QI: multiple choice questions, choose one answer

1. A 17-year girl comes to your office complaining of acne that is unresponsive to the usual treatment
regimen. Physical examination reveals severe nodulocystic acne of her face and upper chest and
back. You consider prescribing isotretinoin (Accutane), but you are concerned about side effects.
Reviewing the literature, you find which of the following to be true about isotretinoin

A. Its efficacy not good for acne

B. It is known to be a teratogen
C. Most patients experience excessive tearing and salivation
D. Severe arthritis necessitating cessation of the drug occurs in about 15% ofpatients
E. Significant decrease in serum triglyceride levels are noted in 25% of patients

2 . As you are about to step out of a newly delivered mother’s room, she
mentions that she wants to breast-feed her healthy infant, but that her
obstetrician was concerned about one of the medicines she was taking.
Which of the woman’s medicines, listed below, is clearly contraindicated in
breast-feeding?

A. Ibuprofen as needed for pain or fever

B. Labetolol for her chronic hypertension
C. ciprofloxacin for her urinary tract infection
D. Ceftriaxone for meningitis
E.Acyclovir for her HSV outbreak

3. The nurse from the neonatal intensive care nursery calls you to evaluate a baby. The infant, born at
32 weeks’ gestation, is now 1 week old and had been doing well on increasing nasogastric feedings. This
afternoon, however, the nurse noted that the infant has vomitted the last two feedings and seems less
active. Your examination reveals a tense and distended abdomen with decreased bowel sounds. As
you are evaluating the child, he has a grossly bloody stool. Your management of this infant should
include

A. Surgical consultation for an emergent exploratory laparotomy

B. Continued feeding of the infant, as gastroenteritis is usually self-limited
C. Stool culture to identify the etiology of the bloody diarrhea and an infectious diseases consultation
D. Stopping feeds, beginning intravenous fluids, ordering serial abdominal films, and initiating systemic
antibiotics
E. Upper GI series and barium enema to evaluate for obstruction
4. A primiparous woman whose blood type is O positive gives birth at term to an infant who has A-
positive blood and a hematocrit of 55%. A serum bilirubin level obtained at 36 h of age is 12 mg/dL.
Which of the following laboratory findings would be characteristic of ABO hemolytic disease?

A. A normal reticulocyte count

B. schistocytes, spherocytes and nucleated RBCs
C. Crescent-shaped red blood cells in the blood smear
D. Elevated hemoglobin
E. Petechiae

5. A 3-day-old infant born at 32 weeks’ gestation and weighing 1700 g (3 lb, 12 oz) has three episodes of
apnea, each lasting 20 to 25 s and occurring after a feeding. During these episodes, the heart rate drops
from 140 to 100 beats per min, and the child remains motionless; between episodes, however, the child
displays normal activity. Blood sugar is 90 mg/dL and serum calcium is normal. The child’s apneic periods
most likely are

A. Due to an immature respiratory center

B. A part of periodic breathing
C. Secondary to hypoglycemia
D. Manifestations of seizures
E. Evidence of underlying pulmonary disease

6. You are seeing a 2-week-old boy at a routine visit. The mother complains that he has been
constipated, jaundiced, sluggish, and excessively sleepy. The physical examination is normal except for
mild jaundice and a distended abdomen in a sleepy infant. The most appropriate course to pursue
initially is assessment of

A. The mother’s serum for autoantibodies to thyroid gland

B. Levels of thyrotropin-releasing hormone (TRH)
C. The results of the neonatal metabolic screen
D. thyroid-stimulating hormone TSH
E. The effects on growth and symptoms with increasing feeds by 20% per day

7. if the all above investigation fail to secure the diagnosis , the most appropriate next step is to

A. Repeat all the baby’s abnormal laboratory results (if any)

B. Obtain x-rays of the baby’s skull, wrists, and knees
C. Begin on the baby oral sodium-L-thyroxine, 10 to 15 mg/(kgd)
D. Evaluate the neonate in 2 weeks for the results of symptomatic treatment
E. Obtain a pediatric endocrinology consultation within 2 weeks
 8. A 5-year-old boy has a history of bed-wetting about four to five times a week. He has recently
begun to attend kindergarten. He was toilet trained (dry during the day) by age 3 but has
never been consistently dry at night. He denies any dysuria or frequency. There is no history of
increased thirst or frequent urination. The urinalysis is negative for blood, protein, glucose,
or ketones; there are no white cells or bacteria; the specific gravity is 1.020. Which of the following is
the most likely diagnosis?

