1 4th NATIONAL MCQ EXAMINATION NATIONAL BOARD OF EVALUATION, INDONESIAN COLLEGE OF PAEDIATRICS NOVEMBER 19, 2008 SELECT THE

ONE BEST ANSWER, put your answers in the answer sheet Time allocation: 100 minutes GROWTH AND DEVELOPMENT A newborn girl named Sitti presents to the evening nurse in the general care nursery with floppy tone and dysmorphic features. She is born full term to a 28 year old G2 P1 whose first pregnancy resulted in a healthy daughter. She has delivered a full term 3 kg girl. Pregnancy, labor, and delivery were all uncomplicated. The obstetrician has told the parents that all went well. A. What are the medical examination findings that occur in 50% but not in 90% of individuals with Down syndrome ? A. Mid face hypoplasia B. Excess nuchal skin C. Small ears D. Central hypotonia E. Wide space between first and second toes B. Your examination reveals a clustering of craniofacial dysmorphism, central hypotonia, and a strong Moro. When you come in to discuss your concerns with the family, you should : A. Talk to the father alone B. Tell the nurse what to say to mother C. Talk to both parents and describe what the process will involve D. Talk to both parents and say that you do not know what to do for children with Down syndrome E. Describe in detail all that children with Down syndrome cannot do C. What medical concern listed below is not associated with GI malformations ? A. Oligohydramnions B. Vomiting after first feed C. Delayed passage of meconium D. Choking during feedings E. Double bubble on abdominal radiograph D. Which of the following cardiac malformations does not commonly occur in infants with Down syndrome ? A. Atrioventricular canal B. Tetralogy of Fallot C. Hypoplastic left heart syndrome D. Atrial septal defects E. Ventricular septal defects IMMUNIZATION A. An outbreak of measles is occurring in a large urban city. Measles vaccine can be administered to children as young as : A. 4 weeks B. 4 months C. 6 months D. 9 months E. 12 months B. Compared with natural infection with varicella-zoster-virus, varicella vaccine is more likely to result in: A. Herpes zoster B. Transmission of virus to contacts C. Mild varicella disease if breakthrough varicella occurs D. The serious adverse event of encephalitis E. Fever

2 ENDOCRINOLOGY A 10 year old boy comes into your office for a routine physical examination. His only complaint is that he is shorter than all of his friends, and that he cant ride the mega roller coaster at the local amusement park because he is shorter than the requirement. You have followed this child for many years, but most visits have been for illness, and his height has not been measured for the last few years. He is on no medications. He reports occasional fatigue and occasional constipation. On physical examination, his height is less than the 3 rd percentile and he is prepubertal 5. Of the following, which is the least likely to help with his diagnosis ? A. Parental heights B. Growth velocity C. Actual height D. Bone age E. BMI 6. What is the most likely diagnosis if his growth rate is 5 cm/year, height age is 8 years, and bone age is 10 years ? A. Constitutional delay of growth and puberty B. Intrinsic short stature C. Hypothyroidism D. Growth hormone deficiency E. Cushings syndrome C. What is the most likely diagnosis if he has abnormal body proportions and a narrow interpedicular distance in the lower lumbosacral area ? A. Noonans syndrome B. Achondroplasia C. Hypochondroplasia D. Klinefelters syndrome E. Exogenous obesity D. Which of the following is one of the most common causes of short stature in children ? A. Familial intrinsic short stature B. Growth hormone deficiency C. Poor nutrition D. Chronic illness E. Hypothyroidism

INFECTIOUS DISEASE E. An 18-month-old child presents to the emergency center having had a brief, generalized tonic clonic seizure. He is now postictal and has a temperature of 40C. During the lumbar puncture (which proves to be normal), he has a large, watery stool, that has both blood and mucus in it. The most likely diagnosis in this patient is: A. Salmonella B. Enterovirus C. Rotavirus D. Campylobacter E. Shigella F. The 3-year-old sister of a newborn baby develops a cough diagnosed as pertussis by nasopharyngeal culture. The mother gives a history of having been immunized as a child. A correct statement regarding this clinical situation is: A. The mother has no risk of acquiring the disease because she was immunized B. Hyperimmune globulin is effective in protecting the infant C. The risk to the infant depends on the immune status of the mother D. Erythromycin should be administered to the infant E. The 3-year-old sister should be immediately immunized with an additional dose of pertussis vaccine

3 G. A 14-month-old infant suddenly develops a fever of 40.2C. Physical examination shows an alert, active infant who drinks milk eagerly. No physical abnormalities are noted. The white blood cell count is 22.000/mm3 with 78% polymorphonuclear leucocytes, 18% of which are band forms. The most likely diagnosis is: A. Pneumococcal bacteremia B. Roseola C. Streptococcosis D. Typhoid fever E. Diphteria H. A 4-year-old child presents in the clinic with mumps. Correct statements about this condition include which of the following? A. Arthritis is a common presenting complaint in children B. The disease could have been prevented by prior immunization with killed whole cell vaccine C. Involvement of the CNS may occur 10 days after the resolution of parotitis D. Orchitis occur almost exclusively in prepubertal males E. Subendocardial fibrolastosis is a common complication in this age child

GASTROENTEROLOGY I. An awake, alert infant with a 2 day-history of diarrhea presents with a depressed fontanel, tachycardia, sunken eyes, and the loss of skin elasticity. The appropriate percent of dehydration is: A. Less than 1 percent B. 1 percent to 5 percent C. 5 percent to 9 percent D. 10 percent to 15 percent E. More than 20 percent J. An 11-year-old child has been diagnosed with hepatitis C infection. Which of the following may be considered in the treatment of chronic hepatitis C infection? A. Active vaccination B. Interferon C. Gamma globulin D. Zidovudine E. Low protein diet K. An 8-month-old child regularly regurgitates a large portion of her feeds. In the diagnostic evaluation of gastroeosophageal reflux for this infant, the least helpful procedure is A. Barium swallow and upper GI series B. Urea breath test C. Esophageal manometry D. Esophageal pH probe E. Technetium 99m scintiscan L. A 55-day-old former 27-week premature infant is noted by the neonatal nurse to have a swelling in the left groin extending into the scrotum but not involving the testicle. The swelling is not tender, firm, hot or red, and it does not transilluminate. It seems to resolve with pressure, but returns when the infants begin to perform the Valsalva maneuver. The most appropriate course of action at this point is to: A. Obtain a surgical consultation B. Perform a needle aspiration C. Order a barium enema D. Order a KUB E. Do nothing, spontaneous resolution will occur

4 NUTRITION 19. Syndrome of vitamin A deficiency is as follows: xerophthalmia, keratomalacia, hyperkeratosis, growth failure and death. Which of the following option is most likely a part of the syndrome. A. Conjunctivitis B. Hordeolum C. Bitot spots D. Subconjunctival bleeding E. Retinal ablation 20. Medium chain triglyceride or MCT is beneficial for certain conditions like cholestasis and premature baby. An explanation for MCT recommendation in those situations is: A. MCT does not need any lipase for its digestion in guts B. MCT may directly enter the enterocytes without any support of bile salt C. MCT has a medium length of carbonic chain, therefore gastric juice easily break down it into small fractions D. MCT is a polyunsaturated fatty acid which is more accessible in binding bile salt E. MCT stimulates the production of bile salt that promotes the absorption of dietary fats NEUROLOGY 21. A 15 year- old male with a history of complex partial seizures recently moves into your practice area. He comes into your office for a general physical examination. During the visit, he states that he has been seizure free for approximately 2 years. His spells consisted of staring with automatisms, but occasionally they would progress to generalized tonic clonic seizures. As he is concerned about driving next year, he asks you when he can go off his medication. He is currently treated with carbamazepine. The most appropriate response would be which of the following ? A. Lets obtain an EEG. If that test is normal, there is an approximately 70% chance you will be seizure free. B. Never. Epilepsy is a lifelong condition. C. :Children with complex partial seizures need to be seizure free for at least 5 years before a decision can be made. D. It all depends on the epilepsy syndrome or type and complex partial seizures seldom go into remission.
E. If a child is seizure-free for two years it may be possible to stop their medication straight away

22. Which of the following antiepileptic drugs are generally considered the first and second line therapies for neonatal seizures ? A. Diazepam and phenobarbital B. Phenobarbital and phenytoin C. Phenytoin and midazolam D. Phenobarbital and lorazepam E. Phenobarbital and valproic acid 22. Which of the following is the most common form of childhood seizures ? A. Complex partial seizures B. Absence seizures C. Infantile spasms D. Benign rolandic epilepsy E. Febrile seizures 23. Which of the following statements is not true about febrile seizures ? A. A febrile seizure is considered complex if it is prolonged, focal, or occurs multiple times per febrile illness B. A family history of febrile seizures in a first or second degree relative is a risk factor for the development of febrile seizures C. Developmental delay is a risk factor for the development of a first febrile seizure D. Up to 10 % of patients with febrile seizures develop epilepsy E. Carbamazepine and phenytoin are equally effective in the treatment of febrile seizures should one consider treatment

5 RESPIROLOGY 25. A 2 year old female child developed fever, cough and respiratory distress. On chest x-ray consolidation is seen in right lower lobe. She improved with antibiotics but on follow up at 8 weeks was again found to have increasing consolidation in right lower lobe and fever. Your next investigation would be ? A. Bronchoscopy B. Bacterial culture of the nasopharynx C. CT scan of the chest D. Allergen sensitivity test E. Mantoux test 26. The new mother of a 3 week-old infant is concerned that her child is having breathing difficulty. She states he is a noisy breather but has remained afebrile and sleeps/feeds well. After a history/physical exam, it would be prudent to: A. Begin iv antibiotics B. Prescribe a decongestant C. Reassure mom and send home with saline nasal spray D. Begin albuterol nebulizer E. Begin a bronchodilator 27. A patient comes into your office in severe respiratory distress with a deep barky cough and stridor. You diagnose the child with croup and decide to admit the child. Along with securing an airway what are other treatment options? A. Albuterol jet nebulizer B. Ice cream PO C. Racemic epinephrine and steroids D. No treatment options are available E. Bronchodilator nebulizer 28. A 15 year old boy comes to your office for follow up of his reactive airway disease. He describes his symptoms as daily and also experiencing nocturnal symptoms approximately 2x per week. Spirometry performed in your office reveal that his FEV1/ PEFR is 75% of his predicted value. These results classify his severity of asthma as: A. Severe persistent B. Moderate persistent C. Mild persistent D. Mild intermittent E. Moderate intermittent GENERAL PAEDIATRICS 49. A 15 year- old comes to you for a football physical. Which finding below in this childs history would preclude him from a contact sport? A. Sickle cell disease B. Asthma C. Anemia D. Patient has one kidney E. Myalgia

HEMATOLOGY 29. A 5 year-old boy is brought for evaluation during winter by his mother because of recurrent nosebleeds. They happen between one and three times a week, last 2 minutes, and are difficult to stop. This has been going on for about 6 weeks. All of the following would prompt you to explore the etiology of this boys nosebleeds except : A. Nosebleeds that dont stop within 2 minutes or more as a cut-off B. Family history of bleeding disorder C. Nosebleeds associated with fever and anemia D. Nosebleeds with low thrombocyte on screening E. Evidence of gum bleeding

