his mother
with generalized tonic-clonic seizure
lasting for 3 minutes an hour ago.
While you are assessing the child in the
emergency room, he again develops
tonic-clonic seizure which lasted for 5
minutes. The child is febrile and irritable
with rectal temperature 39C.
All immunizations are up to date. Rest of
the examination is unremarkable.
What would you consider next?
a. Full blood count
b. Serum glucose
c. Serum calcium
d. No further investigation needed
e. Lumbar puncture
Answer detail:
The correct answer is e.
88.A 4-year-old male child is brought by her
mother with a clean lacerated wound and
a history of 2 tetanus vaccinations.
 What would you consider regarding his
tetanus prophylaxis?
a. DTPa vaccine
b. ADT and tetanus immunoglobulin
c. Tetanus toxoid and oral antibiotics
d. Tetanus toxoid
e. Tetanus immunoglobulin
Answer detail:
The correct answer is a.
Vaccination against tetanus is included
in the National Immunization Program
schedule in Australia.
As a primary vaccine, tetanus toxoid is
given in combination with diphtheria
toxoid and acellular pertussis as DTPa
vaccine.
Primary course of vaccination includes
DTPa vaccination at 2, 4 and 6 months
age. Then a first booster of DTPa is
given at 4 years of age.
Then a second booster of DTPa is given
between 12-17 years. So by the age of
17, an Australian young adult should
have received 5 doses of tetanus toxoid
containing vaccine.
This child at the age of 4 year should be
ready to receive first booster of tetanus
toxoid containing vaccine.
However he has only received two
primary vaccinations for tetanus instead
of three. So he needs to receive tetanus
toxoid containing vaccine in
combination with diphtheria toxoid and
acellular pertussis.
As his wound is a clean laceration, no
immunoglobulin required and no
antibiotics needed. He needs to have
either DTP (diphtheria tetanus and
pertussis) or DTPa which contains
acellular pertussis. This will provide
additional immunity against diphtheria
and pertussis as well as tetanus which
is a primary concern here.
Diphtheria tetanus toxoid vaccine (ADT)
should be used if child has allergy or
contraindication to pertussis
vaccination.
89.A 20-month-old baby is brought in by his
parents with chronic diarrhea and weight
loss. On examination, the baby has
growth retardation, muscle wasting and
distended abdomen with hyperactive
bowel sounds. Chest examination is clear.
Laboratory investigations show decrease
serum iron or folate levels. Patient has
been on the lactose-free diet for 3 days
without resolution of symptoms.
What is the most likely diagnosis?
a. Primary lactose intolerance
b. Coeliac disease
c. Cystic fibrosis
d. Bacterial over growth
e. Chronic liver disease
Answer detail:
The correct answer is b.
This patient has the clinical diagnosis of
coeliac disease. It presents as severe
malabsorction syndrome in children
with chronic diarrhea, failure to thrive,
muscle wasting and hyperactive bowel
sounds.
Primary lactose tolerance is due to
deficiency of lactase in a small intestine
and is a malabsorption syndrome
presenting with abdominal pain,
bloating, distension, flatulence and
watery diarrhea. It usually resolves
with a lactose-free diet for about 2
weeks.
Cystic fibrosis is an inherited autosomal
recessive disease and is the most
common cause of bronchiectasis and
chronic suppurative lung disease in
Caucasian children.
Bacterial overgrowth in the small bowel
causes diarrhea and nutrient
malabsoption. Most patients with
bacterial overgrowth have intestinal
stasis associated with underlying
anatomical abnormalities including
strictures, jejunal diverticulosis, motility
disorder and various operations that
create blind loops.
Clinical manifestations of bacterial
growth include diarrhea, weight loss
and anemia due to vitamin B12
deficiency.
90.A 4-year-old male child is brought to the
emergency department by an ambulance
with 3 days history of fever, associated
altered consciousness. There has been
progressive personality changes and
occasional drowsiness.
An emergency lumbar puncture is done
which confirms the diagnosis of viral
meningitis.
Which of the following is the best choice
for this condition?
a. Ceftriaxone intravenously (IV)
b. Benzyl penicillin IV
c. Ciprofloxacin IV
d. Acyclovir IV
e. Cefuroxime IV
Answer detail:
The correct answer is d.
This case is suggestive of viral
encephalitis. Encephalitis is an