(A) a urinary tract infection (UTI)

(B) primary nocturnal enuresis
(C) secondary enuresis caused by stress of the new school
(D) diabetes mellitus
(E) diabetes insipidus

9. A routine prenatal ultrasound reveals a male fetus with meningomylocele. The 24-year-old
primigravid mother is told the infant will require surgery shortly after birth. You counsel her about the
etiology of this defect and the risk of further pregnancies being similarly affected, stating that

A. The condition is hereditary

B.diagnosis can be made by the detection of very low levels of α- fetoprotein in the amniotic fluid
C. Subsequent pregnancies are not at increased risk compared to the general population
D. Supplementation of maternal diet with folate leads to a decrease in incidence of This condition
E. Neither environmental nor social factors have been shown to influence the incidence

10. A couple expecting their first infant in a few weeks scheduled an appointment in your
pediatric clinic to get a head start on child care issues (a prenatal visit). You ask about the pregnancy
course, and the mother notes that she was recently told she had oligohydramnios. At delivery of
this infant, you plan to evaluate for which of the following conditions?

A. Anencephaly
B. Trisomy 18
C. Renal agenesis
D. Duodenal atresia
E. Tracheoesophageal fistula

11. A 5-week-old bottle-fed boy presents with persistent and worsening projectile vomiting, poor
weight gain, and hypochloremic metabolic alkalosis. Of the following diagnostic modalities, which
would most likely reveal the diagnosis?

(A) Ultrasound of abdomen

(B) Barium enema
(C) Evaluation of stool for ova and parasites
(D) Urine analysis
(E) Serum thyroxine
12. A 7-year-old boy presents with a rash. His mother states that he was well until 3 days ago
when he developed fever and malaise. The next day, the rash started as papules on the trunk,
which rapidly changed to vesicles. The lesions have spread all over the body. On physical
examination, he has no fever and seems well.You note numerous vesicles all over the body, some of
which have crusted over. Which of the following is the most likely diagnosis?

(A) chicken pox

(B) Kawasaki disease
(C) measles
(D) rubella
(E) staphylococcal scalded skin syndrome

13. A 3-year-old male presents after having a tonic clonic seizure lasting about 1 minute.
On examination, the child now has no neurologic abnormalities. He has a temperature of 40.3°C
and has an obvious otitis media on the left but no other abnormalities on physical examination. You
correctly counsel the family with which one of the following statements?

(A) The child will need hospitalization, a lumbar puncture, and antibiotics.
(B) An EEG and CNS imaging must be done.
(C) Anticonvulsants must be stated and continued for 6 months.
(D) next time give antipyretic and diazepam as necessary
(E) The child must be monitored carefully for long-term neurologic damage.

14. A 15-year-old girl with short stature, neck webbing, and sexual infantilism is found to have
coarctation of the aorta. A chromosomal analysis would demonstrate , XO karyotypes which is related to

A. Mutation at chromosome 15q21.1

B. Trisomy 21
C. Turner’s syndrome
D. Defect at chromosome 4p16
E. Normal chromosome analysis

15. During a regular checkup on an 8-year-old child, you note a loud first heart sound with a fixed and
widely split second heart sound at the upper left sternal border that does not change with respirations.
The patient is otherwise active and healthy. The mostly likely heart lesion to explain these findings is

A. Atrial septal defect

B. Ventricular septal defect
C. Isolated tricuspid regurgitation
D. Tetralogy of Fallot
E. Mitral valve prolapsed
16. A previously well 1-year-old infant has had a runny nose and has been sneezing and coughing for 2
days. Two other members of the family had similar symptoms. Four hours ago, his cough became much
worse. On physical examination, he is in moderate respiratory distress with nasal flaring,
hyperexpansion of the chest, and easily audible wheezing without rales. The most likely diagnosis is

A. Bronchiolitis
B. Viral croup
C. Asthma
D. Epiglottitis
E. Diphtheria

17. The most likely agent responsible for the infant’s condition in the preceding question is

A. Staphylococcus aureus
B. Haemophilus influenzae
C. Corynebacterium diphtheriae
D. Respiratory syncytial virus
E. Echovirus

18. A previously healthy, active 18-month-old child presents with unilateral nasal obstruction and foul-
smelling discharge. The child’s examination is otherwise unremarkable. The most likely diagnosis is

A. Foreign body
B. Nasal polyps
C. Frontal sinusitis
D. Deviated septum
E. Choanal atresia

19. A fully immunized 2-year-old presents to the emergency room withseveral days of low-grade fever,
barking cough, and noisy breathing. Overthe last few hours he has developed a fever to 40°C (104°F) and
looks toxic.He has inspiratory and expiratory stridor. The family has not noticed drooling, and he seems
to be drinking without pain. Direct laryngoscopy revealsa normal epiglottis. The management of this
disease process includes

