General pediatric in training Examination 2008

Dr. AbdulRahman Alnemri, MDAssociate professor of pediatric

Consultant NeonatologistAFHSR

DIRECTION

Each of the questions or incomplete

statements below is followed by five

suggested answers or completions. Select

the one that is BEST in each case and mark

your answer sheet by filling in the circle

containing the corresponding letter.

1. A 30-month old, previously healthy girl is brought to theemergency department after her mother grabbed her by the wrist to prevent her from running into the street. The child isalert but the right arm hangs limply at her side with theelbow slightly flexed. She does not seem to be able tostraighten the arm nor will she move it actively on request.There are no bruises and no other evidence of trauma. Theremainder of the findings on physical examination isnormal.Your next step in the management of this child would be

to :A. Order an x-ray of the right wristB. Order an x-ray study of the entire right arm.C. Order an x-ray studies of the skeleton and skullD. Splint the forearmE. Supinate the forearm with the elbow in flexion

1. A 30-month old, previously healthy girl is brought to theemergency department after her mother grabbed her by the wrist to prevent her from running into the street. The child isalert but the right arm hangs limply at her side with theelbow slightly flexed. She does not seem to be able tostraighten the arm nor will she move it actively on request.There are no bruises and no other evidence of trauma. Theremainder of the findings on physical examination isnormal.Your next step in the management of this child would be

to :A. Order an x-ray of the right wristB. Order an x-ray study of the entire right arm.C. Order an x-ray studies of the skeleton and skullD. Splint the forearmE. Supinate the forearm with the elbow in flexion

2. For a child who has had re-current otitis media and serous otitis, the therapy among the following that is most likely to prevent recurrences of acute otitis media is:

A. Administration of polyvalent pneumococcal vaccine

B. Myringotomy and tympanostomy tube

C. Adenoidectomy

D. Daily administration of an antihistamine

E. Daily use of a long-acting nasal decongestant spray.

2. For a child who has had re-current otitis media and serous otitis, the therapy among the following that is most likely to prevent recurrences of acute otitis media is:

A. Administration of polyvalent pneumococcal vaccine

B. Myringotomy and tympanostomy tube

C. Adenoidectomy

D. Daily administration of an antihistamine

E. Daily use of a long-acting nasal decongestant spray.

3. Tachypnea and progressive weakness gradually develop in a 4-month old boy who appeared normal at birth. He has fed poorly for the past month. Physical examination shows diffuse muscular weakness, a large tongue and hepatomegaly. An x-ray study of the chest demonstrates marked cardiomegaly. An electrogram showed massive voltage and s short PR interval.

This clinical picture is most likely associated withA. Congenital hypothyroidismB. Beckwith-Weidman SyndromeC. Prader-Willi SyndromeD. Glycogen storage diseaseE. Down’s Syndrome

3. Tachypnea and progressive weakness gradually develop in a 4-month old boy who appeared normal at birth. He has fed poorly for the past month. Physical examination shows diffuse muscular weakness, a large tongue and hepatomegaly. An x-ray study of the chest demonstrates marked cardiomegaly. An electrogram showed massive voltage and s short PR interval.

This clinical picture is most likely associated withA. Congenital hypothyroidismB. Beckwith-Weidman SyndromeC. Prader-Willi SyndromeD. Glycogen storage diseaseE. Down’s Syndrome

4. A 2 ½ -year old boy is referred to you for evaluation of short stature. His height is 82.5 cm (<3rd percentile). His weight is 10.8 kg (<3rd percentile).

Which of the following would be most helpful in the evaluation of this patient’s condition?

A. Developmental history

B. Urinalysis

C. Previous growth record

D. Determination of bone age

E. Determination of the serum somatomedin-C concentration

4. A 2 ½ -year old boy is referred to you for evaluation of short stature. His height is 82.5 cm (<3rd percentile). His weight is 10.8 kg (<3rd percentile).