6 30 A 5 year-old boy awoke this morning covered in red dots. He had a cold approximately 2 weeks previously, but otherwise has been well. The family history is noncontributory. On physical exam, the child is well-appearing and afebrile. He has diffuse petechiae covering his face, neck, chest, back, stomach, arms and legs. He has no palpable lymphadenopathy or hepatosplenomegaly. A complete blood count done in the emergency room is within normal except for a platelet count of 8,000/L. Which of the following laboratory abnormalities is most commonly associated with the development of petechiae? A. Thrombocytopenia B. Prolonged prothrombin time C. Elevated fibrin degradation products D. Low factor VIII level E. Clotting time

NEFROLOGY 31. A mother of a 4 yr-old child noticed that there is a solid mass in the right area of her child which she noticed for the first time with occasional blood in urine. What is your initial diagnosis ? A. Neuroblastoma B. Wilms tumour C. Hydronephrosis D. Polycystic kidney E. Hepatoblastoma 32. A 71/2 year old child presents with non-blanching rash over the extensor aspect of arm with swelling over knee. Urine analysis shows proteinurea + and hematuria +++. On kidney biopsy which finding will be most commonly seen ? A. Fusion of podocytes B. Acute tubular necrosis C. Deposition of IgA D. Thickened basement membrane E. Deposition of IgG and complement 33. A child has a history of repaired high imperforate anus. He now has a urinary tract infection. What is the most likely cause? A. Vesicoureteral reflux B. Rectourethral fistula C. Neurogenic bladder D. Posterior urethral valves. E. Vesicorectal fistula 34. A 15 year- old girl presents after referral to you for proteinuria. Urinalysis (U/A) shows 1+ proteinuria (no other abnormalities), no edema, normal cholesterol, and no significant Past Medical History / Family History (PMH/FH). Urine protein/creatinine ratio is 0.148 and quantitative protein is 25 (normal 2-10). What is the most likely diagnosis? A. Minimal change B. Post streptococcal GN C. Benign orthostatic proteinuria D. Membranous GN E. Lupus nephritis

7 GENERAL PAEDIATRICS 50. A 10 year-old boy presents for a pre-participation sports physical examination. He has previously been well with no significant past medical history. His vital signs demonstrate a heart rate of 101 bpm and a blood pressure of 130/85 mm Hg (greater than the 95th percentile for age). The remainder of his exam is normal. What is the most appropriate next step? A. Recheck the blood pressure with a smaller blood pressure cuff B. Recheck the blood pressure on at least two other separate occasions before beginning further evaluation C. Begin medical therapy with antihypertensive medications D. Order a renal ultrasound E. Order an ECG

CARDIOLOGY 35. A 2 year-old child presents with a 10 day-history of fever, a heart murmur, bilateral nonexudative conjunctivitis, swollen and erythematous lips and strawberry tongue with erythematous and edematous hands and feet and a polymorphous rash on the face, trunks, and extremities. The most likely diagnosis in this patient is: A. Kawasaki disease B. Measles C. Viral upper respiratory tract infection D. Group A beta hemolytic streptococcal pharyngitis E. Infective endocarditis diagnosis ?

36. What acute finding would not be expected to be associated with this 2 year-olds A. Sterile pyuria B. Hydrops of the gallbladder C. Cervical adenopathy greater than 1,5 cm D. Thrombocytosis is associated with myocardial infarction. E. Anterior uveitis in 70% cases

37. Which of the following statements is true regarding coronary artery involvement with this 2 year -olds disease ? A. There is a 50% incidence of coronary artery aneurysms if untreated B. The peak incidence for coronary artery aneurysms is 6 to 12 months following the onset of fever C. Patients with giant coronary artery aneurysms greater than 8 mm in diameter are at highest risk for late stenosis and myocardial infarction D. Coronary artery rupture is the most common cause of mortality within the first 7 days of the onset of fever E. Smaller aneurysms mostly do not resolve on their own 38. Name the two drugs most commonly used for acute management of this disease. A. Aspirin and IVIG B. Penicillin and IVIG C. Steroids and aspirin D. Steroids and penicillin E. Steroids and IVIG

8 PERINATOLOGY 39. A one day- old neonate presents with bilious vomiting. An abdominal film demonstrates air within the distended stomach and duodenum with a small amount of air in the distal small bowel. The patient has a normal barium enema (specifically, there is no evidence of microcolon.) Which of the following would be the least likely diagnoses? A. Duodenal atresia B. Preduodenal portal vein C. Midgut volvulus D. Duodenal web E. Pyloric stenosis 40. A term infant has not passed meconium for 48 hours. He presents with distension of abdomen and emesis since one day. Next most appropriate investigation would be: A. Genetic testing for cystic fibrosis B. Manometry C. Lower bowel contrast enema D. Oesophagoscopy E. Abdomen X ray
41. A full-term baby is born to a 16 year-old mother. The prenatal course was notable for suspected intrauterine growth retardation. The birth weight is 2325 g, small for gestational age. In the evaluation of a low-birthweight, term, small for gestational age (SGA) newborn, which of the following should not be considered in the management of this newborn baby? A. Maternal vascular disease B. Fetal chromosomal disorder C. In utero infection D. Maternal fibroids E. Maternal size and parity.

42. The differential diagnosis of a newborn who is SGA with a normal physical examination includes : ? A. Herpes B. Rubella C. Toxoplasmosis D. Varicella E. Syphilis

EMERGENCY A 5 year old boy presents to the emergency room with a 12 hour history of fever and drooling. He was well previously. His temperature is 39.5oC and he appears toxic. There have been no other symptoms and no sick contacs. He has received immunizations. On physical exam, the heart rate is 120 bpm, the respiratory rate is 26, and the room air blood oxygen saturation is 92%. The child has marked inspiratory stridor and refuses to swallow. He is sitting, leaning forward slightly and refuses to lie down for the examination. A chest radiograph is normal. The leukocyte count is 28,000/mm3 with significant left shift. 43. In this case, if the diagnosis is epiglottitis, what is the likely pathogen ? A. Coagulase negative staphylococcus B. Streptococcus pneumoniae C. Haemophilus influenzae D. Parainfluenza virus E. Respiratory syncitial virus 44. If the diagnosis of epiglottitis is confirmed in the operating room by direct visualization by an otolaryngologist, the best next step would be : A. A transfer to the ICU with supplemental humidified oxygen B. A transfer to the ICU with administration of corticosteroids C. A transfer to the ICU with administration of nebulized salbutamol D. An endotracheal intubation before transfer to the ICU E. A tracheotomy before transfer to the ICU

45. Differences between viral croup and epiglottitis include : A. The child with viral croup is often older than the patient with epiglottitis B. The child with viral croup always has a more abrupt onset of stridor than the patient with epiglottitis C. The child with viral croup is more likely to present in the middle of an upper respiratory infection than the patient with epiglottitis D. The child with viral croup clinically looks identical to the child with epiglottitis. E. The child with viral croup never presents with high fever

ALLERGY IMMUNOLOGY 46. For the past few days a 5 year old child has been complaining of intermittent abdominal pain. No emesis or diarrhea was reported. Then her mother noted a red rash on her legs, and brought her to your office. Your examination reveals a non toxic child who is afebrile. She has palpable purpuric lesions, coalescing by the ankles, and ascending up to the buttocks. Her abdominal exam reveals mild diffuse tenderness, but no rebound. You suspect that she has Henoch Schonlein purpura (HSP). All of the following are true about HSP except : A. Rash frequently recurs over the first 6 weeks after presentation, often increasing after physical activity B. Arthritis, especially of ankles and knees, is common C. In a small percentage of children, the purpuric rash is secondary to thrombocytopenia D. Edema of the scalp, hands and feet is common in children younger than 4 years old E. Skin biopsy will show a leukocytoclastic vascultis with IgA deposition. 47. All the following are true about GI involvement in HSP except : A. GI hemorrhage is common, and may be occult or gross B. GI symptoms can present before the rash C. A normal barium enema rules out intussusception in HSP D. Complications include intussusception, bowel infarction and perforation E. Ultrasonography may show edema of bowel wall and may identify an intussusception 48. Which statement is true for renal involvement secondary to HSP ? A. The majority of children who have hematuria during the acute phase of HSP illness have progression of renal disease B. It is associated with a membranous lesion on renal biopsy C. It usually presents shortly after HSP diagnosis with nephritic syndrome and hypertension D. It may persist in 1% to 5% of children and may progress to end stage disease in approximately 1% E. It occurs more commonly in patients < 8 years old at the time of HSP diagnosis

10 NATIONAL MCQ EXAMINATION NATIONAL BOARD OF EVALUATION INDONESIAN COLLEGE OF PEDIATRICS JUNE 1, 2009

SELECT THE ONE BEST ANSWER, put your answer in The Answer Sheet TIME ALLOCATION : 100 MINUTES GASTRO-HEPATOLOGY 1. A girl aged 6 years old has experienced recurrent abdominal pain since the last 6 months. No abnormalities are evident on physical examination. She complains of persistent or recurrent pain or discomfort centered in the upper abdomen (cranial to the umbilicus). The pain is not associated with the onset of a change in stool frequency or stool form. She feels also early satiety, bloating and nausea. The most likely diagnosis is: A. Functional dyspepsia B. Irritable bowel syndrome C. Abdominal migraine D. Gastroesophageal reflux disease E. Functional abdominal pain 2. A baby, 4 months of age has 5 bowel movements a day for the last 3 days, which is soft and contains blood and mucus. She looks healthy, has a good appetite and no signs of dehydration. What is the most likely diagnosis? A. Shigellosis B. Salmonellosis C. Cows milk allergy D. Intussusceptions E. Amebic colitis 3. A 3-year old girl present to the Emergency Department with fever, vomiting and abdominal pain. She has right upper quadrant tenderness and hepatomegaly. Her serum transaminases are elevated, but her total and direct bilirubin are only slightly above normal. Several other children in her day care are sick with similar symptoms. Which of the following statements is FALSE : A. Most patients with this illness do not develop fulminant or chronic disease B. Jaundice is common in young children with this illness C. Highly effective vaccines exist against this disease D. Most commonly transmitted by fecal-oral contact E. This disease more commonly occur in a crowded community (urban) 4. A 3 week-old baby came to the emergency department with the main complaint of profuse non-bilious vomiting after feeds. He was uneventfully born at term with a birth-weight of 3 kg. on physical examination, the BW was 2.5 kg along with moderate dehydration and hypokalemia. The most probable diagnosis in this case is: A. Gastroesophageal Reflux B. Atresia Duodenum C. Hirschprung Disease D. Hypertrophic Pyloric Stenosis E. Pancreas Annulare 5. In any infant or toddler who present with acute abdominal pain, bilious emesis, and guarding, which of the following imaging studies is the initial study of choice most likely to confirm your suspicions? A. Magnetic resonance imaging B. Ultrasonography C. CT Scan D. Barium enema E. Upper GI series