A. Intubation and intravenous antibiotics

B. Inhaled epinephrine
C. Inhaled steroids
D. Observation only
E. Oral antibiotics and outpatient follow-up
20. A 10-year-old has had a “cold” for 14 days. In the 2 days prior to thevisit to your office, she has
developed a fever to 39°C (102.2°F), purulentnasal discharge, facial pain, and a daytime cough.
Examination of the noseafter topical decongestants shows pus in the middle meatus. The most
likely diagnosis is

A. Brain abscess
B. sinusitis
C. Streptococcal throat infection
D. Sphenoid sinusitis
E. Middle-ear infection

21. You are awakened in the night by your 2-year-old son, who hasdeveloped noisy breathing on
inspiration, marked retractions of the chestwall, flaring of the nostrils, and a barking cough. He has had a
mild upperrespiratory infection (URI) for 2 days. The most likely diagnosis is?

A. Asthma
B. Epiglottitis
C. Bronchiolitis
D. Viral croup
E. Foreign body in the right mainstem bronchus

22. A 10-month-old boy, recently arrived from south somalia, has a 5 days historyof crying, with
intermittent drawing up of his knees to his chest. On the wayto the emergency room he passes a loose,
bloody stool. He has had no vomiting and has refused his bottle since the crying began. Physical
examinationis noteworthy for an irritable infant whose abdomen is very difficult toexamine because of
constant crying. His temperature is 38.8°C (101.8°F).The rectal ampulla is empty, but there is some gross
blood on the examining finger described as red currant jelly like. The most helpful study in the
immediate management of this patient would be?

A. Stool culture
B. Examination of the stool for ova and parasites
C An air-contrast enema
D. Examination of the blood smear
E. Coagulation studies

23. A 12-month-old girl has been spitting up her meals since 1 month ofage. Her growth is at the ninety-
fifth percentile, and she is otherwise asymptomatic and without findings on physical examination. The
most likely diagnosis is

A. Pyloric stenosis
B. Partial duodenal atresia
C. Hypothyroidism
D. Gastroesophageal reflux disease
E. Tracheoesophageal fistula
24. 125.A 1-day-old infant who was born by a difficult forceps delivery is alert and active. She does not
move her left arm, however, which she keeps internally rotated by her side with the forearm extended
and pronated; she also does not move it during a Moro reflex. The rest of her physical examination is
normal. This clinical picture most likely indicates

A. Fracture of the left clavicle

B. Fracture of the left humerus
C. Left-sided Erb-Duchenne paralysis
D. Left-sided Klumpke paralysis
E. Spinal injury with left hemiparesis

25. A 2-year-old boy with undescended testes is referred to a urologist.Surgical correction will probably
eliminate the risk of

A. Testicular malignancy
B. Decreased sperm count
C. Torsion of testes
D. Urinary tract infection
E. Epididymitis

26. A 6-year-old black boy has brown urine and healing impetigo Lesions. He presents with
hypertension, dyspnea, and periorbital edema. The most likely cause of his problem is

A. IgA nephropathy
B. Poststreptococcal glomerulonephritis
C. Idiopathic hypercalciuria
D. Pyelonephritis
E. Sexually transmitted disease

27. The examination of a newborn’s back reveals a quarter-size “lump” ofsoft tissue overlying the lower
spine. Evaluation with ultrasound of thislesion may demonstrate

A. Ebstein pearl
B. Mongolian spot
C. Cephalohematoma
D. Omphalocele
E. Occult spina bifida
28. A 9-year-old girl is brought to her pediatrician with the complaint ofsevere, intermittent headaches
for the last several months. The physicalexamination, including a careful neurologic examination, is
normal. Whichof the following characteristics support the diagnosis of migrainein this patient?

A. Strong family history of migraine

B. Frequently isolated to the occipital region
C. Frequently associated with attention deficit hyperactive disorder
D. Duration of headache more than 24 h
E. Persistence of headache after sleep

29. A 3-year-old boy’s parents complain that their child has difficultywalking. The child rolled, sat, and
first stood at essentially normal ages andfirst walked at 13 months of age. Over the past several months,
the family has noticed an increased inward curvature of the lower spine as he walksand that his gait has
become more “waddling” in nature. On examination,you confirm these findings and also notice that he
has enlargement of hiscalves. This child most likely has

A. Occult spina bifida

B. Muscular dystrophy
C. Brain tumor
D. Guillain-Barré syndrome
E. Botulism

30. Two weeks after a viral syndrome, a 2-year-old child develops bruising and generalized petechiae,
more prominent over the legs. No hepatosplenomegaly or lymph node enlargement is noted. The
examination is otherwise unremarkable. Laboratory testing shows the patient to have anormal
hemoglobin, hematocrit, and white blood count and differential. The platelet count is 15,000/µL. The
most likely diagnosis is

