33.

Desmopressin acetate is a synthetic analog of antidiuretic hormone that

reduces urine production overnight. This medication is FDA-approved in
children and is preferable to be used as
A. tablet
B. IM injection
C. IV injection
D. nasal spray
E. skin patch

34. Which of the following types of renal stones are radiolucent on plain
abdominal radiograph?
A. Calcium oxalate
B. Calcium phosphate
C. Cystine
D. Struvite
E. Uric acid

35. What is the MOST common cause of priapism in children?

A. Sickle cell disease
B. Sildenafil ingestion
C. Leukemia
D. Perineal trauma
E. Idiopathic

36. Which of the following syndromes causes micropenis due to

hypergonadotropic hypogonadism?
A. Robinow syndrome
B. Kallmann syndrome
C. Prader-Willi syndrome
D. Bardet–Biedl syndrome
E. Lawrence-Moon-Bardet-Biedl syndrome

37. What is the maximum age the testes can be descended spontaneously in a
baby with cryptorchidism?
A. 2 months
B. 4 months
C. 6 months
D. 9 months
563
 E. 12 months

38. A 4-year-old boy with cryptorchidism presents with inguinal pain and
swelling.
Which of the following is the MOST likely diagnosis?
A. Seminoma
B. Femoral hernia
C. Testicular torsion
D. Germ cell malignancy
E. Varicocele

39. A 10-year-old girl presents with loin pain and hematuria. Urine dipstick
demonstrates blood ++++, nitrates +ve, leukocyte +++, and protein ++, urine
culture shows Proteus infection. KUB demonstrates a stag-horn calculus in the
left renal pelvis.
What is the MOST likely composition of this renal stone?
A. Calcium oxalate
B. Xanthine
C. Cystine
D. Struvite
E. Urate

40. Which of the following is the only complication cystinuria?

A. Renal tubular acidosis
B. Chronic renal failure
C. Renal calculi
D. Nephrocalcinosis
E. Recurrent UTI

41. Which of the following is the MOST common organism in a 9-year-old boy
with scrotal pain, erythema, and swelling?
A. Escherichia coli
B. Chlamydia
C. Gonococcus
D. Enterovirus
E. Adenovirus

564
42. Which of the following can differentiate testicular torsion from an
incarcerated hernia?
A. Tender testis
B. Swollen scrotum
C. Absent cremasteric reflex
D. Absent swelling in the inguinal area
E. Associated nausea and vomiting

43. Which of the following anatomical sites of renal stones is asymptomatic?

A. Ureteropelvic junction
B. Mid-ureter
C. Ureterovesical junction
D. Urinary bladder
E. Urethra

44. What is the MOST appropriate imaging modality in suspected renal colic?
A. KUB
B. U/S
C. spiral CT scan
D. MRI
E. IV pyelography