inflammation of brain parenchyma.11 is
mainly caused by viruses although other
organisms including bacteria,
mycoplasma, rickettsia and Histoplasma
can cause encephalitis.
Suspect it when a viral prodrome is
followed by irrational behavior, altered
consciousness and possibly cranial
nerve lesions.
In this case, the cerebrospinal fluid
analysis reveals viral meningitis thus
viral etiology is entertained.
This patient should be hospitalized and
treatment will be supportive. Suspected
herpes simplex encephalitis should be
treated with intravenous acyclovir
immediately.
91.An 18-year-old mother brings her 5
month old child in the emergency
department. Mother is concerned that
child has been crying excessively since
yesterday and she noticed today that
child was unable to move the left arm.
There is no external bruising. Mother
does not remember any history of trauma
to the child. X-ray showed mid-shaft
fracture of the humerus.
What is the most appropriate next step?
a. Social worker review t
b. Admission to hospital
c. Discharge and follow up with GP
d. Analgesia and external
manipulation in emergency
department
e. Notify police
Answer detail:
The correct answer is b.
This child has most likely diagnosis of
non-accidental injury to left humerus
which has resulted in fracture.
In this case, there has been delay in
seeking advice (child crying since
yesterday) arc mother is denying any
trauma to the baby. A fracture is an
evidence that physical trauma has
happened.
So the most appropriate things to do
include admission to the hospital (do
not discharge this Patient hone as risk
of further injuries is high), orthopedics
review and notification to child
protection services.
Child protection services can be
contacted any time throughout
Australia.
Notification of suspected child abuse is
mandatory and later on, if no child
abuse is proven, health practitioners are
protected by Australia National. Law
from any legal action by parents.
Social worker review and notification to
police not required. Any external
manipulation in children must be guided
by orthopedic team.
92.A mother brings her 3 year-old male
Aboriginal child for passing loose stools
over last 2 weeks. The child lost 2 kg
weight after the onset of diarrhea. Child
looks fatigued. Clinical examination is
remarkable for mild dehydration.
What is the most likely diagnosis?
a. Lactose intolerance
b. Food poisoning
c. Coeliac disease
d. Cystic fibrosis
e. Giardiasis
Answer detail:
The correct answer is e.
This child has signs and symptoms
consistent with diagnosis of Giardiasis.
It is caused by a parasite called as
Giardia lamblia.
Symptoms of Giardiasis include:
1. Diarrhea, which may be watery,
usually lasting more than 1-2 weeks.
2. Weight loss.
3. Frequent loose or pale, greasy stools
which may float in the toilet bowl.
4. Fatigue.
Lactose intolerance may develop in 20-
40% of cases of giardiasis and last
several weeks. However it is not
primary diagnosis here.
Coeliac disease presents titer
introduction of glutin-containing solid
diet in a child during weaning. It starts
during first year of life.
Cystic fibrosis presents with frequent
respiratory and gastrointestinal
infections from the birth. This child was
previously healthy, so cystic fibrosis is
unlikely diagnosis.
93.Which of the following statement is
correct regarding anti-glomerular
basement membrane disease?
a. Antibodies are directed against non-
collagenous domain of type IV
collagen
b. Antibodies are directed against
collagenous domain of type IV
collagen
c. Type IV collagen is found in skeletal
muscle
d. It is most commonly seen in people
above 50
e. If treated with steroids, relapses
are very common
Answer detail:
The correct answer is a.
Anti-glomerular basement membrane
disease is also known as Goodpasture's
disease.
It is caused by the development of auto
antibodies against non-collagenous
domain of type IV collagen.
Type IV collagen is also found in the
lung and hemoptysis may also be a
feature, particularly in smokers.
Young males are most commonly
affected, but it can occur at any age or
in any gender.
Treatment options include plasma
exchange, corticosteroids and cytotoxic
therapy.
It treatment is stared early, the disease
can be cured and relapses are rare.
Patients present with macroscopic
hematuria progressing rapidly to
oliguria and renal failure it left
untreated.