Which of the following would be most helpful in the evaluation of this patient’s condition?

A. Developmental history

B. Urinalysis

C. Previous growth record

D. Determination of bone age

E. Determination of the serum somatomedin-C concentration

5. A 4 years old child is found to have the classical murmur of a patent ductus. He is under weight for age but otherwise well. Which of the following would you recommend for this patient ?

A.  Recommend early operative closure?

B. Review the child constantly, expecting spontaneous closure within the next five years?

C. recommend prophylactic penicillin until operation is performed?.

D. Delay operation until the child has reached its expected weight for age?.

E. Explain to the patients that this is of little significance and can be ignored.

5. A 4 years old child is found to have the classical murmur of a patent ductus. He is under weight for age but otherwise well. Which of the following would you recommend for this patient ?

A.  Recommend early operative closure?

B. Review the child constantly, expecting spontaneous closure within the next five years?

C. recommend prophylactic penicillin until operation is performed?.

D. Delay operation until the child has reached its expected weight for age?.

E. Explain to the patients that this is of little significance and can be ignored.

6. An 11-year old child has had leukemia for some time. It is now clear that the child will die soon. The parents request that their child have the opportunity to die at home, where there are two other children, ages 8 and 15 years. The patient has begun to ask whether he will die or will get better.

The issue of impending death in this 11-year old child with leukemia should

A. Not be discussed with the 8-year old siblingB. Be discussed with anyone who raises the questionC. Be discussed with each family member, including

the dying childD. Be discussed with parents onlyE. Be discussed with the dying child by a psychiatrist

6. An 11-year old child has had leukemia for some time. It is now clear that the child will die soon. The parents request that their child have the opportunity to die at home, where there are two other children, ages 8 and 15 years. The patient has begun to ask whether he will die or will get better.

The issue of impending death in this 11-year old child with leukemia should

A. Not be discussed with the 8-year old siblingB. Be discussed with anyone who raises the questionC. Be discussed with each family member,

including the dying childD. Be discussed with parents onlyE. Be discussed with the dying child by a psychiatrist

7. Three to four times each while sleeping, a 3 year old girl suddenly sits up and screams. The eyes are open, she appears frightened and she is difficult to console initially. The next morning. She has no memory of the events.

Of the following, the most likely diagnosis is:

A. Complex partial seizuresB. Sleep apneaC. SomniloquismD. NightmaresE. Night terrors

7. Three to four times each while sleeping, a 3 year old girl suddenly sits up and screams. The eyes are open, she appears frightened and she is difficult to console initially. The next morning. She has no memory of the events.

Of the following, the most likely diagnosis is:

A. Complex partial seizuresB. Sleep apneaC. SomniloquismD. NightmaresE. Night terrors

8. In children with acute lymphocytic leukemia who are receiving intensive maintenance chemotherapy, the greatest reduction in incidence of pneumonia due to Pneumocystis carinii has been achieved by which of the following ?

A. Deletion of Prednisolone from the maintenance regimen

B. One-week courses of vincristine every ten weeks

C. Regular prophylactic injections of pentamidine isethionate

D. Regular prophylactic oral administration of trimethroprim with sulfamethoxazole

E. Regular prophylactic administration of chloramphenicol

8. In children with acute lymphocytic leukemia who are receiving intensive maintenance chemotherapy, the greatest reduction in incidence of pneumonia due to Pneumocystis carinii has been achieved by which of the following ?

A. Deletion of Prednisolone from the maintenance regimen

B. One-week courses of vincristine every ten weeks

C. Regular prophylactic injections of pentamidine isethionate

D. Regular prophylactic oral administration of trimethroprim with sulfamethoxazole

E. Regular prophylactic administration of chloramphenicol

9.The mother of an 18-month old girl consults you regarding her daughter’s language development. The infant’s tympanic membranes appear normal and are mobile on pneumatic otoscopy. The patient has a 12-word vocabulary and uses a considerable amount of jargon, but she does not use any two-word phrases.