A. von Willebrand disease

B. Acute leukemia
C. Idiopathic (immune) thrombocytopenic purpura
D. Aplastic anemia
E. Thrombotic thrombocytopenic purpura

31. Appropriate treatment of this child includes

A. Intravenous gamma globulin

B. Platelet transfusion
C. Aspirin therapy
D. Factor VIII infusion
E. Prednisone, vincristine, and asparaginase induction followed by methotrexateand 6-mercaptopurine
32. A 7-year-old boy has crampy abdominal pain and a rash mainly on the back of his legs and buttocks
as well as on the extensor surfaces of his forearms. Laboratory analysis reveals proteinuria and
microhematuria. He is most likely to be affected by

A. Systemic lupus erythematosus

B. Anaphylactoid purpura
C. Poststreptococcal glomerulonephritis
D. Takayasu arteritis
E. Dermatomyositis

33. A 10-year-old boy comes to your office in thewinter with a sore throat he has had for 2 days. In
addition, he has had fever, headache, andabdominal pain. He does not have any allergies to
medications. On examination, he has a temperature of 38.6°C, an erythematous pharynx,and tender
cervical adenopathy. A rapid screening test for group A streptococcus is performedand is positive. Which
of the following wouldbe the most appropriate antimicrobial agent?

(A) gentamicin
(B) penicillin
(C) trimethoprim-sulfamethoxazole
(D) azithromycin
(E) cefaclor

34. The same child returns to your office the nextday. He has taken the medication you prescribed.
He is feeling a little better. His feverhas resolved, but he has developed a rash. Hisexamination is
unchanged, except that he isafebrile and has a fine, papular rash over his body, which is accentuated in
his axilla andgroin. Which of the following is the most likelycause of his rash?

(A) Allergic reaction to the antibiotic

(B) Rash from the antibiotic seen in patientswith mononucleosis
(C) Scarlet fever
(D) Serum sickness
(E) viral exanthem typical of enterovirus

35. A 6-year-old girl has a low-grade fever, headache, and nasal congestion. She has aflushed face and
has developed a lacy reticularrash on the trunk and extensor surface of herarms and legs. Palms and
soles are spared. Hermother has been ill with a low-grade fever andsome joint stiffness and pain. Which
of the following is the most likely diagnosis?

(A) rubella
(B) measles
C. scarlet fever
D. roseola infantum
E. erythema infectiosum
36. An 18-month-old girl is brought to the hospital with a history of 6 days of bloody diarrhea.
She has been drinking well but has not beenwetting her diaper. She has been irritable. Onphysical
examination, she has periorbitaledema. She appears pale and is tachycardic.Her CBC shows a
hemoglobin of 6 g/dL and aplatelet count of 100,000/mm3. Her blood ureanitrogen (BUN) is 50 mg/dL
and creatinine is5.5 mg/dL. Her urinalysis shows gross hematuria. Which of the following is the most
likelycausative organism for her clinical problem?

(A) E. coli0157:H7
(B) GroupA Streptococci
(C) Group B Streptococci (GBS)
(D) S. aureus
(E) The cause of this illness is not known

37. A 13-year-old girl presents with lethargy, fever,severe headache, and a stiff neck. On examination, a
unilateral fixed, dilated pupil and papilledema are noted. Which of the following is the most appropriate
initial step in managing this patient?

(A) Administration of IV cefotaxime

(B) Administration of IV mannitol
(C) CT of the head
(D) Intubation and hyperventilation
(E) Performance of a lumbar puncture

38. A previously healthy 8-year-old boy has a 3-week history of low-grade fever of unknown source,
fatigue, weight loss, myalgia, and headaches. On repeated examinations during this time, he is found to
have developed a heart murmur, petechiae, and mild splenomegaly. The most likely diagnosis is

A. Rheumatic fever
B. Kawasaki disease
C. Scarlet fever
D. Endocarditis
E. Tuberculosis

39. A beekeeper’s previously healthy 6-month-old son develops gradual onset of lethargy, poor feeding,
constipation, and generalized weakness. On taking a history, you determine that the child has recently
been placed on a homemade formula consisting of evaporated milk, water, and honey. Which of the
following is the most likely explanation for this symptom complex?