565
CHAPTER 23
Urologic Disorders
Answers
QAHTAN ALOBAIDY
1.(B) The arguments against such participation are that the contralateral normal
kidney is hypertrophic and not as well protected by the ribs, and a serious renal
injury could have serious lifelong consequences.
2.(E) MCDK is a congenital condition in which the kidney is replaced by cysts and
does not function; it can result from ureteral atresia. Kidney size is highly
variable. The incidence is approximately 1 in 2,000. MCDK usually is unilateral
and generally is not inherited.
3.(B) A multilocular cyst (multilocular cystic nephroma) is a lesion in the kidney
that falls in a spectrum of diseases, along with multilocular cyst with partially
differentiated Wilms tumor, multilocular cyst with nodules of Wilms tumor, or
cystic Wilms tumor. The multilocular cyst is considered benign and is unrelated
to the multicystic dysplastic kidney. More than 95% occur in children < 4 yr, and
most are discovered during evaluation for an abdominal or flank mass. The
lesion should be removed.
4.(A) Upper urinary tract anomalies are more common in children with certain
physical findings. The incidence of renal anomalies is increased if there is a
single umbilical artery and an abnormality of another organ system (congenital
heart disease).
5.(B) External ear anomalies (particularly if the child has multiple congenital
anomalies), imperforate anus, and scoliosis are associated with renal anomalies.
Infants with these physical findings should undergo a renal sonogram.
6.(D) Urinary tract infections are caused primarily by colonic bacteria.
Escherichia coli cause 54–67% of all UTIs, followed by Klebsiella spp. and
Proteus spp., Enterococcus, and Pseudomonas. Other bacteria known to cause
UTIs include Staphylococcus saprophyticus, group B streptococcus, and, less
commonly, Staphylococcus aureus, Candida spp., and Salmonella spp.
7.(D)
8.(B) Fever may be the only manifestation; particular consideration should
occur for a temperature > 39C without another source lasting more than 24 hr
for males and more than 48 hr for females.
566
9.(E) Xanthogranulomatous pyelonephritis is a rare type of renal infection
characterized by granulomatous inflammation with giant cells and foamy
histiocytes. It can manifest clinically as a renal mass or an acute or chronic
infection. Renal calculi, obstruction, and infection with Proteus spp. or E. coli
contribute to the development of this lesion, which usually requires total or
partial nephrectomy.
10.(C) D-penicillamine is a chelating agent that binds to cysteine or
homocysteine, increasing the solubility of the product. Although poorly
tolerated by many patients, it has been reported to be effective in dissolving
cystine stones and in preventing recurrences when hydration and urinary
alkalinization fail.
11.(D) Nitrites and leukocyte esterase are often positive in infected urine.
Bacteria generally require 4 hr for metabolism of nitrates to nitrites. Nitrites
may not be detected in cases of UTI if the organism does not convert nitrates to
nitrites (most notably enterococcus) or if the child has urinary frequency, where
there may not be enough time for the conversion to nitrites. In febrile infants
less than 60 days old, the presence of pyuria, nitrites, or leukocyte esterase has
a high sensitivity and specificity for a UTI.
12.(C) Sterile pyuria (positive leukocytes, negative culture) may occur in partially
treated bacterial UTIs, viral infections, urolithiasis, renal tuberculosis, renal
abscess, UTI in the presence of urinary obstruction, urethritis as a consequence
of a sexually transmitted infection, inflammation near the ureter or bladder
(appendicitis, Crohn disease), Kawasaki disease, schistosomiasis, neoplasm,
renal transplant rejection, or interstitial nephritis (eosinophils).
13.(D) Nitrofurantoin should not be used routinely in children with a febrile UTI,
because it does not achieve significant renal tissue levels.
14.(D) The rate of renal scarring increases between days 2 and 3 of fever; this
makes the prompt evaluation and appropriate treatment of a recurrent UTI
important. Urine cultures are typically negative within 24 hr of initiation of
antibiotic therapy, and therefore a urine culture during treatment is almost
invariably negative.
15.(A) Primary VUR appears to be an autosomal dominant inherited trait with
variable penetrance.
16.(C)
17.(A) Radiation exposure during a radionuclide cystogram is significantly less
than that from a contrast VCUG.
18.(D)
19.(B)
567
20.(A)
21.(B) Because neonatal oliguria can cause temporary decompression of a
dilated renal pelvis, it is ideal to perform the first postnatal US after the 3rd day
of life. Delaying the US may be impractical.
22.(A) The prognosis ultimately depends on the degree of pulmonary hypoplasia
and renal dysplasia. One third of children with prune-belly syndrome are
stillborn or die in the first few mo of life because of pulmonary hypoplasia.
23.(C) The most common cause of severe obstructive uropathy in children is
PUVs, affecting 1 in 8,000 males. While the most severe form of obstructive
uropathy in males is urethral atresia, a rare condition.
24.(C)
25.(D) They occur commonly in children with connective tissue disorders,
including Williams syndrome, Ehlers-Danlos syndrome, and Menkes syndrome.
26.(B) A patent urachus results in continuous urinary drainage from the
umbilicus. Vesicourachal diverticulum, which is a diverticulum of the bladder
dome, and umbilical–urachal sinus, which is a blind external sinus that opens at
the umbilicus. These lesions should be excised.
27.(D) Bladder calculi have developed in as many as 70% of children followed
for 10 yr after enterocystoplasty. The calculi develop in response to mucus that
accumulates in the bladder and act as a nidus for stone formation. This
complication can be prevented by daily irrigation of the bladder with sterile
saline.
28.(A) Approximately 30–45% of children with a high imperforate anus have a
neuropathic bladder, often because of sacral agenesis. Newborns with
imperforate anus should undergo a spinal ultrasound during their initial
evaluation.
29.(A) The most common causes of daytime incontinence are overactive
bladder (urge incontinence) and bladder–bowel dysfunction.
30.(B) Hinman syndrome is a very serious but uncommon disorder involving
failure of the external sphincter to relax during voiding in children without
neurologic abnormalities. Children with this syndrome also called
nonneurogenic neurogenic bladder, typically exhibit a staccato stream, day and
night wetting, recurrent UTIs, constipation, and encopresis.
31.(B) In children up to the age of 14 yr, the mean bladder capacity in milliliters
is equal to the age + 2 (in years) times 30 (e.g., the bladder capacity of a 6 yr old
should be 240 mL).
32.(C) Reassure the child and parents that the condition is self-limited and to
avoid punitive measures that can affect the child's psychological development
568
adversely. Active treatment should be avoided in children younger than 6 yr of
age, because enuresis is extremely common in younger children.
33.(A) In the past a nasal spray was used, but some children experienced
hyponatremia and convulsions with this formulation, and the nasal spray is no
longer recommended for nocturnal enuresis. Hyponatremia has not been
reported in children using the oral tablets.
34.(E) These stones are radiolucent on x-ray. The diagnosis should be suspected
in a patient with persistently acid urine and urate crystalluria.
35.(A) The most common cause of priapism in children is sickle cell disease,
which is characterized by a predominance of sickle cell hemoglobin. As many as
27.5% of children with sickle cell disease develop priapism. The priapism is
generally related to a low-flow state, secondary to sickling of red blood cells
within the sinusoids of the corpora cavernosa during normal erection, resulting
in venous stasis.
36.(A) Primary testicular failure can result from gonadal dysgenesis or
rudimentary testes syndrome and also occurs in Robinow syndrome
(characterized by hypoplastic genitalia, shortening of the forearms, frontal
bossing, hypertelorism, wide palpebral fissures, short broad nose, long
philtrum, small chin, brachydactyly, and a normal karyotype).
37.(B) Spontaneous descent occurs secondary to a temporary testosterone
surge (termed a minipuberty) during the first 2 mo, which also results in
significant penile growth. If the testis has not descended by 4 mo, it will remain
undescended.
38.(C) Inguinal pain and/or swelling in a male with an undescended testis should
raise the suspicion of an inguinal hernia or torsion of the undescended testis.
39.(D) Urinary tract infections caused by urea-splitting organisms (most often
Proteus spp., and occasionally Klebsiella spp., Escherichia coli, Pseudomonas
spp., and others) result in urinary alkalinization and excessive production of
ammonia, which can lead to the precipitation of magnesium ammonium
phosphate (struvite) and calcium phosphate. In the kidney, the calculi often
have a staghorn configuration, filling the calyces. The calculi act as foreign
bodies, causing obstruction, perpetuating infection, and causing gradual kidney
damage.
40.(C) Cystinuria is a rare autosomal recessive disorder of the epithelial cells of
the renal tubule that prevents absorption of the four dibasic amino acids
(cystine, ornithine, arginine, lysine) and results in excessive urinary excretion of
these products. The only known complication of this familial disease is the