A. Refer the infant for tympanometry

B. Refer the infant for brain stem-evoked audiometry

C. Refer the infant to a speech pathologist

D. Assure the mother that language development is normal

E. Refer the infant for a complete developmental evaluation

9.The mother of an 18-month old girl consults you regarding her daughter’s language development. The infant’s tympanic membranes appear normal and are mobile on pneumatic otoscopy. The patient has a 12-word vocabulary and uses a considerable amount of jargon, but she does not use any two-word phrases.

A. Refer the infant for tympanometry

B. Refer the infant for brain stem-evoked audiometry

C. Refer the infant to a speech pathologist

D. Assure the mother that language development is normal

E. Refer the infant for a complete developmental evaluation

10.Which of the following decreases the serum half-life of theophylline?

A. Phenobarbital

B. Carbohydrates

C. Liver Disease

D. Erythromycin

E. Fever

10. Which of the following decreases the serum half-life of theophylline?

A. Phenobarbital

B. Carbohydrates

C. Liver Disease

D. Erythromycin

E. Fever

11. A 15-year old boy with a history of juvenile-onset obesity expresses his concern with his small genitals. He is somewhat withdrawn, anxious, obese adolescent boy whose height is at the 25th percentile and whose weight is greater than 97th percentile. Sex maturity rating (Tanner) of pubic hair is stage 5 and of genitalia is stage 4. Testes are normally firm, measuring 3.0 by 4.0 cm.

Which of the following statements most accurately describes this boy’s pubertal development?

A. His developmental delay is likely the result of his obesity

B. He has not attained the peak of his linear growth spurtC. His bone age is expected to be at least two years

delayed in comparison with chronologic ageD. He has evidence of hypogonadism and should be

further evaluatedE. Sexual development is normal and appropriate for age.

11. A 15-year old boy with a history of juvenile-onset obesity expresses his concern with his small genitals. He is somewhat withdrawn, anxious, obese adolescent boy whose height is at the 25th percentile and whose weight is greater than 97th percentile. Sex maturity rating (Tanner) of pubic hair is stage 5 and of genitalia is stage 4. Testes are normally firm, measuring 3.0 by 4.0 cm.

Which of the following statements most accurately describes this boy’s pubertal development?

A. His developmental delay is likely the result of his obesityB. He has not attained the peak of his linear growth spurtC. His bone age is expected to be at least two years delayed in

comparison with chronologic ageD. He has evidence of hypogonadism and should be further

evaluatedE. Sexual development is normal and appropriate for age.

12. A 5-month old girl brought to your office because of failure to gain weight and intermittent vomiting during the past four weeks. Five weeks ago, she was weaned from breast feeding and a regimen of cow milk, fruits and vegetables were initiated.

The most likely diagnosis is

A. Hypothyroidism

B. Galactosemia

C. Hereditary fructose intolerance

D. Sensitivity to B-Lactoglobulin

E. Glycogen storage disease type I

12. A 5-month old girl brought to your office because of failure to gain weight and intermittent vomiting during the past four weeks. Five weeks ago, she was weaned from breast feeding and a regimen of cow milk, fruits and vegetables were initiated.

The most likely diagnosis is

A. Hypothyroidism

B. Galactosemia

C. Hereditary fructose intolerance

D. Sensitivity to B-Lactoglobulin

E. Glycogen storage disease type I

13. A 10-year old girl was treated successfully two months ago for a urinary tract infection. Findings on renal ultrasonography now are normal. A voiding cystourethrogram demonstrates reflux into the lower half of the left ureter during voiding.