94.Which ONE of the following is unlikely to
require ant-D administration in an Rh
negative woman who have not actively
formed their own Anti-D?
a. Threatened abortion before 12
weeks of gestation
b. Spontaneous abortion
c. External cephalic version
d. Significant closed intra-abdominal
trauma
e. Termination of pregnancy
Answer detail:
The correct answer is a.
There is insufficient evidence to suggest
that a threatened miscarriage before 12
weeks gestation requires Anti-D.
Indications to use ant-Din all Rh
negative women who have not actively
formed their own Anti-D include:
- Spontaneous abortion
- External cephalic version
- Significant closed intra-abdominal
trauma
- Termination of pregnancy.
- Chorionic Villus Sampling.
- Ectopic pregnancy.
- Threatened abortion after 12 weeks of
gestation.
95.A mother brings her 4 months old son as
he wakes her a loran night She is tearful,
crying and anxious. She tells you that she
has not slept since he was born. She has
lost her appetite and does not enjoy her
life.
What is the most likely diagnosis?
a. Insomnia
b. Postpartum psychosis
c. Sleep deprivation
d. Postpartum depression
e. Postpartum blues
Answer detail:
The correct answer is d.
This woman has developed postnatal
depression. The diagnosis of postpartum
depression should be considered in
woman after child birth with following
clinical features persisting more than 2
weeks:
- Low mood, tearfulness, anxiety
- Insomnia
- Loss of appetite
- Loss of weight
- Loss of self-esteem
- Loss of enjoyment
- Impairment of functions in normal life
- Poor memory and concentration.
Postnatal depression occurs in 10-30%
of women in first 6-12 months
postpartum.
Postnatal blues occur in 80% of the
women during first 2 weeks after child
birth. Patient feels sad or depressed
with mood swings and irritability.
Insomnia, tiredness and lack of
confidence are also commonly seen in
postpartum blues. This is transient
condition and lasts for 4 to 14 days
only.
All other options are incorrect.
96.Which of the following is an absolute
contra-indication to use progestogen-only
pills?
a. Rifampicin
b. History of liver disease
c. Migraine
d. Malabsorption syndrome
e. Smoking
Answer detail:
The correct answer is a.
Concomitant use of enzyme-inducing
drugs results in decreased efficacy of
progestogen-only pills and can result in
pregnancy.
Enzyme inducers include anti-epileptic
drugs, rifampicin and barbiturates etc.
Enzyme inducing drugs (rifampicin) are
an absolute contraindication to use
progestogen-only pills.
As rifampicin and rifabutin are
particularly potent enzyme inducers,
women using these drugs long term,
should be advised to switch to a method
that is unaffected by enzyme-inducing
drugs.
History of liver disease and
malabsorption syndrome are relative
contraindications to use progestogen-
only pills.
Progestogen-only pills are suitable for
patients with a history of smoking and
migraine.
97.Warfarin is contraindicated during
pregnancy. Which of the following
complications develop if warfarin is used
in the second trimester of gestation?
a. Foetal chondrodysplasia Punctata
b. Hypercalcaemia
c. Facial anomalies
d. Maternal cerebral bleeding
e. Foetal optic atrophy
Answer detail:
The correct answer is e.
Warfarin is contraindicated in the first
trimester as it causes foetal
chondrodysplasia punclata. If used in
second and third trimester, warfarin
causes foetal optic atrophy and mental
retardation.
Warfarin does not cause hypercalcaemia
and foetal facial anomalies if used
during second and third trimester.
98.Which of the following is the indication to
perform cervical cordage at 14 weeks of
gestation?
a. 2 or more consecutive prior second
trimester pregnancy losses
b. Short cervix at <24 weeks with no
prior preterm birth
c. One preterm birth before 34 weeks
d. Carcinoma cervix
e. Vaginal polyp
Answer detail:
The correct answer is a.
A minority of recurrent second trimester
abortions are due to cervical
insufficiency exclusively.
Cervical cerclage is a preventive
measure and is performed at 12 to 14
weeks of gestation.
Indications of cervical cerclage include:
- Two or more consecutive prior second
trimester pregnancy losses or
- Three or more preterm births before
34 weeks of gestation
Short cervix less than 24 weeks of
gestation without any preterm birth is
not a reason to do cerclage.
Similarly carcinoma cervix and vaginal
polyp are also not indications to
perform cerclage.
99.A 35-year-old lady presented with
irritability, anxiety, breast tenderness and
headaches about 5 days before the onset
of menses every month, since the last 6
months.
These symptoms are relieved with the
onset of menses. She has to take a week
off from work due to these symptoms.
She is non-alcoholic and does not use any
regular medication.
Which of the following is the
a. Premenstrual dysphonic disorder
b. Premenstrual syndrome
c. Normal menstrual physiology
d. Generalized anxiety disorder
e. Depression
Answer detail:
The correct answer is b.
This patient fulfils the criteria for the
diagnosis of the premenstrual
syndrome.
Diagnostic criteria for premenstrual
syndrome include affective and somatic
symptoms during the 5 days before
menses in each of the 3 prior menstrual
cycles.
Affective symptoms include:
- Depression
- Anger outbursts.
- Irritability
- Anxiety
- Confusion
- Social withdrawal.
Somatic symptoms include breast
tenderness, abdominal bloating,