569
formation of calculi, because of the low solubility of cystine. The patients
usually have acidic urine, which leads to a higher rate of precipitation.
41.(A) In younger males, the responsible organismis often Escherichia coli. After
puberty, bacterial epididymitis becomes progressively more common and can
cause acute painful scrotal swelling in young sexually active males. Urinalysis
usually reveals pyuria. Epididymitis can be infectious (usually gonococcus or
Chlamydia), but often the organism remains undetermined. Additional
etiologies include familial Mediterranean fever, enterovirus, and adenoviruses.
42.(D) Testicular torsion produces acute pain and swelling of the scrotum. On
examination, the scrotum is swollen, and the testis is exquisitely tender and
often difficult to examine. The cremasteric reflex nearly always is absent. The
position (lie) of the testis is abnormal, and the testis position often is high in the
scrotum. In addition, often there is associated nausea and vomiting. The
condition can be differentiated from an incarcerated hernia because swelling in
the inguinal area typically is absent with torsion.
43.(D) Children with urolithiasis usually have gross or microscopic hematuria,
severe flank pain and can have irritative symptoms of dysuria, urgency, and
frequency. If the calculus is in the distal ureter, the child can have irritative
symptoms of dysuria, urgency, and frequency. If the stone passes into the
bladder, the child usually becomes asymptomatic. If the stone is in the urethra,
dysuria and difficulty voiding can result, particularly in males.
44.(C) In a child with suspected renal colic, there are multiple imaging options.
The most accurate study is an unenhanced spiral CT scan of the abdomen and
pelvis. This study takes only a few minutes to perform, has 96% sensitivity and
specificity in delineating the number and location of calculi, and demonstrates
whether the involved kidney is hydronephrotic.