Of the following, the most appropriate course of action would be to

A. Schedule intravenous pyelography

B. Schedule voiding cystourethrography in two months

C. Refer the patient to a urologist for re-implantation of the left urether

D. Schedule a renal nucleotide scan

E. Obtain a urine culture

13. A 10-year old girl was treated successfully two months ago for a urinary tract infection. Findings on renal ultrasonography now are normal. A voiding cystourethrogram demonstrates reflux into the lower half of the left ureter during voiding.

Of the following, the most appropriate course of action would be to

A. Schedule intravenous pyelography

B. Schedule voiding cystourethrography in two months

C. Refer the patient to a urologist for re-implantation of the left urether

D. Schedule a renal nucleotide scan

E. Obtain a urine culture

14. The average infant is able to pick up a grain of cereal such as puffed rice between thumb and forefinger at about the same time he or she

A. Begins to pull to a standing position

B. Can walk without assistance

C. First rolls over

D. First exhibits a social smile

E. First transfers large objects from hand to hand

14. The average infant is able to pick up a grain of cereal such as puffed rice between thumb and forefinger at about the same time he or she

A. Begins to pull to a standing position

B. Can walk without assistance

C. First rolls over

D. First exhibits a social smile

E. First transfers large objects from hand to hand

15. An 6-year old , previously well girl has had low grade fever, headache, myalgia, malaise and a generalized maculopapular rash for the past three days. He frequently plays with a 3-month old kitten. You note localized lymphadenopathy with hepatosplenomegaly on physical examination.

The most likely diagnosis isA. Cat scratch fever

B. Rocky Mountain spotted fever

C. Infectious mononucleosis

D. Cytomegalovirus infection

E. Toxoplasmosis1

15. An 6-year old , previously well girl has had low grade fever, headache, myalgia, malaise and a generalized maculopapular rash for the past three days. He frequently plays with a 3-month old kitten. You note localized lymphadenopathy with hepatosplenomegaly on physical examination.

The most likely diagnosis isA. Cat scratch fever

B. Rocky Mountain spotted fever

C. Infectious mononucleosis

D. Cytomegalovirus infection

E. Toxoplasmosis

16. A neonate does not pass meconium for 48 hrs after birth. A fortnight later his mother states that he is not passing stool regularly. He has been bottle fed since discharge. Investigations reveal massive dilatation of the colon proximal to the rectum

Where is the developmental abnormality responsible for this child’s presentation?

A. Ectoderm.B. Endoderm.C. Neural crest.D. Neural ectoderm.E. Splanchnic mesoderm

16. A neonate does not pass meconium for 48 hrs after birth. A fortnight later his mother states that he is not passing stool regularly. He has been bottle fed since discharge. Investigations reveal massive dilatation of the colon proximal to the rectum

Where is the developmental abnormality responsible for this child’s presentation?

A. Ectoderm.B. Endoderm.C. Neural crestD. Neural ectoderm.E. Splanchnic mesoderm

17. A 12-year old boy has been drinking at least 6 L of fluid each day for the past year. Serum urea nitrogen concentration is 4 mg/dL and serum creatinine concentration is 0.6 mg/dL. Results of urinalysis and determination of serum electrolyte concentrations are normal. After a 12-hour water deprivation test, urine osmolality increased from 80 to 475 mOsm/kg H2O; serum osmolality increased from 285 to 289 mOsm/kg H2O. Body weight decreased from 42 to 40 kg. DDAVP, 5 ug is administered intranasally. One hour later, urine osmolality is 500 mOsm/kg H20. You conclude that the

A. Patient has nephrogenic diabetes insipidusB. Patient has hypothalamic diabetes insipidusC. Patient has pseudohyperaldosteronism (Liddle

Syndrome)D. Patient has psychogenic polydipsiaE. Water deprivation test should be repeated