11 HEMATOLOGY 6. On a routine-screening of complete blood count, a 1 year-old is noted to have a microcytic anemia. Followup hemoglobin electrophoresis demonstates an increased concentration of hemoglobin A2. The child is most likely to have A. Iron deficiency B. thalasemia trait C. Sickle cell anemia D. Chronic systemic illness E. Lead poisoning 7. A 3 year-old develops pallor and recurrent epistaxis. There is no hepatosplenomegaly or lymphnode enlargement. Laboratory finding shows hemogloblin level 3g/dl, hematocrit 14 %, red blood cell count 2,500.000/ , white blood cell count 11.000/ , and platelet count 180,00/ . The most likely diagnosis of the patient is : A. Hemolytic anemia B. Aplastic anemia C. Post-hemorrhagic anemia D. Leukimia E. Iron deficiency anemia 8. A 5 year old boy came with rashes like purpura in the lower extremities, lower trunk and buttocks. There was a history of low grade fever for few days. There was no other complaint. Physical examination was unremarkable. Complete blood count reveals slight leukocytosis and normal platelet count. Hemostatic function also reveals normal. What is the most possible diagnosis in this child ? A. Immune Thrombocytopenic Purpura B. Secondary Thrombocytopenic Purpura C. Systemic Lupus Erithematous D. Henoch-Schonlein Purpura E. Drug Allergy 9. A Patient suffered from fever and chills 30 minutes during Packed Red Cell transfusion. There was no history of transfusion before. In emergency situation like this, what should you do? A. Give paracetamol and continue transfusion B. Give paracetamol and antihistamin, and then continue transfusion C. Stop the transfusion and change into washed erythrocyte transfusion D. Stop the transfusion and change with another Packed Red Cell bag E. Stop the transfusion, keep the intravenous line open with Psychological Saline until the symptom resolved

ALLERGY-IMMUNOLOGY 10. A 3 month old boy was admitted because he had red, raised, palpable wheals all over his body, along with cyanosis, tachycardia, and breathing difficulty. He had been breastfed and his mother recently gave him cows milk formula 5 days before admission. What is the babys diagnosis? A. Urticaria B. Angloedema C. Anaphylaxis D. Asthma E. Heart Problems 11. The drug of choice for this patient is: A. Antihistamine B. Epinephrine C. Corticosteroid D. Digitalis E. Ephedrine

12 12. You are a doctor on duty when a pregnant woman visit you and ask if you can do something to avoid her baby from getting allergy after the baby is born. Your immediate management step to the case , is : A. B. C. D. E. To do allergy screening by taking both parent and siblings history of allergy Suggest parent to give hypoallergenic formula anytime when manifestasion of allergy appear Consider long term antihistamine for the baby soon after delivery Treat allergy symptom when it appears Improving quality of life of the allergic baby

13. A 5 years old girl presented to you with purpura that spread over her buttock and lower extremities. You noticed that the purpura was palpable. Assuming this case to be Henoch Schonlein Purpura, you asked for laboratory investigation. What you expected to find is: A. Prolonged clotting time B. Prolonged APTT C. Prolonged PTT D. Thrombocyte count below the normal limit E. Thrombocyte count exceeding the normal limit TROPICAL/INFECTIOUS DISEASE 14. A 10 years old girl present with a history of sore throat for 4 days, along with breathing difficulty of 1 days duration. On examination she is very ill-appearing. She has some inspiratory stridor and thick white-gray material covering her tonsils and faucial pillars, and she has swelling of her neck. What kind of treatment will you give for the patient at the time? A. B2 agonist nebulization B. Corticosteroid C. Ceftriaxon injection D. Immunzation with DT E. ADS 40.000 IU 15. A 14 year old girl awakens with a mild sore throat, low-grade fever, and a diffuse maculopapular rash. During the next 24 hours, she develops tender swelling of her wrists and redness of her eyes. In addition, her physician notes mild tenderness and marked swelling of her posterior cervical and occipital lymph nodes. Four days after the onset of illness the rash has vanished. The most likely diagnosis of this girls condition is A. Rubella B. Rubeola C. Roseola D. Erythema infectiosum E. Erythema multiforme 16. A 20 month-old baby has a three week history of diarrhea and recurrent fever. He is noted to have oral thrush. He was hospitalized 3 times with the same complaint. At the moment he has a body weight of 7 kg, and appears moderately ill. His head, ear, heart and lung exams are normal. His oral exam is significant for thrush. He has liver, spleen enlargement along with anterior/posterior cervical and occipital lymphadenopathies. Which one of the following is used as a screening test in HIV infection diagnosis? A. Enzyme immunoassay B. Polymerase chain reaction C. Western-blot D. Immune fluorescence assay E. Viral culture 17. Which is the following vaccines is contra-indicated in HIV-infected children? A. IPV B. MMR C. HIB D. Pneumococcal E. BCG

13 NEUROLOGY 18. A 5-year-old boy present with a limp. This was preceded by a febrile illness, but there has been no preceding trauma. On examination he has weakness of all muscle groups in his right lower limb. The limb is hypotonic, and deep tendon reflexes cannot be elicited. There is no pain on movement of the joints nor is there tenderness. Sensory examination is normal. What would be the most likely diagnosis? A. Guillain Barre Syndrome B. Poliomyelitis C. Diphtheritic Polyneuropathy D. Chikungunya E. Spinal tumour 19. What kind of examination would you suggest for the patient? A. Head CT scan B. Stool culture C. CK-MB examination D. Serum electrolyte E. Lumbal puncture 20. A 2 month-old baby came to the Emergency Department with seizures and unconsciousness. There was no history of fever, cough or other illness. The baby was uneventfully born spontaneously with good condition and had only been breastfed. Physical examination showed a very weak baby, along with pallor and bulging fontanella. CBC revealed Hb 7.2 g/dL normal white blood count and platelet count. Haemostatic function revealed PPT 45 (control 11.3) and APTT 53.1 (control 26.3). What is the most possible diagnosis of this baby? A. Hemophilia B. Von Willebrand Disease C. Acquired Prothrombin Complex Deficiency D. DIC E. ITP 21. A previously healthy 10 year old girl has developed progressive weakness, areflexia, paresis of extraocular muscles and respiratory insufficiency over a 2 week period. The MOST likely diagnosis is A. Polymyositis B. Myasthenia gravis C. Acute spinal muscular atrophy D. Guillain-Barre syndrome E. Botulism

NEPHROLOGY 22. A 6 year old boy is being evaluated for high fever of unknown etiology, flank pain, vomiting, toxic appearance, haematuria and leucocyturia. Volding cystoureterography reveals findings as a shown below. Which of the following is a working diagnosis option? A. Urethritis B. Cystitis C. Pyelonephritis D. Eneuresis E. Nephritis 23. Which of the following is an appropriate treatment option? A. Intravenous antibiotics for 3 days B. Intravenous antibiotics for 7 days C. Oral antibiotics for 3 days D. Oral antibiotics for 7 days E. Oral antibiotics for 10 days 24. A 6 week old child is being evaluated for a fever of unknown etiology. As part of the laboratory evaluation, a urine specimen was obtained that grew Escherichia coli with a colony count of 2000/L. These findings will be definite evidence of a urinary tract infection if the sampled urine.

14 A. B. C. D. E. Is the first morning sample Is from an ileal loop bag Is from a suprapubic tap Is from a bag attached to the perineum of uncircumcised boy Has a specific gravity of 1.008

ENDOCRINOLOGY 25. A pregnant woman has a low urinary estriol level. At delivery, her male infant develops hyponatermia, hyperkalemia, and hypoglycemia. What diagnosis should you consider? A. Inappropriate antidiuretic hormone B. Congenital adrenal hypoplasia C. Juvenille diabetes mellitus D. Phenylketonuria E. Hyperthyroid 26. An 8 year old boy has short stature. He has begun to gain quite a bit of weight over the last year, has little or no energy, sleeps more than normal, and complains of feeling cold. His growth demonstrates that he has fallen from to the percentile for height, but his weight has increased to percentile. On examination, he is obese, has an immature facies, thin hair, and slow reflexes. Which is the following is the most appropriate course of action for this child? A. Measure thyroid function B. Determine bone age C. Order a growth hormone level D. Reassure the mother that the child has normal prepubertal development E. Chromosomal analysis 27. A normal-apperaring 9 month old boy is discovered on routine herniorrhaphy to have bilateral Fallopian tubes and a rudimentary uterus. Biopsy of the gonads performed during this procedure revealed normal testicular tissue. On examination today, his phallus is normal in size and appearance, and his descended testes are both 2 mL in volume. Of the following, the MOST likely sex chromosome complement for this child is: A. XX B. XX/XY C. XXY D. XO/XY E. XY

PEDIATRIC EMERGENCY 28. A 2 year old girl who having difficulty breathing and a barky cough has had a fever and runny nose for the past 3 days. She is alert and sitting on her mothers lap. Assessment reveals that she has warm, flushed skin, is using her abdominal muscles to breathe, and has increase work of breathing. She has a blood pressure of 88/66 mm Hg, a pulse of 128 beats/min, and respirations of 48 breaths/min. You should immediately determine whether the patient has: A. Stridor B. Delayed capillary refill time C. Weak pulses D. The ability to tolerate oral feedings E. Cyanosis

29. Abdominal breathing in the patient above should be viewed as a : A. Normal finding for a toddler B. Sign of impending respiratory failure C. Sign of decreased perfusion to the respiratory center D. Compensatory mechanism to increase the volume of air inhaled E. Compensatory mechanism to increase the respiratory rate

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30. A 3 month old infant who is extremely lethargic has had a cough, vomiting, and diarrhea for the past 3 days. Assessment reveals that he respond to pain, has mottled skin color, and a capillary refill time of 4 seconds. He has a blood preasure of 74/60 mm Hg, a pulse of 190 beats/min, and rapid, respirations without increased work of breathing at 60 breaths/min. The tachycardia in this infant is most likely due to: A. Anxiety B. Hypovolemia C. Pneumothorax D. Swelling of the brain E. Pain 31. The appropriate initial treatment in patient above is to A. Administer 100% oxygen by mask B. Administer dopamine intravenous C. Administer epinephrine via an intraosseous needle D. Perform endotracheal intubation E. Administer fluid infusion