570
CHAPTER 24
Gynecologic Problems of Childhood
Questions
QAHTAN ALOBAIDY
1. Neonatal vaginal bleeding requires further evaluation if it persists beyond
A. 5 days
B. 10 days
C. 20 days
D. 30 days
E. 45 days

2. Which of the following types of hymens associated with urinary obstruction?

A. Crescentic
B. Redundant
C. Microperforate
D. Septated
E. Imperforate

3. Which of the following clitoral width in a newborn need further evaluation?

A. >2 mm
B. >3 mm
C. >4 mm
D. >5 mm
E. >6 mm

4. What is the MOST common cause of ambiguous genitals in the neonatal

period?
A. Congenital adrenal hyperplasia
B. Complete androgen insensitivity
C. Male pseudohermaphrodite
D. True hermaphrodite
E. Idiopathic

571
5. A 15-year-old girl presented with external genital pruritus and skin lesion.
Examination reveals skin-colored papules, some with a shaggy, cauliflower-like
appearance.
Of the following, the MOST likely diagnosis is
A. molluscum contagiosum
B. condyloma acuminata
C. herpes simplex
D. lichen sclerosus
E. contact dermatitis

6. Which of the following antibiotics is recommended as first line therapy in

vulvovaginal Infections caused by Haemophilus influenza?
A. Cotrimoxazole
B. Clarithromycin
C. Azithromycin
D. Amoxicillin
E. Erythromycin ethyl succinate

7. Which of the following antibiotics is recommended as first line therapy in

vulvovaginal Infections caused by Yersinia?
A. Cotrimoxazole
B. Clarithromycin
C. Penicillin V
D. Amoxicillin
E. Erythromycin ethyl succinate

8. A 3-month-old girl presents with napkin rash treated by increasing the

frequency of diaper changes, allowing her to be diaper free, frequent bathing,
and application of zinc oxide but without significant benefit.
Which of the following can decrease the inflammation of his diaper dermatitis
when applied topically?
A. Antifungal
B. Steroid
C. Coconut oil
D. Gention violet
E. Antibiotic

572
9. Which of the following is FIRST-LINE therapy in patients with labial adhesions
and difficulty voiding?
A. Topical estrogen
B. Surgical correction
C. Topical antibiotic
D. Systemic antibiotic
E. Systemic anticholinergic

10. Which of the following syndromes is the MOST common cause of vaginal
agenesis?
A. Fraser
B. McKusick-Kaufman
C. Johanson-Blizzard
D. Renal-genital-middle ear anomalies
E. Mayer-Rokitansky-Küster-Hauser

11. Which of the following dermatologic conditions affect the vulvar area in
children and can lead to destruction and scarring of normal genital
architecture?
A. Vulvar psoriasis
B. Lichen sclerosis
C. Idiopathic vulvar aphthoses
D. Contact dermatitis
E. Lichen planus