17. A 12-year old boy has been drinking at least 6 L of fluid each day for the past year. Serum urea nitrogen concentration is 4 mg/dL and serum creatinine concentration is 0.6 mg/dL. Results of urinalysis and determination of serum electrolyte concentrations are normal. After a 12-hour water deprivation test, urine osmolality increased from 80 to 475 mOsm/kg H2O; serum osmolality increased from 285 to 289 mOsm/kg H2O. Body weight decreased from 42 to 40 kg. DDAVP, 5 ug is administered intranasally. One hour later, urine osmolality is 500 mOsm/kg H20. You conclude that the

A. Patient has nephrogenic diabetes insipidusB. Patient has hypothalamic diabetes insipidusC. Patient has pseudohyperaldosteronism (Liddle

Syndrome)D. Patient has psychogenic polydipsiaE. Water deprivation test should be repeated

18. A 7-year old boy is referred to you because of obesity. By 18 months of age,he was at the 97th percentile for weight and is now 20.5 kg (45 lb) overweight. Developmental landmarks were all delayed. He is presently repeating the first grade after also spending a year in a transitional class between kindergarten and first grade. Present height is at the 10th percentile. The hands and feet are small. There is no family history of obesity.

The most likely diagnosis isA. Prader- Willi SyndromeB. Laurence –Moon-Biedl SyndromeC. Lesch-Nyhan SyndromeD. Hurler SyndromeE. William’s Syndrome

18. A 7-year old boy is referred to you because of obesity. By 18 months of age,he was at the 97th percentile for weight and is now 20.5 kg (45 lb) overweight. Developmental landmarks were all delayed. He is presently repeating the first grade after also spending a year in a transitional class between kindergarten and first grade. Present height is at the 10th percentile. The hands and feet are small. There is no family history of obesity.

The most likely diagnosis isA. Prader- Willi SyndromeB. Laurence –Moon-Biedl SyndromeC. Lesch-Nyhan SyndromeD. Hurler SyndromeE. William’s Syndrome

19.For patients receiving intravenous maintenance therapy, which of the following doses of sodium for very 100 kcal metabolized is most appropriate?

A. 0.5 mEq

B. 2 to 3 mEq

C. 4 to 5 mEq

D. 6 to 7 mEq

E. 8 to 10 mEq

19.For patients receiving intravenous maintenance therapy, which of the following doses of sodium for very 100 kcal metabolized is most appropriate?

A. 0.5 mEq

B. 2 to 3 mEq

C. 4 to 5 mEq

D. 6 to 7 mEq

E. 8 to 10 mEq

20. The Stanford-Binet test and the Wechsler Scale for children are commonly used with children to measure

A. Cognitive functioning

B. Social development

C. Neurologic development

D. Emotional stability

E. Academic achievement

20. The Stanford-Binet test and the Wechsler Scale for children are commonly used with children to measure

A. Cognitive functioning

B. Social development

C. Neurologic development

D. Emotional stability

E. Academic achievement

21. A 12-year old male is tall and pubertal developmental is normal for age. He has hypermobility of joints, a high-arched palate, and arm span exceeding his height.

Which of the following studies should be included in the examination?

A. Ultrasonography of the kidneys

B. Echocardiography

C. Computed tomography (CT scan) of the head

D. Liver-spleen scan

E. X-ray study of the long bones

21. A 12-year old male is tall and pubertal developmental is normal for age. He has hypermobility of joints, a high-arched palate, and arm span exceeding his height.

Which of the following studies should be included in the examination?

A. Ultrasonography of the kidneys

B. Echocardiography

C. Computed tomography (CT scan) of the head

D. Liver-spleen scan

E. X-ray study of the long bones

22. You are called to examine a 3-year old boy who has been brought to the emergency department because of increasing lethargy and irritability. His mother states that he has had diarrhea and abdominal cramps for the past two days and was treated with diphenoxylate with atropine to relieve his symptoms. Physical examination reveals a somnolent boy with shallow respirations; his rectal temperature is 36.C0. The remaining of the physical examination is normal.

Which of the following would you do at this time?