NUTRITION 32. A 3 year old boy who suffer from diarrhea more than 6 times a day was brought to the clinic. No bloody stool was found. The boy was slimy, the ribs pronounce, the skin wasting, hyper-pigmented skin and edema on the feet. The boys face resembled old man face, along with flag sign hair. He had measles two months before. The boys weight is 9 kg and his height 90 cm. (using gold standard CDC -2000). What the diagnosis of the child? A. Kwashiorkor B. Marasmus C. Marasmic-Kwashiorkor D. Failure to thrive E. Stunting 33. A 2 year old girl came with obvious pallor. On admission the body weight was 6 kg, she did not show any sign of respiratory distress or cardiac emergencies. The hemoglobin level was 6 g/dL. Proper management would be: A. Blood transfusion given as soon as possible B. Immediate transfer to intensive or high care ward C. Oral iron supplementation is allowed starting at second week of hospitalization D. Immediately starting a high calorie diet of 200 KKal/kg E. High protein along with a low fat diet 34. A 3 year old boy came with a history of nausea, vomiting, diarrhea, anorexia, fatigue and headache. He showed confusion and appeared psychotic. Laboratory examination revealed hypercalcuria. This child most probably had a deficiency of A. Vitamin A B. Thiamin C. Vitamin C D. Vitamin D E. Vitamin E

16 35. A 24 month old girl was admitted to the emergency department the main complaint of high fever. Seven days before admission, she got high fever, cough and cold. There was no history of vomiting and diarrhea. On clinical findings, she look weak, the respiratory rate was 54x/minute and Capillary Refill Time 10 seconds. There were fine moist rales on both lungs. The heart and bowel sounds were within normal limits. The body weight was 10 kg, body length 85 cm, and the ideal body weight 11.9 kg; the percent ideal body weight was 84%. When should enteral feeding be given or this patient? A. B. C. D. E. As soon as possible after stable condition After 72 hours 48 72 hours After the patient was conscious As soon as possible after 24 hours

GROWTH AND DEVELOPMENT 36. An infant is brought by his mother to your well-baby clinic. He can move his head from side to side while following a moving object, can lift his head from a prone position 45 off the examining table, smiles when encourage and make cooing sounds. He cannot maintain seated position. The most likely age of the infant is A. 1 month B. 3 months C. 6 months D. 8 months E. 10 months 37. The mother has concerns about maintaining a safe environment for her child. In providing age-appropriate anticipatory guidance, you tell her that A. Pillows in the crib should be soft to provide a comfortable sleeping environment B. She should set her water heater to 70C to ensure the sterility, thereby decreasing the risk of infections C. She can start to give solid food like pieces of apple or banana D. Her baby should be placed on his back to sleep, as this decreases the risk of Sudden Infant Death Syndrome E. She should give him small objects such as round pliable toys, to increase his fine motor development 38. A 3.5 year old boy says only three single words, and these are poorly articulated. He uses gestures to communicate. There are no other reported problems, gross and fine motor skills are normal for age and physical examination, including tympanography, is normal. Which of the following is the MOST LIKELY explanation? A. Intellectual disability B. Deafness C. Manipulative behaviour D. Dysarthria E. Autism

PERINATOLOGY 39. A 4.5 kg infant is delivered at 37 weeks of gestation. The mother is a 29 year old juvenile diabetic. A cesarean section is performed when fetal distress is noted. The Apgar scores are 4 and 7 at 1 and 5 minutes respectively. Maternal blood glucose prior to delivery was 320 mg/dl. The infant is lethargic in the nursery and the blood Dextrostix test is found to be undetectable. The next appropriate step is: A. Obtain serum for blood sugar analysis to confirm the Dextrostix value B. Administer glucose water by mouth C. Administer 10 ml/kg 50% dextrose intravenously D. Administer glucagon intravenously E. Administer 2ml/kg 10% dextrose intravenously

17 40. A 2 day old is brought to ED after a generalized seizure lasting 3 minutes. If the seizure were related to birth trauma, the most likely finding would be: A. Subarachnoid hemorrhage B. Epidural hematoma C. Subdural hematoma D. Focal brain contusion E. Concussion 41. A 27 year old gravida 1 para 0 female presents with a history of prolonged rupture of membranes and is presently in active labor. Tocolytics are started, and despite medical intervention, a 30 week gestational infant is delivered. The baby demonstrates nasal flaring, grunting, and intercostal retractions and is intubated. Positive pressure ventilation is initiated. A chest radiograph reveals a fine granular appearance of the lung fields. The baby is hypotensive and poor is noted. Initial arterial blood gas reveals pH 7.16, PCO2 50 mm Hg, PO2 55 mm Hg, and base excess -14. Which of the following is the most appropriate intervention at this time? A. Administer endotracheal surfactant immediately B. Increase the ventilator settings to keep PaCO2 below 40 mm Hg C. Administer 10 ml/kg 0.9% sodium chloride IV D. Administer a dopamine infusion at 10 mgm/kg/min E. Administer broad-spectrum antibiotics immediately 42. A patient presents in labour at a level 1 clinic. By her date and abdominal palpation she is 32 weeks pregnant. After a short labour she delivers a male infant weighing 1400 grams. The New Ballard Score confirm the gestational age. How would you classify this infant by weight for gestational age? A. Low birth weight B. Premature infant C. Appropriate for Gestational Age (AGA) D. Small for Gestational Age (SGA) E. Large for Gestational Age (LGA)

CARDIOLOGY 43. A five year old girl presents with fever for 8 days, weight loss, night sweats, a new heart murmur, splenomegaly, joint pains and a history of having her teeth cleaned by a dentist 1 month prior to this visit. What is the most likely diagnosis for this patient? A. Kawasaki disease B. Juvenile rheumatoid arthritis C. Acute rheumatic fever D. Infective endocarditis E. Systemic Lupus Erythematosus 44. A one month old is seen after turning blue when feeding. Auscultation of the heart reveals a harsh grade ill systolic ejection murmur over the pulmonary area that radiates to the back. Arterial blood gas shows a normal pH, PaCO2, and PaO2 at rest. The ECG demonstrates right axis deviation and right ventricular hypertrophy. The chest x-ray film reveals a large heart with a reduced main pulmonary artery segment. Which of the following congenital heart disorder is consistent with these findings? A. Atrial septal defect B. Coarctation of the aorta C. Tetralogy of Fallot D. Patent ductus arterious E. Ventricular septal defect

18 45. A 4 year old boy was referred for dyspnea on exertion. Poor weight gain, cold sweat on the forehead. There is distended neck veins and tachycardia. The CXR showed cardiomegaly with increased pulomnary vascular marking. The ECG showed LVH. What is the diagnose? A. Infective endocarditis B. Congestive heart failure C. Cardiomyopathy D. Cardiogenic shock E. Septic shock 46. A 6 year old boy was referred for prolonged fever and welling, severe pain and redness of ankles. The precordium is normal except for a mild thrill in the apex. S1 and S2 are normal, but a harsh holosystolic murmur is heard in the apex. The abdomen is soft and there is no organomegaly. What is the diagnosis? A. Juvenile rematoid arthritis B. Acute rheumatic fever C. Myocarditis D. Infective endocarditis E. Cardiomyopathy

RESPIROLOGY 47. A 7 month old boy was brought to the hospital with the chief complaint of difficulty in breathing since 3 hours prior to admission. He started to have cough, rhinorrhea and fever 2 days before. Physical examination revealed that the baby was alert, appeared distressed, with no evidence of cyanosis. Heart rate was 112 times per minute, respiration rate 60 times per minute, the body temperature was 38.5 C. Lung auscultation appeared wheezing; no rhales or crackels was evident. The patient then underwent Chest X Ray. Peripheral Blood Smear, and Blood Gas Analysis. Working diagnosis of the cas is: A. Pneumonia B. Bronchopneumonia C. Acute Bronchitis D. Bronchiolitis E. Acute asthma attack 48. The result of CXR or BGA is predicted as: A. Diffuse infiltrate on CXR and Hypoxemia, Metabolic acodosis on BGA B. Hyperaeration on CXR and Hypercapnia, Respiratory acodosis on BGA C. Emphysematous lung, alveolar infiltrate on CXR and Metabolic acodosis on BGA D. Alveolar infiltrate on CXR and no hypoxemia, only metabolic acodosis on BGA E. Pleural effusion on CXR and Hypoxemia, Respiratory acodosis on BGA 49. A 13 year old girl was admitted to the hospital due to chronic cough and difficulty of breathing since 2 days ago. She complained that this condition recurs almost every month, with each attack typically lasting for 1 or 2 days, especially at night. The mother had a history of having allergic rhinitis, while the father was a heavy smoker. On physical examinantion the child looked slightly dyspneic, with increased expiration time. Diffuse wheeze was heard over both lungs. She was able to communicate to the physician, with clear and uninterrupted sentences. All other vital signs were normal. Proper initial prompt treatment of this case : A. Administration of broad spectrum antibiotics B. Inhalation therapy with B2 Agonist C. Simultaneous steroid and aminophyllin intravenously D. Oral mucolitic to dissolve mucus E. Antitussive to depress coughing

19 50. A 3 year old boy was brought to pediatric clinic for consultation. His father suffered from haemopthysis and has been treated with antituberculous drugs since a week ago. The child was symptomless with normal body weight. Tuberculin skin test result was 12 mm, and the chest x-ray doesnt show any suggestion for tuberculosis. Which of the following answers is the most appropriate management in this child? A. Primary chemoprophylaxis with isoniazid for 3 months B. Primary chemoprophylaxis with isoniazid + rifampin for 3 months C. Secondary chemoprophylaxis with isoniazid for 6 months D. Secondary chemoprophylaxis with isoniazid + rifampin for 6 months E. Give isoniazid, rifampin, and pyrazinamide for 2 months, follow with isoniazid and rifampin for 4 months

NATIONAL MCQ EXAMINATION NATIONAL BOARD OF EVALUATION INDONESIAN COLLEGE OF PEDIATRICS DECEMBER , 2009

SELECT THE ONE BEST ANSWER, PUT YOUR ANSWER IN THE ANSWER SHEET TIME ALLOCATION IS 100 MINUTES GASTRO-HEPATOLOGY 1. A pediatrician received result of fractionated bilirubin on a 1 month old infant. Total bilirubin was 4.6 mg/dl, unconjugated bilirubin was 1.2 mg/dl, conjugated bilirubin was 3.1 mg/dl. The best course of action is to: A. Repeat blood work in two months since presence of unconjugated bilirubin suggest to breast milk jaundice. B. Inform the family that it must be a lab error since conjugated bilirubin suggests breast milk jaundice. C. Refer the patient for evaluation of neonatal cholestatis D. Inform the family that liver biopsy and cholanglogram are associated with high risk of bleeding and shoud be avoided at all cost. E. Explore the possibility of ABO incompatibility. 2. A 10 day old mate presents with bilious emesis. What is the most likely diagnosis? A. Appendicitis B. Pyloric stenosis C. Malrotation with midgut volvulus D. Feeding intolerance E. Functional intestinal obstruction HEMATOLOGY 3. The family of a child just diagnosed with acute lymphoblastic leukemia asks for information about the childs a prognosis. Included as a poor prognostic sign is which of the following? A. Presence of a mediastinal mass B. Hyperdiploidy with more than 50 chromosomes C. White blood cell count at diagnosis of less than 100,000/L D. Age between 1and 10 years E. Early pre-B-cell variety of the disease 4. A 4 year old child presents a petechial rash but is otherwise well and without physical findings. Platelet count is 20,000/L, Hemoglobin and WBC are 12,4 g/dl and 7,200/L respectively. Which of the following laboratory abnormalities is most commonly found in this case? A. Prolonged bleeding time B. Prolonged prothrombin time (PT) C. Elevated fibrin degradation products D. Prolonged APTT E. Prolonged clotting time