12. History is often more predictive than physical exam in the diagnosis of which
of the following conditions?
A. Vaginal foreign body
B. Pinworms infestation
C. Labial agglutination
D. Molluscum contagiosum
E. Condyloma acuminata

13. A 10-year-old girl presents with blood-tinged and foul-smelling vaginal

discharge fails to respond to hygiene measures.
Of the following, the MOST likely diagnosis is
A. vaginal foreign body
B. acute genital ulcer
573
 C. herpes simplex infection
D. molluscum contagiosum
E. condyloma acuminata

14. Lack of development of the breast is considered delayed and warrants

evaluation at which of the following ages?
A. 10 year
B. 11 year
C. 12 year
D. 13 year
E. 14 year

15. Which of the following is characterized by amastia and aplasia of the

pectoralis muscles?
A. Ectodermal dysplasia
B. Congenital adrenal hyperplasia
C. Gonadal dysgenesis
D. Hypogonadotropic hypogonadism
E. Poland syndrome

16. Which of the following is the MOST common cause of breast pain in
adolescent’s girls?
A. Exercise
B. Pregnancy
C. Prolactinoma
D. Fibroadenoma
E. Polycystic ovary syndrome

17. Which of the following drugs can cause unilateral thelarche?

A. Diazepam
B. Cimetidine
C. Haloperidol
D. Cyproheptadine
E. Oral contraceptives

18. Which of the following is the MOST common solid mass seen in the breast
of an adolescent girl?
A. Lipoma
574
 B. Intraductal papilloma
C. fibroadenoma
D. Breast carcinoma
E. Intramammary lymph node

19. Which of the following is the MOST common ovarian neoplasm in children
and adolescents?
A. Dysgerminoma
B. Cystadenomas
C. Gonadoblastoma
D. Gynandroblastoma
E. Mature cystic teratoma

20. A 10-year-old girl presents with acute lower abdominal pain, nausea, and
vomiting. Examination revels abdominal tenderness. Pelvic ultrasound shows
enlargement of left adnexa and demonstrate the presence of Doppler flow, free
pelvic fluid, and “whirlpool sign”. Of the following ,the MOST likely diagnosis is
A. tubo-ovarian abscess
B. endometriomas
C. adnexal torsion
D. ovarian cyst
E. uterine rhabdomyosarcoma

21. Which of the following heritable syndromes associated with müllerian

anomalies is X-linked type of inheritance?
A. Camptobrachydactyly
B. Hand-foot-genital
C. Fraser
D. Uterine hernia
E. Renal-genital-middle ear anomalies

22. Which of the following is the MOST sensitive and specific imaging technique
used for evaluating müllerian anomalies?
A. MRI
B. Ultrasound
C. Hysterosalpingogram
D. Sonohysterography
E. CT scan
575
CHAPTER 24
Gynecologic Problems of Childhood
Answers
QAHTAN ALOBAIDY
1.(D) Estrogenic effects commonly notable in neonates include prominence of
the labia majora and a white vaginal discharge. The labia minora and hymen
may protrude slightly from the vestibule. A small amount of neonatal vaginal
bleeding from endometrial sloughing following maternal hormone withdrawal
might occur. Bleeding that is excessive or persistent beyond 1 mo of life
requires further evaluation.
2.(E) Cervico-vaginal mucus secretions can accumulate behind the blocked
outflow tract of an imperforate hymen and manifest as a mucocolpos. In this
instance and if urinary obstruction occurs, correction of the imperforate hymen
in the neonatal period is indicated.
3.(E) The clitoris may appear large in proportion to the other genital structures,
especially in premature infants. If the clitoris appears enlarged, the clitoral
width should be measured; values > 6 mm in a newborn indicate a need for
further evaluation. If clitoromegaly and ambiguous genitals are present, the
obstetrician and pediatrician should immediately obtain expert consultation for
evaluation of the infant and to counsel the parents.
4.(A) Congenital adrenal hyperplasia is the most common cause of ambiguous
genitals (accounting for > 90% of cases), and the salt-wasting forms can lead to
rapid dehydration with subsequent fluid and electrolyte imbalance. Delay in the
diagnosis and treatment of congenital adrenal hyperplasia may be life-
threatening.
5.(B)
6.(D)
7.(A)
8.(A) First-line treatment includes hygiene measures such as increasing the
frequency of diaper changes, allowing the infant to be diaper free, frequent
bathing, and application of water-repellant barriers such as zinc oxide. If diaper
dermatitis persists after these conservative measures, or if the classic satellite
lesions of Candida are present, treatment with a topical antifungal can decrease
the inflammation.