A. Examine the cerebrospinal fluidB. Administer physostigmineC. Perform a guaiac test of the stool for occult bloodD. Order a determination of the blood ammonia

concentrationE. Administer Naloxone

22. You are called to examine a 3-year old boy who has been brought to the emergency department because of increasing lethargy and irritability. His mother states that he has had diarrhea and abdominal cramps for the past two days and was treated with diphenoxylate with atropine to relieve his symptoms. Physical examination reveals a somnolent boy with shallow respirations; his rectal temperature is 36.C0. The remaining of the physical examination is normal.

Which of the following would you do at this time?

A. Examine the cerebrospinal fluidB. Administer physostigmineC. Perform a guaiac test of the stool for occult bloodD. Order a determination of the blood ammonia

concentrationE. Administer Naloxone

23. A 5-year old girl toes on the left side.

Of the following, the most likely diagnosis is

A. Femoral anteversion

B. Ligamentous lxity

C. Blount disease

D. Tibial torsion

E. Metatarsus adductus

23. A 5-year old girl toes on the left side.

Of the following, the most likely diagnosis is

A. Femoral anteversion

B. Ligamentous lxity

C. Blount disease

D. Tibial torsion

E. Metatarsus adductus

24 . The mother of a 2-year old child enrolled in a day care center is concerned that he has had eight upper respiratory tract infections between October and April. The child should

A. Be removed form the day care center

B. Be given Gamma Globulin injections monthly until age 4 years

C. Have a throat culture every two weeks during the winter months

D. Receive prophylactic antibiotic therapy

E. Be regarded to have upper respiratory tract infections at a frequency within normal limits

24 . The mother of a 2-year old child enrolled in a day care center is concerned that he has had eight upper respiratory tract infections between October and April. The child should

A. Be removed form the day care center

B. Be given Gamma Globulin injections monthly until age 4 years

C. Have a throat culture every two weeks during the winter months

D. Receive prophylactic antibiotic therapy

E. Be regarded to have upper respiratory tract infections at a frequency within normal limits

25. A 10 years old boy presents with a history of passing smoky coloured urine for 3 months intermittently. On the day of admission he is admitted with sever right loin pain radiating to the groin coming in spasms every few minutes. On examination he is intermittently writhing around the bed and crying. He is apyrexial but sweating. Respiratory rate is 15/min and heart rate 95/min. He has slight tenderness in the right loin.

What is the most likely diagnosis?.

A. Benign familial Haematuria

B. Renal calculi.

C. Urinary tract infection

D. IgA nephropathy

E. Glomerulonephritis.

25. A 10 years old boy presents with a history of passing smoky coloured urine for 3 months intermittently. On the day of admission he is admitted with sever right loin pain radiating to the groin coming in spasms every few minutes. On examination he is intermittently writhing around the bed and crying. He is apyrexial but sweating. Respiratory rate is 15/min and heart rate 95/min. He has slight tenderness in the right loin.

What is the most likely diagnosis?.

A. Benign familial Haematuria

B. Renal calculi.

C. Urinary tract infection

D. IgA nephropathy

E. Glomerulonephritis.

26. A mother complains that her 4-year old son wets the bed almost every night. She reports that his sister achieved bladder control at night before 3 years of age. There are no other symptoms. Findings on urinalysis are normal.

Which of the following courses of action would you pursue?

A. Schedule voiding cystourethrography

B. Reassure the mother that this situation is normal

C. Prescribe imipramine and restrict fluids after 5 PM

D. Prescribe DDAVP

E. Set up a program to reward the boy when he is dry and punish him when he wets

26. A mother complains that her 4-year old son wets the bed almost every night. She reports that his sister achieved bladder control at night before 3 years of age. There are no other symptoms. Findings on urinalysis are normal.

Which of the following courses of action would you pursue?