headache and swelling of extremities.
Symptoms are usually relieved within 4
days of onset of menses and are present
in the absence of any pharmacological
therapy, or drug or alcohol use.
The patient suffers from identifiable
dysfunction in social or economic
performance.
Premenstrual dysphonic disorder is a
severe form of premenstrual syndrome
and is characterized by a severe feeling
of sadness, emotional liability with
frequent tearfulness, loss of interest in
daily activities, decreased
concentration, fatigue, insomnia and
feeling of being overwhelmed or out of
control.
Symptoms must have been there for
most of the during the last 12 months
and have resulted in interference with
daily activities.
Generalized anxiety disorder and
depression alone are the unlikely
diagnoses.
100. A 17-year-old girl comes to
your office with a history of vaginal
bleeding after 6 weeks of amenorrhea.
She has been having normal regular
periods every 4 weeks. She has done a
home pregnancy test which was positive.
On examination, there is no tenderness
and the cervical os is closed. The pelvic
ultrasound shows empty sac and there is
no fluid in the pouch of Douglas.
What is the most likely diagnosis?
a. Complete abortion
b. Missed abortion
c. False positive pregnancy test
d. Ectopic pregnancy
e. Septic abortion
Answer detail:
The correct answer is a.
This patient has developed clinical
features of early pregnancy loss. A
complete miscarriage is a miscarriage in
which early pregnancy tissue is
completely expelled.
- Gestation typically 6 to 8 weeks
- No fetal activity ever detected
- Empty sac enlarge sac with minimal
structures without fetal heart activity
- Beta hCG levels show an initial rise
and then fall.
A missed miscarriage is the one with
ultrasound features consistent with a
non-viable or non-continuing
pregnancy, even in the absence of
clinical features. Early pregnancy tissue
may be partially expelled.
An incomplete miscarriage is a
miscarriage in which early pregnancy
tissue is partially expelled.
The clinical features of ectopic
pregnancy include lower abdominal
pain, significant vaginal bleeding, and
amenorrhea. This patient has
intrauterine gestational sac (although
empty) and there is no fluid in Pouch of
Douglas. So this is unlikely ectopic
pregnancy.
101. A 27-year-old female
presents with sudden onset of a severe
headache at 37 weeks of gestation. She
also feels dizzy and nauseated. Her
mother noted slurred speech and
repetitions of words while she was
complaining of the headache. She is
clinically stable and has not developed
any obstetric complication. She has no
history of a migraine.
What will you do next in her
management?
a. Aspirin
b. CT brain
c. MIZI brain
d. Lumbar puncture
e. Observation in the ward
Answer detail:
The correct answer is b.
This patient has developed clinical
features of subarachnoid hemorrhage
and needs CT scan of the brain to rule
out intracranial hemorrhage.
With proper shielding of the uterus,
radiation exposure to the fetus is
minimal.
Aspirin should be avoided until CT scan
of the brain is performed and any
intracranial hemorrhage is ruled out.
Lumbar puncture should be carried out
if the patient has clinical features
suggestive of subarachnoid hemorrhage
and CT head is normal. It should be
performed 12 hours after the onset of a
headache.
Observation in the ward is not
appropriate without ruling out
subarachnoid hemorrhage.
102. You are principal house
officer at a GP clinic. You would refer all
of the following presentations for
specialist opinion except?
a. Unexplained persistent pelvic pain
b. A pelvic mass tender on bimanual
vaginal examination
c. Primary infertility of greater than
three months
d. Symptoms of endometriosis
unresponsive to initial treatment
e. Primay infertility of greater than
one year
Answer detail:
The correct answer is c.
Australian health system works well
coordinated between specialists in large
hospitals and general practitioners at
surgeries and clinics. It is always
recommended to refer the patient if
specialist opinion is needed.
You should refers patient to
Gynecologists or Obstetrician if you find
a patient with:
• Unexplained pelvic pain.
• Pelvic mass which is tender on bi-
manual vaginal examination
• Primary infertility of greater than a
year
• Patient with suspected diagnosis of
endometriosis unresponsive to initial
treatment.
Primary infertility of greater than three
months is not an indication of referral to
the specialist.
103. A 30-year-old woman
developed deep vein thrombosis at 30
week of pregnancy. She was treated with
low molecular weight heparin. Now she is
at 34 weeks of pregnancy and her
expected date of delivery is in next 4
weeks. What would be your advice for
today?
a. Low molecular weight heparin
should be switched to unfractionated
heparin
b. Continue low molecular weight
heparin until delivery
c. Switch to warfarin and check INO in
2 days
d. Use both low molecular weight
heparin and warfarin for 5 days
e. Cease all anti-coagulants
Answer detail:
The correct answer is a.

A patient with deep vein thrombosis

during pregnancy requires 3-6 months
treatment with low molecular weight
heparin (LMWH) or unfractionated
heparin.

LMWH may be associated with an

increased risk of epidural hematoma in
women receiving an epidural anesthetic
in labor.

Four weeks prior to anticipated delivery,

LMWH should be switched to
unfractionated heparin.