576
9.(A) First-line therapy in patients with difficulty voiding, persistent infections,
or pain includes topical estrogen (Premarin or Estrace cream 0.01%) or a topical
steroid (Betamethasone 0.05% ointment) applied twice daily to the midline
raphe under gentle traction. Surgical correction is rarely necessary, but
recurrence is common until the age of puberty.
10.(E) The most common cause of vaginal agenesis is MayerRokitansky-Küster-
Hauser (MRKH) syndrome, with an incidence reported at 1 in 4,000-5,000
female births. After gonadal dysgenesis, müllerian agenesis is the second most
common cause of primary amenorrhea. The etiology is believed to be
multigenetic and multifactorial. This condition is present at birth but often not
diagnosed until mid-adolescence.
11.(B) Lichen sclerosus is commonly seen in the anogenital region and has a
characteristic appearance of white skin changes associated with areas of
erosion, ulceration, and petechiae. This disease can cause severe discomfort
and most commonly presents with vulvar or perianal pruritus, dysuria, and
constipation.
12.(B) If pinworms are suspected, transparent adhesive tape or an anal swab
should be applied to the anal region in the morning before defecation or
bathing and then placed on a slide. Eggs seen on microscopic examination
confirm the diagnosis, and sometimes the pinworms can be seen at the anal
verge. Clinical history is often more indicative of disease than physical exam,
and a negative tape test does not rule out this pathogen as a cause.
13.(A) Vaginal foreign bodies are a common finding in children presenting with
blood-tinged and foul-smelling discharge. Quick identification and removal of
the foreign body avoids potential complications, including recurrent urinary
tract infections, dermatologic abnormalities, vaginal perforation, or fistula
formation. The most common object found in the prepubertal vagina is retained
toilet paper.
14.(D)
15.(E) Amastia is usually unilateral and can be congenital or associated with
systemic disorders (e.g., ectodermal dysplasia), endocrine disorders (e.g.,
congenital adrenal hyperplasia, gonadal dysgenesis, hypogonadotropic
hypogonadism), or novel gene mutations. It can be associated with anomalies of
the underlying mesoderm, such as abnormal pectoralis muscles seen in Poland
syndrome (aplasia of the pectoralis muscles, rib deformities, webbed fingers,
and radial nerve aplasia).
16.(A) The most common causes of breast pain in adolescents are exercise and
benign breast changes. Physiologic swelling and tenderness occur on a cyclic
577
basis, most commonly during the premenstrual phase, and are secondary to
hormonal stimulation and resulting proliferative changes.
17.(B) Unilateral thelarche has also been reported as a side effect of cimetidine
and is reversible when the medication is stopped.
18.(C) The most common solid mass seen in adolescent girls is the
fibroadenoma. Fibroadenomas are most often located in the upper outer
quadrant of the breast. The average size is 2-3 cm, and 10–25% of patients have
multiple lesions. The physical examination is usually diagnostic because these
lesions are well circumscribed, rubbery, mobile, and not tender. In equivocal
cases, an ultrasound may be helpful in making the diagnosis.
19.(E) The most common ovarian neoplasm in children and adolescents is the
mature cystic teratoma (dermoid cyst). Most are benign and contain mature
tissue of ectodermal (skin, hair, sebaceous glands, neuroectodermal tissue),
mesodermal (muscle, bone, cartilage, fat, teeth), and/or endodermal (thyroid,
salivary, respiratory, gastrointestinal) origin.
20.(C) Adnexal torsion of the ovary and/or fallopian tube is the fifth most
common gynecologic emergency and occurs more often in children and
adolescents than in adults. It can occur in individuals with normal adnexa but
more often occurs in adnexa enlarged by cystic (follicular, tubal) changes or
ovarian (teratoma, cystadenoma) neoplasms.
21.(D)
22.(A) MRI is considered standard of care and best suited for complex
anomalies because of its noninvasive, high-quality capabilities. MRI is the most
sensitive and specific imaging technique used for evaluating müllerian
anomalies because it can image nearly all reproductive structures, blood flow,
external contours, junctional zone resolution on T2-weighted images, and
associated renal and other anomalies. MRI also has a high correlation with
surgical findings because of its multiplanar capabilities and high spatial
resolution.