A. Schedule voiding cystourethrography

B. Reassure the mother that this situation is normal

C. Prescribe imipramine and restrict fluids after 5 PM

D. Prescribe DDAVP

E. Set up a program to reward the boy when he is dry and punish him when he wets

27 A patient with acute asthma is most likely to have decreased

A. Forced expiratory volume in 1 second

B. Residual volume

C. Functional residual capacity

D. Total lung capacity

E. Tidal volume

27 A patient with acute asthma is most likely to have decreased

A. Forced expiratory volume in 1 second

B. Residual volume

C. Functional residual capacity

D. Total lung capacity

E. Tidal volume

28. A 1-day old , 3.0 kg, full term infant has a grade 3/6 ejection murmur. On the third day after birth, hepatomegaly develops. Heart rate is 160/min and respiratory rate is 60/min. Blood pressure is 100/60 mmHg in the upper extremities and 60/40 mmHg in the lower extremities.

Which of the following forms of therapy would be most effective ?

A. Ballon atrial septostomy

B. Intravenous administration of Prostaglandin

C. Restriction of fluid intake

D. Systemic to pulmonary artery shunt

E. Intravenous administration of Indomethacin

28. A 1-day old , 3.0 kg, full term infant has a grade 3/6 ejection murmur. On the third day after birth, hepatomegaly develops. Heart rate is 160/min and respiratory rate is 60/min. Blood pressure is 100/60 mmHg in the upper extremities and 60/40 mmHg in the lower extremities.

Which of the following forms of therapy would be most effective ?

A. Ballon atrial septostomy

B. Intravenous administration of Prostaglandin

C. Restriction of fluid intake

D. Systemic to pulmonary artery shunt

E. Intravenous administration of Indomethacin

29. A 2.9 kg newborn infant has pink skin, a thick vernix, thin ear cartilage with good recoil, raised breast areolae with 1 to 2 mm breast nodules, a prominent clitoris with size of labia minora equal to size of labia majora, frog leg position and flexion in all limbs. She has no edema, no facial lanugo and no prominent arm recoil. Her gestational age most closely approximates

A. 28 weeks

B. 32 weeks

C. 36 weeks

D. 38 weeks

E. 40 weeks

29. A 2.9 kg newborn infant has pink skin, a thick vernix, thin ear cartilage with good recoil, raised breast areolae with 1 to 2 mm breast nodules, a prominent clitoris with size of labia minora equal to size of labia majora, frog leg position and flexion in all limbs. She has no edema, no facial lanugo and no prominent arm recoil. Her gestational age most closely approximates

A. 28 weeks

B. 32 weeks

C. 36 weeks

D. 38 weeks

E. 40 weeks

30. A 10-year old boy has osteomyelitis due to pseudomonas aeruginosa. You elect to treat the patient with Amikacin. When administering this drug, which of the following rules should be observed?

A. The drug should not be administered with meals

B. Measurement of peak concentrations and trough concentration should be obtained

C. The patient should be tested fro conductive hearing loss before therapy is started

D. The drug should not be administered if there is evidence of abnormal liver function

E. The drug should not be administered for more than ten days

30. A 10-year old boy has osteomyelitis due to pseudomonas aeruginosa. You elect to treat the patient with Amikacin. When administering this drug, which of the following rules should be observed?

A. The drug should not be administered with meals

B. Measurement of peak concentrations and trough concentration should be obtained

C. The patient should be tested fro conductive hearing loss before therapy is started

D. The drug should not be administered if there is evidence of abnormal liver function

E. The drug should not be administered for more than ten days

31. A 7-month old boy has been treated for short bowel syndrome with total parenteral nutrition (TPN) for six months. Perioral and perianal erythema and scaling develop.

Among the following, the TPN solution is most likely deficient in :

A. Copper

B. Folic Acid

C. Zinc

D. Iron

E. Vitamin B12

31. A 7-month old boy has been treated for short bowel syndrome with total parenteral nutrition (TPN) for six months. Perioral and perianal erythema and scaling develop.