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5. A 3 year and 5 month old child presented to the clinic with fever, gum bleeding, melena and purpura. The body temperature was 40C and blood culture positive for a pathogenic microorganism. The blood pressure was 90/70 mmHg and peripheral blood count revealed Hemoglobin 7 g/dl, WBC 22,000/L and platelet count 30,000/L, APTT and PTT were prolonged. The most likely diagnosis of this case is: F. Henoch-Schonlein purpura G. ITP H. Hemophilia I. DIC J. ALL 6. A 5 year old boy came with rashes like purpura in the lower extremities, lower trunk and buttocks. There was history of low grade fever for few days. There was no other complaint. Physical examination was unremarkable. CBC reveals slightly leukocytosis with normal platelet count. Hemostatic function also reveals normal. Which is the most possible diagnosis in this child ? A. Immune Thrombocytopenic Purpura B. Secondary Thrombocytopenic Purpura C. Systemic Lupus Erithematous D. Henoch-Schonlein Purpura E. Drug Allergy 7. The parents of a previously healthy 3 year old girl bring the children to your office because she is complaining that ther tongue hurts. The parent also report that she has not been eating well. The family usually eats a regular diet including meats and vegetables. On physical examination her tounge is smooth, red, and tender. She is pale and has tachycardia. Her complete blood count reveals a macrocytic anemia. The most likely diagnosis in this child is: A. Iron deficiency B. Nutritional deficiency C. Transcobalamin deficiency D. Juvenile pernicious anemia E. Folate deficiency

ALLERGY-IMMUNOLOGY 8. A 15 year old has had persistent year round nasal itching and stuffiness. What is the most likely allergen responsible for the symptoms? A. Dust mite B. Weed C. Tree D. Grass E. Mold 9. A mother of a children with multiple allergic disease asks you for allergy prevention advice for her next child. What would you recommend? A. Germ free environment B. Breast feeding at least 4 months C. Diet control during pregnancy D. Using HEPA air filter and vacuum E. Immunotherapy during pregnancy 10. Two weeks following a viral illness, a teenage boy breaks out in an evolving rash that is remarkable for target lesions. What is the primary treatment? A. Epinephrine B. Glucagon C. Corticosteroids D. Antihistamines E. Symptomatic or supportive therapy depending on severity

21 11. You are seeing a 4 year old girl in the emergency department for treatment of an episode of anaphylaxis. She is currently taking amoxicillin for treatment of otitis media. She had just finished lunch today and taken her medication when she experienced respiratory difficulties, urticaria, and general discomfort. Lunch included foods she normally eats, except for a new brand of chicken noodle soup and shrimp salad for dessert. She does not like eggs, and when she has eaten them in the past, she spat them out. Of the following, the MOST likely cause of her reaction is: A. Drug allergy B. Food allergy C. Food poisoning D. Serum sickness E. Viral urticaria

TROPICAL / INFECTIOUS DISEASE 12. An 8 month old boy born from a HIV infected mother had failure to thrive, prolonged fever, chronic cough, oral candidiasis, and popular eruption. From all the above mentioned symptoms, the most likely that indicate cellular immunodeficiency is A. Failure to thrive B. Prolonged fever C. Chronic cough D. Oral candidiasis E. Popular pruritic eruption 13. A 5 years old boy presents to the clinic with a history of low grade fever for 3 days, along with, tender swelling of both of his mandibula. There was no evidence of cough or coryza. Mother says that there were 2 other children in her neighborhood presenting similar symptoms. The most likely diagnosis of the boys condition is : A. Diphteria B. Mononucleosis infection C. Mumps D. Drug allergy E. Lymphadenopathy tuberculosis 14. A 3 year old is very fussy, febrile and has profuse rhinorrhea. On exam, shallow ulcers are noted on the soft palate and vesicles are noted on one plam and both soles of the feet. The etiology of this infection is likely: A. Group A streptococci B. Arcanobacterium haemolyticum C. Coronavirus D. Coxsacklevirus E. Corynebacterium diphtheria 15. A 6 year old child complains of sore throat and is noted by the parens to have a lot of grayish junk in his mouth and nose. Exam shows an adherent grayish white membrane over both tonsils and the soft palate that, when removed, leaves an edematous, bleeding area of tissue. After calling your state health department, you initiate therapy with: A. Intravenous erythromycin or penicillin G B. The above antibiotics plus antitoxin C. The above antibiotics plus antitoxin plus active immunization D. Antitoxin alone E. IVIG

22 NEUROLOGY 16. A child presents in a coma. There is central hyperventilation. Pupils are mid-position and irregular 3-5 mm and fixed. The vestibule-ocular reflex is intact. He shows bilateral decerebration posturing to noxious stimuli. What is MOST likely to be the position/location of the transtentorial herniation? A. Reticular formation B. Diencephalon C. Mid-brain-upper pons D. Low pons-upper medulla E. medulla 17. A previously healthy 3 year old child has a single generalized convulsion lasting 5 min. she is found to have a reddened throat and a rectal temperature of 39.7C, from which she recovers uneventfully in 5 days. Three months later she again becomes febrile with an upper respiratory tract infection. Which of the following is CORRECT? A. She should be started on oral phenobarbitone B. She should be put in a bath of cold water C. 600 mg aspirin should be administered D. An antibiotic should be administered promptly E. Most such children will not have a further seizure 18. A 7 year old girl develops behavioral changes, and her performance in school begins to deteriorate. Several months later she develops a seizure disorder, ataxia, and focal neurologic symptoms. She is eventually quadriparetic, spastic, and unresponsive. Death occurs within a year. This patient may have had which of the following viral disease at 1 year of age? A. Chickenpox B. German measles C. Measles D. Mumps E. Parvovirus B19 19. A 20 month old child was seen at a well baby visit for routine examination. On physical examination you found that he still has a palpable anterior fontanel. A condition unlikely to cause this problem is : A. Rickets B. Hypothyroidism C. Hydrocephalus D. Undernutrition E. Hypophosphatemia

NEPHROLOGY 20. A 6 year old boy has brown urine and healing impetigo lesions. He present with hypertension, dyspnea, periorbital edema, and hepatomegaly. The most likely cause of this problem is: A. Postsreptococcal glomerulonephritis B. lgA nephropathy C. Nephritic syndrome D. Pyelonephritis E. Idiopathic hypercalciuria 21. After a urinary tract infection, a 1 year old boy is diagnosed with grade 2 vesicourethral reflux. Which of the following is an appropriate treatment option? A. Low doses antibiotic B. Immediate surgical reimplantation of the ureters C. Weekly urinalyses and culture D. Diet low in protein E. Early toilet training

23 22. A 2 year old boy developed bloody diarrhea shortly after eating a fast food restaurant. A few days later, he develops pailor and lethargy, his face looks swollen and his mother reports that he has been urinating very little. Laboratory evaluation reveals low hematocrit and platelet count and positive blood and protein in the urine. Which of the following diagnoses is likely to explain this symptoms? A. lg A nephropathy B. Henoch Schenloin Purpura C. Intussusceptions D. Poststreptococcal glomerulonephritis E. Hemolytic uremic syndrome

ENDOCRINOLOGY 23. A short 16 year old girl presents with primary amenorrhea. Laboratory studies show how low estradiol and elevated follicle-stimulating hormone (FSH) levels. Which of the following conditions is the most likely cause of primary ovarian failure? A. Turner syndrome B. Congenital adrenal hyperplasia C. Autoimmune ovarian failure D. Hypogonadotropic hypogonadism E. Androgen insensitivity syndrome 24. A girl aged 10 years with diabetes type 1 developes polyuria and polydipsia in the course of an eposide of bronchopneumonia. Her urine test have become positive for ketones, and blood glucose is 360 mg/dl. Which of the following approaches is appropriate? A. Wait for improvement of her diabetes over the next 1-2 days, followed by the introduction of antibiotics B. Increase her insulin doses the next day by 30% C. Ask her to recheck her urine ketones again every day D. Advise her to drink clear non-caloric fluids only and stop all solid food E. Admit her to hospital for stabilization 25. An 8 year old girl has a 2 year decline in growth velocity, as determined by plotting her height on a standard growth curve. At age 6 years, her height was at the 60th percentile; at age 7 years, it was the 40th percentile; and ate age 8 years, it was at the 10th percentile. Her parents are of average height. Her history is otherwise unremarkable, and physical examination reveals no abnormalities, although the thyroid gland cannot be palpated. The pair of laboratory test that would best help explain the cause of this patients recent growth retardation is: A. Free T4 and T3 B. Growth hormone and blood urea nitrogen C. Thyroid ultrasonography and technetium pertechnetate scan D. T4 and free T3 E. TSH amd free T4 26. A 15 year old boy is evaluated by a clinician for failure to develop normal male secondary sexual characteristics. Physical examination reveals small testes, a small penis, and gynecomastia. The boy has had some difficulties in school, and the parents say that according to the school psychometrist he had an IQ of 90. This patients condition is most likely to be related to which of the following? A. Deletion B. Nondisjunction of an autosomal chromosome C. Nondisjunction of a sex chromosome D. Non-Robertsonian translocation E. Robertsonian translocation

24 27. A baby is born with small head, small eyes and 6 fingers on each hand. Tow dimensional echocardiography reveals congenital heart defects. Which of the following genetic conditions is most likely to be the cause of this childs presentation? A. Trisomy 13 B. Trisomy 18 C. Trisomy 21 D. XXY E. XYY PEDIATRIC EMERGENCY 28. A 3 year old boy who has a tracheostomy has had difficulty in breathing and coughing for 2 days because of increased secretions. He is on continuous oxygen. His mother states that his breathing is getting much worse. Assessment reveals that he is lethargic, has cool, mottled skin, and has copious secretions in the tracheostomy tube. Which of the following signs suggest significant obstruction of the tracheostomy tube? A. A slow heart rate and poor air movement B. Irregular respiration and wheezing C. Crackles and fever D. Unequal chest rise and wheezing E. No breathing 29. A child with a suspected ingestion presents to the emergency department with delirium, tachycardia, mydriasis, dry mucus membranes and warm/dry skin. This child exhibits signs and symptoms of which toxidrome? A. Anticholinergic B. Sympathomimetic C. Cholinergic D. Opioid E. Sedative hypnotic NUTRITION 30. Breast milk is the natural food for full term and premature infants during the first months of life. There are nutritional, practical, psychological, immunological and physiological benefits to breastfeeding. Which is the following is NOT true about breast feeding? A. Recommended food for infants both term and preterm B. Fifty percent of energy are from proteins C. Contains immunological benefits (i.e. lgA, active lymphocytes) D. Promotes growth of lactobacillus in GI E. Decreases incidence of allergic disorders
PERINATOLOGY