578
Chapter 25
The Endocrine System
Questions
HAYDER ALMUSAWI
1. What is the most sensitive test for primary thyroid dysfunction?
A. Free T3
B. T4
C. TSH
D. TRH
E. Thyroglobulin

2. Thyroxine-Binding Globulin (TBG) level usually decrease in

A. pregnancy
B. administration of glucocorticoids
C. newborn period
D. hepatitis
E. administration of estrogens

3. The result of screening program of a child is low level of total T4 and normal
levels of free T4 and TSH.
What is the most likely diagnosis?
A. Primary hypothyroidism
B. Secondary hypothyroidism
C. Tertiary hypothyroidism
D. TBG deficiency
E. Thyroditis

4. What is the dose of L-T4 for a 7-year old child with acquired hypothyroidism?
A. 1-2 μg/kg
B. 3-5 μg/kg
C. 6-8 μg/kg
D. 9-11 μg/kg
E. 12-15 μg/kg

579
5. Children treated with amiodarone should have serial monitoring of
A. renal function
B. thyroid function
C. liver function
D. platelet count
E. blood sugar

6. Which of the following is a characteristic finding in familial dysalbuminemic

hyperthyroxinemia?
A. Increased serum concentrations of T4
B. Decreased serum concentrations of TSH
C. Increased serum concentrations of free T4
D. Increased serum concentrations of free T3
E. Increased serum concentrations of TSH

7. What is the most common cause of permanent congenital hypothyroidism?

A. Defects in thyroid hormone synthesis
B. Defective Iodide transport
C. Thyroid dysgenesis
D. Defects of Iodine organification
E. Defects of thyroglobulin synthesis

8. A 10-month-old boy found to have bilateral fallopian tubes and a rudimentary

uterus during repair of herniorrhaphy. Biopsy of the gonads reveals normal
testicular tissue. On examination, his phallus is normal in size and appearance,
and his testes size is 2 mL for each.
What is the MOST likely sex chromosome pattern for this child?
A. XY
B. XX/XY
C. XXY
D. XO/XY
E. XYY

9. Which of the following play a role in inhibiting GH release?

A. Sleep
B. Exercise
C. Physical stress
D. Trauma
580
 E. Hyperglycemia

10. Which of the following inhibit release of CRH and ACTH?

A. Atrial natriuretic peptide
B. Arginine vasopressin
C. Oxytocin
D. Angiotensin II
E. Cholecystokinin

11. A 9-year-old boy has been hospitalized for 1 month following road traffic
accident. He is in a full body cast and has not been able to ambulate. In the last
2 days, he becomes irritable, anorectic, with frequent urination.
Of the following, the MOST likely cause is
A. hyperglycemia
B. hyponatremia
C. hypercalcemia
D. hypokalemia
E. cytitis

12. Which of the following is an indication for rhGH treatment to promote linear
growth?
A. Chronic renal failure after transplantation
B. Idiopathic short stature
C. Constitutional growth delay
D. Edward syndrome
E. Thalassemia

13. Which of the following is a reasonable Criterion for stopping GH treatment?

A. A decision by the patient that he or she is tall enough
B. A growth rate <3 inch/yr
C. A bone age >16 yr in girls
D. A bone age >18 yr in boys
E. Recurrent abdominal pain