(A) Sodium intoxication

(B) Hirschsprung disease
(C) Hypothyroidism
(D) Spinal cord tumor
E. botulism
40. A 10-year-old boy presents with a 3- to 4-day history of left ear pain. He is afebrile; he has had no
symptoms of cold or cough. He has been swimming daily.On physical examination, there is pain on
moving the pinna and the tragus. There is erythema and swellingof the ear canal; Which of the
following is the most likely diagnosis?

(A) Otitis externa

(B) Furunculosis
(C) Otitis media with effusion
(D) Mastoiditis
(E) Foreign body in the ear

MARKS: 5*40=200 marks

QII: extended matching question, you can use the options once or more, and not at all
A. Respiratory distress syndrome (hyaline membrane disease)
B. Meconium aspiration
C. Transient tachypnea of the newborn
D. Caput succedaneum
E. Neurofibromatosis
F. Salmon patch
G. Neonatal acne
H. Pustular melanosis
I. Erythema toxicum
J. Milia
K. seborrheic dermatitis

1. 1. A 1-week-old child’s mother complains that the child has a transient rash that has
splotchy areas of erythema with a central clear pustule. Your microscopic
examination of the liquid in the pustule reveals eosinophils, what is the diagnosis?

Erythema toxicum

2. An adolescent boy complains of a splotchy red rash on the nape of hisneck,

discovered when he had his head shaved for football season. The rash seems to get
more prominent with exercise or emotion. His mother notes that he has had the
rash since infancy, but that it became invisible as hair grew. He had a similar rash on
his eyelids that resolved in the newborn period, what is the diagnosis?

Salmon patch
3. 3.A nurse calls you to evaluate an African American baby that seems tohave a
bacterial skin infection, with many scattered pustules full of a milky fluid. Upon
examining a pustule, it easily wipes away, revealing a hyper pigmented spot, what is

the diagnosis? Pustular melanosis

4. 4. A newborn’s mother complains that her infant seems to have very small white
dots all over his nose. The dots do not wipe off with bathing, but they are also not

erythematous, what is the diagnosis? Milia

5. 5 .A newborn’s father complains that his son has dandruff, with manywaxy flakes of
skin on the scalp. When he scrapes the lesions, hair often comes off with the flakes
of skin. In addition, the baby has flaking of the eyebrows , what is the diagnosis?

Seborrheic dermatitis

6. 6. An infant with seizures, a hypsarrhythmic EEG pattern, and ash-

leafdepigmentation on her back, what is the diagnosis?

Neurofibromatosis

7. 7. A term infant delivered via scheduled cesarean section develops, at15 min of age,
tachypnea, grunting, flaring, and retractions. A chest radiograph reveals well-
aerated lungs with fluid in the fissure on the right, Prominent pulmonary
vascular markings and flat diaphragms. The child is Mildly hypoxic on room air with
89% oxygen saturation. Over the next 6 h she improves and no longer requires
oxygen. What is the diagnosis? Transient tachypnea of the
new born

8. 8. A post term infant is born at home after a prolonged and difficult labor. The
maternal grandmother brings the infant to the hospital at 1 h of life because of fast
 breathing. Grandmother notes that the child spit up some dark brown particulate
fluid shortly after birth. Physical examination reveals an infant in marked respiratory
distress. Other findings include both an umbilical cord and flaking skin with a
yellow-green hue. Chest radiograph reveals patchy infiltrates bilaterally. What is the

diagnosis? Meconium aspiration

9. 9. An infant of uncertain dates is born via emergent cesarean section after the
mother was critically injured in a motor vehicle accident. Birth weight was 1075 g.
The infant has poor respiratory effort and you begin bag-mask ventilation but find it
extremely difficult to cause chest wall movement. A chest radiograph reveals diffuse
white out of both lungs, with an occasional air bronchogram. What is the diagnosis?

Hyaline membrane disease

10. 10. A 1-day-old healthy infant with a superficial swelling over the right
parietotemporal region that does not cross the suture lines, what is the diagnosis?

Caput succedaneum
MARKS: 3*10=30 marks

Good luck

Answer of the MCQ’S

1. B 21. D
2. 2. C 22. C
3. D 23. D
4. B 24. D
5. A 25. A
6. D 26. B
7. B 27. E
8. B 28. A
9. D 29. B
10. C 30. C
11. A 31. A
12. A 32. A
13. D 33. B
14. C34. B
15. A35. E
16. A36. A
17. D 37. C
18. A 38. D
19. B39. E
20. B40. A
EXTENDED MATCHING ANSWERS

11. Erythema toxicum

12. Salmon patch
13. Pustular melanosis
14. Milia
15. Seborrheic dermatitis
16. Neurofibromatosis
17. Transient tachypnea of the new born
18. Meconium aspiration
19. Hyaline membrane disease
20. Caput succedaneum