31. A one week old newborn is irritable and has several episodes of bilious emesis after the most recent feeding. You are called to ask for new feeding orders. The baby has tachycardia but otherwise the vital signs are stable. On physical examination the abdomen was full without marked abnormalities. What would be the next step in this case? A. Consider the possibility of gastro-esophageal reflux B. Start a proton pump inhibitor C. Perform ultrasound examination of the pylorus D. Perform an upper gastrointestinal contrast study E. Change oral feeding to a soy-based formula 32. A newborn infant presents with the following clinical picture: coughing and cyanosis immediately after ingesting fluids, no difficulty in swallowing, coarse rhonchi and rales after swallowing, gastric distension after crying, no symptoms after gavage feeding. The most likely diagnosis is: A. Tracheo-esophageal fistula with esophageal atresia B. Tracheo-esophageal fistula without esophageal atresia C. Isolated esophageal atresia D. Pyloric stenosis E. Achalasia

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33. A baby who was apparently normal at birth, develops persistent regurgitation and vomiting in the second and third weeks of life. No fever is present and hematologic studies and blood chemistries are normal. Which of the following therapies is most likely to be effective in this case? A. Antacids B. Barium enema C. Gastric resection D. Oral antibiotics E. Pyloromyotomy 34. A 12 year old girl presents with poor feeding, vomiting nd lethargy. She was born uneventfully at 37 weeks gestation with a body weight of 2900 grams, and there were no neonatal problems. No drugs or other medications were given. On examination she is thin and wasted. She has lost weight <3%, the temperature is 36,5 5C, RR 40/min, and HR 150/min. the chest is clear with no evidence of murmur. There is no organomegaly, no rash or dysmorphic features. What is the most likely diagnosis? A. Congenital adrenal hyperplasia B. Congenital heart disease C. Inborn errors of metabolism D. Sepsis E. Congenital hypothyroid 35. When evaluating a hypoglycemic infant, the first thing to assess is: A. Ballard exam B. Presence or absence of symptoms C. Airway, breathing, circulation D. Presence or absence of a suck reflex E. Apgar score

36. Which of the following conditions is LEAST likely to be associated with neonatal seizures? A. E. Coli meningitis B. Syndrome of inappropriate diuretic hormone C. Neonatal hypoglycemia D. Transient tachypnea of the newborn E. Umbilical cord prolapse GROWTH AND DEVELOPMENT 37. A baby boy was born at 32 weeks gestation. He smiled at 6 weeks and could pick up a small object with his finger and thumb at 10 months. He is not yet walking at the age of 16 months. His speech is normal. Likely diagnoses is: A. Mental subnormality B. Gross motor delay C. Muscular dystrophy D. Spina bifida occulta E. phenylketonuria 38. A child is brought to your clinic for routine examination. She can dress with help, can ride a tricycle, kows her own age, and can speak in short sentences. She had difficulty in copying a square. The age of this child is most likely A. 1 year B. 2 years C. 3 years D. 4 years E. 5 years

26 39. A 3.5 year old boy says only three single words, and thes are poorly articulated. He uses gestures to communicate. There are no other reported problems, gross and fine motor skills are normal for age and physical examination, including tympanigraphy, is normal. Which of the following is the MOST LIKELY explanation? A. Intellectual disability B. Deafness C. Manipulative behavior D. Dysarthria E. Autism 40. A 2 year old girl comes in for a well baby check up. She should be able to do all of the following except: A. Turn pages one at a time B. Use 2-3 word phrases C. Follow two step commands D. Participate in group play E. Walk unsupported

CARDIOLOGY 41. A 7 years old girl is referred for chronic recurrent cough. She shows normal vital signs, pulses, and abdomen. The RV impulse is accentuated. S2 is fixed and widely split. A nonspecific 2/6 almost vibratory systolic ejection murmur is best heard at the left sterna border, and there is also a 2/6 middiastolic murmur at the lowest left sterna border, what is the lesion? A. VSD (Ventricular Septal Defect) B. ASD (Atrium Septal Defect) C. PDA (Patent Ductus Arteriosus) D. AVSD (Atrio-Ventricular Septal Defect) E. PS (Pulmonal Stenosis)

42. A 6 year old boy was referred for prolonged fever and swelling, severe pain and redness of his ankles. The precordium is normal except for a mild thrill in the apex. S1 and S2 are normal, but harsh holosystolic murmur is heard at the apex. The abdomen is soft and there is no organomegaly. What is the diagnosis? A. Juvenile rematoid arthritis B. Acute rheumatic fever C. Myocarditis D. Infective endocarditis E. Cardiomyopathy 43. An eight year old boy with known diagnosis of unrepaired tetralogy of Fallot becomes severely cyanotic while crying. Which of the following is NOT indicated for acute management of this situation? A. Placing in knee chest position B. Oxygen C. Morphine sulfate D. Propranolol E. Insert rectal tube 44. A patient presents with cyanosis and clubbing of the toes with sparing of the fingers. A rough murmur is heard at the left upper sternal border. What is the most likely diagnosis? A. Atrial septal defect B. Sinus of valsava fistula C. Common atrioventricular canal defect D. Patent ductus arterious E. Ventricular septal defect

27 RESPIROLOGY 45. A healthy 15 year old complains of swollen glands in his neck and groin for the last 6 months along with an increasing cough over the previous 2 weeks. He also reports some fevers, especially at night, and possibly some weight loss. On examination, you notice that he has nontender cervical, supraclavicular, axillary, and inguinal nodes. No hepatosplenomegaly, and otherwise looks to be fairly healthy. Which of the following would be the appropriate next step? A. Biopsy of a node B. Complete blood count and differential C. Trial of antituberculos drugs D. Chest radiograph E. Cat-scratch titers 46. A 3 year old boy was brought to a pediatric clinic for consultation. His father suffered from haemopthysis and had been treated with antituberculous drugs since the week before. The child was symptomless and had a normal body weight. Tuberculin skin test result was 12 mm, and the chest x-ray didnt show any suggestion for tuberculosis. Which of the following answers is the most appropriate management in this child? A. Primary chemoprophylaxis with isoniazid for 3 months B. Primary chemoprophylaxis with isoniazid for + rifampin for 3 months C. Secondary chemoprophylaxis with isoniazid for 6 months D. Secondary chemoprophylaxis with isoniazid + rifampin for 6 months E. Give isoniazid, rifampin, and pyrazinamide for 2 months, follow with isoniazid and rifampin for 4 months 47. A 3 month old girl has suffered from dyspnea since 2 days befor admission. She also complains of rhinorrhea, cough, fever, and vomiting. There is no family history of atopy. On physical examination fever, tachypnea, nasal flaring, chest indrawing, crackles, and wheezing were evident. Her laboratory result are WBC: 4000/ with a preponderance of polymorphonuclear. What is the most likely diagnosis for this patient? A. Severe asthma exacerbation B. Severe pneumonia C. Pneumonia with asthma exacerbation D. Pneumonia with GER E. Bronchiolitis 48. A 10 year old girl came to the outpatient clinic with the chief complaint of cough for 3 weeks. She had no fever, no dyspnea and no TB contact. On physical examination she had good nutritional status, no abnormalities were found except for a slight decrease of her right field breath sound. The Tuberculin SkinTest resulted in a 5 mm induration and the Chest X-Ray was as attached below. The most appropriate assessment and management of choice would be: A. Pertussis, aminoglycoside B. Atypical pneumonia, macrolide C. Pneumococcal pneumonia, cephalosporin D. Tuberculosis, rifampicin E. Asthma, salbutamol nebulizer 49. A 2 year old boy suffer of inspiratory stridor. On the physical examination revealed suprasternal and intercostals retractions, nasal flaring, and barking cough. He has ha a mild upper respiratory tract infection for 3 days. The most likely diagnosis in the patient is: A. Foreign body aspiration B. Acute laryngitis C. Acute epiglottitis D. Papilloma of larynx E. Viral croup

28 50. A patient with tuberculosis develops bright orange-red urine. His mother was in a panic because she is afraid he is bleeding into the urine. The patient has no other urinary tract symptoms. Which of the following medications is most likely to procedure this side effect? A. Ethambutol B. Isoniazid C. Pyridoxine D. Rifampin E. Streptomycin

7th NATIONAL MCQ EXAMINATION NATIONAL BOARD OF EVALUATION INDONESIAN COLLEGE OF PEDIATRICS JULY 14, 2010 SELECT THE ONE BEST ANSWER, PUT YOUR ANSWERS IN THE ANSWER SHEET TIME ALLOCATION : 100 MINUTE

GASTRO-HEPATOLOGY 1. A 7-week-old,full-term girl has worsening jaundice that the parents first noticed 10 days ago. On her examination, she is well appearing and is noted to have a liver edge 4 cm below her costal margin. Her direct bilirubin is 9. The most likely cause of her direct hyperbilirubinemia is which of the following : A. Billiary atresia B. Cholecystitis C. Sepsis D. Acetaminophen toxicity E. Chollytiasis F. An 8-year-old girl presents to your office with a 3 day-history of decreased appetite and abdominal pain. She denies fever or diarrhea but has nausea and intermittent vomitting. Physical examination reveals a jaundiced girl with a height and weight at the 50 percentile for age. The abdomen is soft and nondistended with positive bowel sounds, but the patient has diffuse right upper quadrant pain and enlargement of the liver without splenomegaly. Your initial evaluation includes A. Hepatitis A antibody B. Monospot C. Hepatitis B surface antigen D. Hepatitis B antibody E. Hepatitis B e antigen 3. A 5-year-old girl has had intermittent, painless, bright red colored bleeding from the rectum in association with bowel movements for the past 3 months. Inspection of the anus reveals no fissures, but blood is present on the examiners finger following digital examination of the rectum. Of the following, the most likely cause of this patients rectal bleeding is : A. Intussusception B. Juvenile polyp C. Meckels diverticulum D. Peptic ulcer disease E. Ulcerative colitis

29 PERINATOLOGY 4. A newborn male spits up his first feeding and subsequently develops bilious emesis following further feddings. On physical examination, he appears ill, has a scaphoid abdomen, and has absent bowel sounds. A plain radiograph reveals air in the proximal small bowel but a paucity of air in the distal digestive tract. Of the following, the most likely cause for this infants vomiting and clinical findings is : A. Antral web B. Choledochal cyst C. Hirschsprung disease D. Tracheoesophageal fistula E. Volvulus

5. A baby boy was born from a mother who had positive AFB from her sputum. His mother was on antituberculosis treatment since 1 month before the baby was born. The baby was doing well with 9/10 Apgar Score. His Birth Weight was 3100 gram and his placenta didnt show any tubercle. He also had two siblings. His 8 years old sister was well nourished and had no complaints. His 3 years old brother was also in a good condition. The most appropriate time for BCG immunization would be : A. Immediately after Birth B. At the age of 2 months as a routine immunization schedule C. At the age of 1 months, when the clinical condition is good and tuberculin test negative D. At the age of 3 months, when the clinical condition is good and tuberculin test negative E. There is no need for giving BCG immunization