14. Which of the following can be caused by recombinant IGF-1?

A. Hypertension
B. Hypocalcaemia
C. Hypoglycemia
581
 D. Anemia
E. Acidosis

15. Which of the following results can establish the diagnosis of diabetis inspidis
(DI)?
A. Serum potassium <3.5 mmol/ L and serum sodium <145 mmol/L
B. Serum potassium >4.5 mmol/L and serum sodium >135 mmol/L
C. Serum osmolality is <270 mOsm/kg and the urine osmolality is >600
mOsm/kg
D. Serum osmolality is >300 mOsm/kg and the urine osmolality is <300
mOsm/kg
E. Serum osmolality is >270 mOsm/kg and the urine osmolality is >330
mOsm/kg

16. The initial approach to a patient with hyponatremia begins with

determination of
A. volume status
B. urine sodium
C. urine specific gravity
D. serum potassium
E. BUN

17. Which of the following causes of hyponatremia is associated with

hypovolemia and high urine sodium?
A. Systemic dehydration
B. SIADH
C. Renal primary salt loss
D. Runner's hyponatremia
E. Factitious hyponatremia

18. Syndrome of inappropriate antidiuretic hormone secretion (SIADH) is

characterized by
A. hypernatremia
B. concentrated urine (>100 mosm/kg)
C. decreased plasma volume
D. low urine sodium
E. high serum uric acid

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19. What is the maximum amount of water a person with normal renal function
can consume daily?
A. 4 L/m2
B. 6 L/m2
C. 8 L/m2
D. 10 L/m2
E. 12 L/m2

20. What is the MOST commonly diagnosed adenoma during childhood?

A. Prolactinoma
B. Corticotropinoma
C. Somatotropinoma
D. Thyrotropinoma
E. Gonadotropinoma

21. The nurse in NICU called you because of persistent hypoglycemia in a 3-day-
old male neonate, on examination the neonate had eye proptosis with
periorbital fullness, mid-glabellar capillary malformation , earlobe creases,
macroglossia, hepatosplenomegaly, and omphalocele.
What is the most likely cause of hypoglycemia?
A. Poor feeding
B. Systemic infection
C. Adrenal insufficiency
D. Pancreatic β-cell hyperplasia
E. Fatty acid oxidation disorder

22. An 11-year-old boy presents with history of headache, mood disturbance,

behavioral swings, difficulty with sleep, decrease in attention span, and a
decline in school performance for the last 3 months , examination shows diffuse
smooth goiter.
What is the MOST appropriate next step in his management?
A. TSH and T4 level
B. CT brain
C. ESR
D. CBC and blood film
E. Neck ultrasound

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23. Cancer risk is high in patients with Beckwith-Wiedemann syndrome until 8
years of age, so they need regular surveillance with abdominal ultrasound and
A. α-fetoprotein assay
B. HCG assay
C. 17 hydroxyprogesteron assay
D. α-1-antitrypsin assay
E. serum uric acid

24. Which of the following is a diagnostic criteria for diabetes mellitus?

A. Fasting plasma glucose 100-125 mg/dL
B. 2 hr plasma glucose during OGTT ≥ 140 mg/dL
C. Hemoglobin A1C ≥ 6.5%
D. Symptoms of diabetes mellitus plus random plasma glucose ≥ 160 mg/dL
E. Low C peptide

25. The clearest evidence of a role for viral infection in human T1DM is seen in
A. congenital rubella syndrome
B. enteroviral infection
C. mumps infection
D. RSV infection
E. HSV infection

26. A 12-years-old girl presents to the ER with history of repeated vomiting and
abdominal pain , in the preceded 4 days she suffered from frequent urination
and excessive thirst.
What is the next step in her management?
A. Intravenous fluid
B. Analgesia
C. Ultrasound abdomen
D. Blood glucose
E. Surgical consultation

27. An 8-year-old boy presents with abdominal pain and rapid breathing, his
blood sugar is 483 mg/dl.
What is the MOST appropriate next step in his management?
A. Subcutaneous insulin 1 unit/kg
B. 45% glucose saline 20 ml/kg/hr
C. Intravenous insulin 0.2 unit/kg/hr
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