6. A 19 year-old primiparous woman developed toxemia in her trimester of pregnancy and during the course of her labor was treated with magnesium sulfate. At 38 weeks gestation, she delivered a 2100 grams -infant with an Apgar score of 1 at 1 minute and 5 at 5 minutes. Laboratory studies at 18 hours of age revealed a hematocrit of 79 %, platetet count of 100,000/micro, glucose 41 mg/dl, magnesium 2,5 mEg/l, and calcium 8,7 mg/dl. Soon after, the infant had a generalized convulsion. Of the following the infants seizure was most likely caused by A. Polycythemia B. Hypoglycemia C. Hypocalcemia D. Hypermagnesemia E. Thrombocytopenia 7. A premature infant had been fed 10 ml for orogastric tube. The gastric residual before feeding is 2 ml which contained digested formula. The physical examination and vital signs are normal. What should you do to the infant? A. Fasting B. Discard the aspirate and continue the feedings C. Take an abdominal radiograph D. Increase the interval of feeding E. Replace the volume B. The examination of a newborns back reveals a quarter-size lump of the soft tissue overlying the lower spine. Evaluation with ultrasound of this lesion may demonstrate : A. Ebstein pearl B. Mongolian spot C. Cephalohematoma D. Omphalocele E. Occult spina bifida

30 TROPICAL/INFECTION DISEASE 9. A 6 year-old boy has a bright, red, punctate, erythematous rash which blanches on pressure, beginning in the axilar along with some perioral pallor and relative facial sparing. The skin feels like sandpaper. The rash fades and desquamates on the hands and feet. A thick white exuadate develops on the tongue which peels off leaving a stawberry tongue with prominent papillae. This description is typical of : A. Scarlet fever B. Kawasakis disease C. Infectious mononucleosis D. Staphylococcal scalded skin syndrome E. Measles 10. A 7 year and 6 months-old girl with a body weight and length of 24 kg and 125 cm respectively, was hospitalized because of dengue virus infection. The patient presented with fever for 5 days, abdominal pain, and vomiting. Caough and cold were not noted. Petechia and echymosis was found on her skin. Blood pressure was 100/70 mmHg, pulse 100/min, body temperature 39C, Hematocrit 47 % and platelet count 90.000/cmm. The most likely diagnosis would be A. Dengue Fever B. Dengue Hemorrhagic Fever grade I C. Dengue Hemorrhagic Fever grade II D. Dengue Hemorrhagic Fever grade III E. Dengue Hemorrhagic Fever grade IV 11 A 9-year-old boy presents with fever >39C for 4 days, watery diarrhea, conjunctival injection, diffuse erythroderma, strawberry tongue, blood pressure of 80/40 mm Hg, and moderately elevated hepatic transaminases. The most likely diagnosis is : A. Staphylococcal scalded skin syndrome B. Kawasaki disease C. Toxic shock syndrome D. Stevens-Johnson syndrome E. Toxic epidermal necrolysis

PEDIATRIC EMERGENCY 14. A 5-year-old boy came to the emmergency departement because of clammy hands. The mother told the doctor that her son had had fever for 4 days. The temperature bacame normal the night before; however a few hours later, she felt that her sons hand got clammy. There were some small red dots on the face and feet, noticed by his parents since the afternoon. There were no history of bleeding, vomiting and diarrhea. His appetite was decreased. Defecation was nornal. Based only on that story, the most likely diagnosis is : A. Septic shock B. Cardiogenic shock C. Dengue shock syndrome D. Hypoglicemia shock E. Anaphylactic shock 15. You are informed that a 6 year-old girl is being transported to your ED following a drowning incident at a nearby pool. The patient is unconscious and total submersion time is unknown. Which of the following would be the most important priority in the prehospital setting? A. Attempts to evacuate aspirated fluid by performing Heimlich maneuver B. Cervical spine immobilization C. Wrap the patient in warm blankets D. Do nothing and continur rapid transport E. Initiate cardiopulmonary resuscitation if the patient is pulseless

31 A. A 5 year-old boy is brought to your emergency departement (ED) for evaluation of scalding burns to face, arms, and torso from hot water. On examination yo note that the burns to the hands and face seem qiute extensive. There is marked edema, erythema, and some blistering present. Which of the following is a management priority in this child? A. Estimate the percentage surface area involved in the burn. If the burn involved more than 15 % body surface area (BSA), begin agressive fluid administration. B. Assess the childs airway and oxygenation status C. Begin humidified oxygen and prepare for intubation D. Determine the circulation status E. Nebulize respiratory treatments to prevent bronchospasm 17. You are at a restaurant when you observe a child apparently choking, the child is not able to cough and is unconscious. Which of the following describes the most appropriate intervention? A. Active emergency medical service (EMS) B. Attempt to remove the foreign body if visualized in oropharynx C. Administer a combination of back blows and chest thrust D. If the cough becomes ineffective, perform the Heimlich manouver E. Place the child on the floor and administer five abdominal thrust RESPIROLOGY 18. A 5 month-old girl came to Emergency Room with difficulty in breathing. Three days prior to admission she suffered from fever and cough. Her physical examination showed increased respiratotory rate along with a chest indrawing. Auscultation revealed crackles without any evidence of whezzing. Her CBC showed a leucocyte count of 27,00 cell/ul and chest X-ray showed multiple blebs in right hemithorax. The possible causative agent of pneumoniae in this baby girl would be : A. Streptococcus pneumoniae B. Staphylococcus aureus C. Haemophylus influenzae D. Staphylococcus epidermidis E. Chlamydia trachomatis

NEUROLOGY 19. An 11-month-old presents to your emergency departement with irritability, fever, and stiff neck. When performing the lumbar puncture in this child, you should A. Quickly push the needle in all the way until a pop is left B. Push the needle in until resistance is left and then withdraw the stylet C. Use a needle without a stylet D. Twirl the needle repeatedly E. Advance the needle by small increments and remove the stylet after each advance to see if cerebrospinal fluid (CSF) comes out 20. A 4 year-old boy was admitted to the hospital with alteration of consciousness since 2 days prior of hospitalization. He has had fever for 3 days, along with headache and projectile vomiting. Seizures developed 2 days before admission, which was of a general type, lasting for 5 minutes and recurred. His bowelmovement and urination were normal. He never received basic immunization, and never got severe disease since birth, except for swollen cheek about 2 weeks before, which resolved by itself. Physical examinations revealed GCS 8 (E2M4V2), hyperthermia, neck stiffness and spasm. His physiological reflexes were increased ang pathological reflexes were present. Laboratory examinations revealed WBC 5,500/mm, Hemoglobin 12.1 g/dl, Platelet count 540,000/cmm. The most reasonable examination which should be perfomed is : A. Head CT-scan B. MRI C. EEG D. Blood culture E. Spinal tap

32 21. A 13-year-old boy admitted for complaints of lower extremity weakness niticed that his legs were weak when getting out of bed. His symptoms seem to be getting worse because now he is having difficulty in walking. He contracted an upper respiratory tract infection about 2 weeks ago but did not experience any fever. He plays football but denies any recent trauma. Physical examination : afebrile, cranial nerves normal, upper extremities is 5/5, no pronator drift and lower extermity strength is 3/5. Sensory normal, gait : unable to walk unassisted. Relfexes are absent in the lower extremities. Give the most likely diagnosis : A. Transverse myelitis B. Poliomyelitis C. Guillain Barre Syndrome D. Myositis E. Myastenia gravis

22. A six year-old boy was brought to the emergency departement because of seizure since one hour before admission. Physical examination revealed an unconcious boy, body temperature was 41,5 C, respiration rate 40/m deep, pulse rate 144 m, BP 130/90, Hb 13 g %, PCV 40 %, leucocyte 18000. His body weight was 33 kg. The working diagnosis of this boy is : A. Encephalitis + obesity + bronchopneumonia B. status epilepticus + hyperpyrexia + obesity C. tuberculosis meningitis D. bacterial meningitis E. complex febrile seizure + hyperpyrexia 23. A mother in the predecing question delivered a 4000 g- baby by a difficult forceps delivery. The baby was alert and active. She did not more her left arm, however, which she kept internally rotated by her side with the forearm extended and pronated; she also did not move it during a Moro reflex. The rest of her physical examination was 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 HEMATOLOGY 24. A12 year-old boy, 20 kg,ith lung TB was consulted to you because of pallor. The patient suffered from lung TB since 4 months ago and now was in 2nd month of TB treatment. The history and physical examination was unremarkable. Laboratory findings revealed Hb 8,9 g/Dl, WBC 7400/cmm, Platelet 176000/cmm, Reticulocyte 1,2 %, differential count 1/-/8/16/54/21, Serum Iron 35 (N 60-90) Total Iron Binding Capacity 275 (N 250-400). A. Iron deficiency B. Chronic disease C. Malnutrition D. Hemoglobinopathy E. Hypoplastic anemia 25. The best management in this patient is A. Give PRC transfusion until Hb 10 g/Dl to increase blood oxygenation B. Give Iron orally C. Give erythropoietin injection D. Continue TB treatment E. Give high calorie diet

33 26. A 3 year-old boy develops pallor, purpura on the skin and recurrent epistaxis. There is no evidence of hepatosplenomegaly or lymphnode enlargement. Laboratory findings reveals a hemoglobin level of 3 g/dl, hematocrit 9,3%, red blood cell count 1,500.000/mm, white blood cell count 1,500/mm and platelet count 55,000/mm. The most likely diagnosis of the patient is : A. Hemolytic anemia B. Aplastic anemia C. Post-hemorrhagic anemia D. Leukimia E. Iron deficiency anemia 27. A 5 year-old has had recurrent hematoma on both his arms and legs since the age of one year. platelet count is 200,000/L, Hb and WBC are 11,1 g/dl and 5,500//L respectively, and bleeding ime is 2 minutes. There is no hepatosplenomegaly or lymphnode enlargement. which of the following is most likely to explain this childs condition? A. Disturbance of thrombocyte function B. Disturbance of synthesis in Von Wiillebrand factor C. Disturbance of vascular D. Disturbance of fibrinolytic system E. Disturbance of coagulation system 28. A 3 year-old boy with ALL (L3 type) suddenly experienced low urine output. The total urine output was 0.3 ml/kg BW/h. The patient was diagnosed as ALL (L type) since 2 weeks before and started induction phase of chemotherapy since 8 days before. The most possible reason for this condition is : A. Acute Kidney Injury B. Tumor Lysis Syndrome C. Not adequate hydration D. Syndrome of Inappropriate Anti Diuretic Hormone (SIADH) E. Hyperleukocytosis 29. A 6 year-old child came to the hospital with the chief complaint of nose-bleed a long with red dot spots on his extremities. There was no fever. There aws no history of bleeding beforehand. He had been circumcized without any problem. There was no history of the same symptoms in his family The physical examination revealed no evidence of hepatosplenomegaly. The most likely cause of these symptoms would be A. Primary Trombocytosis B. Von Willebrands Disease C. Hemophilia D. Vitamin K deficiency E. ITP

NEPHROLOGY 30. A 7 year-old Indonesian boy has complaints, pallor and difficulty to gain weight for one year. A thorough physical examination revealed that he was alert, looked ill with a body weight of 18 kg, body height of 104 cm. Blood pressure was 140/100 mmHg. Laboratoryfindings revealed Hb 9 g/dl, ureum 150 mg/dl, plasma creatinine 3.6 mg/dl, Erythroctre cast, leucocyte : 0-1/HPF, erythrocyte : 20-40/HPF. The most likely diagnosis of this patient is : A. Acute post-streptococcal glomerulonephritis B. Acute pyelonephritis C. Nephrotic syndrome D. Chronic glomerulonephritis E. Chronic pyelonephritis

34 31. Which of the following that is NOT the indication for long-term prophylaxis against urinary tract infection : A. Ureteropelvic junction obstruction B. Posterior urethal valve C. Prune belly syndrome D. Nephrotic syndrome E. Vesico-uretheral reflux 32. A 6 year-old girl with global developmental delay presents with fever and gross haematuria, along with visible pink urine and clots. Birth history revealed full term normal delivery with no neonatal complications. She has been diagnosed as developmental delay at 9 months, and receives spesial schooling. Immunizations are up to date. There is no family or social history of note. On examination she has a temperature of 37.8C, respiratory rate of 18/min and heart rate of 90/min. She has suprapubic tenderness. Urine dipstix testing shows 4+ haematuria, 3+ proteinuria and 3+ nitrites. The most lukely diagnosis is A. Benign familial haematuria B. Glomerulonephritis C. Haemorrhagic cystitis D. Henoch-Schonlein Disease E. Urinany tract infection

33. A 1 year-old male child was brought with fever for 2 days along with decreased appetite. Physical examinations were normal. Urinalysis showed protein +1, abundant leucocytes, erythrocyte 20-30/hpf, bacteria +. What would be the best therapy for this case? A. Oral antibiotics for Gram-positive bacteria B. Oral antibiotics for Gram-negative bacteria C. Intravenous antibiotics for Gram-negative bacteria D. Intravenous antibiotics for Gram-positive bacteria E. Intravenous followed by oral antibiotics for Gram-negative bacteria

ENDOCRINOLOGY 34. An eleven year-old boy presented to the clinic because of short stature. Height was much below 3rd percentile and weight was on 75th percentile. Which of the following is important in your initial evaluation? A. Measure parents height, calculate mid-parental height B. Assure him that his short statute is not pathological C. Immediately do growth hormone stimulation test D. Start growth hormone tratment, if clinically suggestive of GH deficiency E. Start short trial of growth hormone and see the response 35. A ten year-old girl presented with obesity, round plethoric face, hirsutism and short stature. On examination her blood pressure was hidh and her obesity was truncal. Which of the following laboratory finding is expected to be present in the child? A. Metabolic acidosis B. Hyperkalemia C. Hypoglycemia D. Hypokalemia and metabolic alkalosis E. Increased cortisol level

35 36. An 8 year-old male has a 3 week-history of weight loss, polyuria and polydipsia. He has been urinating approximately two or three times per hour for the last few weeks. He has experiended some mild abdominal discomfort but there was no evidence of nausea or vomiting. Taking into consideration that the child has Diabetes, the statements below are true expect A. A patient with poorly controlled diabetes should not undergo elective surgery until glucose is reasonably B. Patient undergoing minor surgial procedures may be brought in on the morning of surgery C. There are only 2 ways of starting insulin D. Lantus is very helpful, as it has a long-acting profile and provides good control of basal hyperglycemic E. Selection and rotation of insulin sites are important 37. A 14 year-old is brought into your office because concerns of lack of pubertal development. The parents report that the child has otherwise been healthy, but the child has been complaining that all of his/her friends seem to be getting much taller than him/her. The childs father is 180 cm and could not recall when he went through puberty, but did remember being shorter than all his friends in high school. The mother is 165 cm and had menarche at age 14 years. On the physical examination, the childs heigh t is less than the 5th percentile, and weight is at the 30 th percentile. The child is entirely prepubertal. What is the most likely diagnosis if this a boy with a bone age of 11 years, and his father grew 10 cm after high school? A. Hypogonadotropic hypogonadism B. Constitutional delay of puberty C. Hypogonadotropic hypogonadism D. Klinefelters syndrome E. Kallmann syndrome

NUTRITION 38. Infant formula is not a sterile product and may be contamined with pathogens that can cause serious illness. Proper handling and correct preparations will reduce the risk. According to the WHO guidelines it has to be reconstituted with A. Boottled water B. Hot boiling water (100C) C. Water directly from water dispenser D. Boiled water that has been allowed to cool to no less than 70C E. Mixture of hot boiling water and cool water to achieve temperature of 70C Nutritional obesity has to be differentiated with obesity as a part of a syndrome. The following feature that is hard to diferentiate between nutritional obesity and syndromic obesity is: A. Short stature B. Delayed development C. Dysmorphic face D. Familial occurrence E. Mentally retarded A two year-old boy was diagnosed as hypercarotenemia. Of the following the most important examination is featuring yellow pigmentation A. in the sclera and oral cavity B. of the skin C. in the sclera and nail D. in the oral cavity E. in the sclera,oral cavity and nail

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36 41. A 2 years-old boy, Body Weight 6,5 kg, Body Length 80 cm, complains of weight loss for the last 6 months, along with loss of appetite. He has the following anthropometric measures: weight-for-age zscore <-3 SD, weight for height = 59%, height for age= 93%. The diagnosis of this patient is A. Severe malnutrition marasmic type B. Severe malnutrition kwarshiorcor type C. Severe malnutrition marasmic- kwarshiorcor type D. Failure to thrive E. Short stature A premature baby is presented with apparent Essential Fatty Acid W-6 defyciency due to prolonged parenteral nutrition without proper supplementation. The following statements are appropriate for Essential Fatty Acid W-6: A. Main source: Deep-sea fist body oil B. Essential for the nervous system and retina development C. Arachidonic acid is thebiological active form D. Pharmacologic action of lowering triglyceride blood level E. Not essential for the healing of skin lesion

42.

GROWTH AND DEVELOPMENT 42 A mother brings her 7 month-old child for a routine check-up. Between the ages of six and eight, children typically become able to participate in a much greater of activities primarily as a result of: A. A significant increase in fine-motor control. B. A latency period of minimal physical growth and development. C. A sudden,dramatic improvment in gross-motor control. D. The eatablishment of handedness and footedness. E. Change of intelligence

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An 18 month-old boy comes to clinic with the chief complaint of not being able to walk yet. He was bom at 32 weeks of gestation. He recently understands simple instruktion,can say dada-tata, and can eat using a spoon. The most probable development problem for this child is: A. Delayed motoric development B. Global delayed development C. Delayed speech D. Delayed fine motor development E. Normal development In his previuos basic immunization,he has got BCG1x, DPT3x, Hepatitis B 3x, Polio 4x, which are appropriate immunization for him now: A. DPT 4, Hepatitis 4, Polio 5 B. Measles C. DPT 4, Polio 5, measles D. DPT 4, Polio 5 E. Hepatitis 4

44.

37 CARDIOLOGY 47 A 5 day old infant bom at 31 weeks gestation is on ventilatory support. He has a grade 2 holosystolic murmur that extends past the second heart sound. Pulses are bounding. Precordial palpation is hyperdynamic. Echocardiography reveals a large patent ductus arteriosus. Concentrations of hemoglobin, electrolytes and creatinine are normal. Of the following the most appropriate INITIAL management is to: A. Administer furosemide intravenously B. Administer indomethacin intravenously C. Administer indomethacin via nasogastric tube. D. Defer intervention because spontaneous closure is likely E. Obtain a surgical consultation of ligation of the ductus. A 3-month old boy comes to you with fast breathing occurring mainly during feeding. The mother tells you that her baby often stops every 5 minutes during breast feeding. On physical examination, you find mild respiratory distress. First and second heart sound are normal, but a lound machinery murmur is heard on the upper left sternal border. The most likely diagnosis is: A. VSD B. ASD C. CAPVD D. PDA E. Tetralogy of Fallot A 1 year-old child is brought to the ER because his parent thought his heart was pounding as they were putting him to bed. EKG reveal a HR of 300/min that spontaneously converts to asinus rate of 100/min. The parents estimate that the tachycardia lasted 20 minutes; the child was asymtomatic throughout. Of the following the MOST appropriate management of this child is; A. Administration of a beta blocker B. Administration of digoxin C. Administration of procainamide D. Administration of verapamil E. Observation without drug therapy

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50.

A 7 year-old child returns for follow up. He is pink and healthy looking with normal vital signs, pulses, and precordial activity. However the anteroposterior diameter of her chest is somewhat increased. The lungs are clear. S1 is normal, but S2 is fixed and widely split. A2/6 medium frequency systolic ejection murmur is heard at the upper left sternal border and all along the left ssternal border; it also heard well in the lung fields. There is also an early 2/6 diastolic murmur, almost descrescendo at the lower left sternal border. The liver is 1 cm below the right costal margin. What is the murmur at the upper left sternal border most likely caused by? A. Relative pulmonary stenosis B. Relative tricuspid stenosis C. Relative mitral sttenosis D. Relative aortic stenosis E. Relative mitral insufficiency

ALLERGY-IMMUNOLOGY 1. A 14-year old girl is exposed to roundworm Ascaris but does not develop clinical signs of infection. Which of the following mechanisms is likely to be responsible for his resistance to infection? A. Antibody-mediated destruction of worm-infected cells B. CTL-induced apoptosis of worm-infected cells C. Complement-mediated lysis of worm attached to host tissues D. IgE-mediated type I hypersensitivity disrupting worm attachment E. Phagocytosis of worms followed by necrosis of phagocytes

38 2. A 15-month old body who has not received any recommended vaccines remains healthy despite his daily assosiation with several other children for the past years in his otherwise well-tended inner city housing area Which of the following merchanisms best explains why he has not contracted diphttheria, measles, pertussis, or polio? A. Hard immunity B. Genetic drift C. Genetic shift D. Immune evasion E. Tolerance 3. A 5-year old, previously healthy boy has had a daily spiking fever up to 40C in the evening for 4 weeks. His temperature is normal between spikes. When febrile, the child is irritable, has malaise and does not want to play or move. He is often active and playful when afebrile. He appears stiff in the morning. His mother is concernet that his finger and knee joints appear swollen. This childs diagnosis is most likely A. Rheumatic fever B. Systemic arthritis C. Periodic fever syndrome D. Kawasaki disease E. Systemic Lupus Erythematosus

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KOLEGIUM ILMU KESEHATAN ANAK INDONESIA 8th MCQ Progress Test Nasional, 11 Mei 2011

Nama IPDSA Tahapan Semster

:..................................................................... : ..................................................................... : ..................................................................... (Yunior / Madya / Senior) : .....................................................................

Petunjuk : Berilah tanda X pada huruf jawaban yang benar pada lembar jawaban 1. Bayi berusia 2 hari diperiksakan ke ruang gawat darurat karena pendarahan dari dubur dan hidung.