Among the following, the TPN solution is most likely deficient in :

A. Copper

B. Folic Acid

C. Zinc

D. Iron

E. Vitamin B12

32. An 11-year old boy has hematuria detected on a routine examination in your office. Three years ago findings on urinalysis were normal. He has had no recent illnesses, trauma, bleeding disorders or ingestion of medications. He looks and feels well. Physical examination discloses no abnormalities. His blood pressure is 90/60 mmHg. Laboratory studies show the erythrocyte sedimentation rate (ESR) is 3 mm/hr. The serum complement concentration, prothrombin time and partial thromboplastin time are normal. Normal urea nitrogen, creatinine, and electrolytes concentrations. An antistreptolysin O titer is normal. Findings on an ultrasonographic examination are normal.

Which of the following is the management of choice?A. Order a renal biopsyB. Arrange for a cystoscopic examinationC. Begin prophylactic therapy with penicillinD. Arrange for an intravenous pyelogram E. Arrange for periodic re-examinations and urinalyses

32. An 11-year old boy has hematuria detected on a routine examination in your office. Three years ago findings on urinalysis were normal. He has had no recent illnesses, trauma, bleeding disorders or ingestion of medications. He looks and feels well. Physical examination discloses no abnormalities. His blood pressure is 90/60 mmHg. Laboratory studies show the erythrocyte sedimentation rate (ESR) is 3 mm/hr. The serum complement concentration, prothrombin time and partial thromboplastin time are normal. Normal urea nitrogen, creatinine, and electrolytes concentrations. An antistreptolysin O titer is normal. Findings on an ultrasonographic examination are normal.

Which of the following is the management of choice?A. Order a renal biopsyB. Arrange for a cystoscopic examinationC. Begin prophylactic therapy with penicillinD. Arrange for an intravenous pyelogram E. Arrange for periodic re-examinations and urinalyses

33. During fetal life, the development of male external genitalia is directly determined by the action of which of the following?

A. Testosterone

B. Dihydrotestosterone

C. Dehydroepiandrosterone

D. Androstenedione

E. H-Y antigen

33. During fetal life, the development of male external genitalia is directly determined by the action of which of the following?

A. Testosterone

B. Dihydrotestosterone

C. Dehydroepiandrosterone

D. Androstenedione

E. H-Y antigen

34. A 3 year old boy in nursery school makes frequent silly excretory activities.

The most likely explanation for this isA. Age appropriate behavior

B. An excessively stimulating nursery school environment

C. Sexually stimulating parental attitudes

D. Regressive behavior

E. Fear of the toilet

34. A 3 year old boy in nursery school makes frequent silly excretory activities.

The most likely explanation for this isA. Age appropriate behavior

B. An excessively stimulating nursery school environment

C. Sexually stimulating parental attitudes

D. Regressive behavior

E. Fear of the toilet

35- A 17-yeard old girl has primary amenorrhea. Her height is normal for her age. The sex maturity rating (Tanner) of breast development is stage 5. She has a paucity of axillary and pubic hair. Vaginal examination reveals a 2 cm in depth with no visible cervix. A 3-4 cm ovoid mass is palpable in each inguinal canal.

The most likely result of chromosome analysis in this patient is

A. 46,XYB. 45,XC. 47 XXYD. 46, XXE. 47,XXX

35-A 17-yeard old girl has primary amenorrhea. Her height is normal for her age. The sex maturity rating (Tanner) of breast development is stage 5. She has a paucity of axillary and pubic hair. Vaginal examination reveals a 2 cm in depth with no visible cervix. A 3-4 cm ovoid mass is palpable in each inguinal canal.

The most likely result of chromosome analysis in this patient is

A. 46,XYB. 45,XC. 47 XXYD. 46, XXE. 47,XXX

36-A 10-year old boy with asthma has failed to respond to a home treatment program. He is admitted to the hospital and treated with intravenous administration of fluids, Aminophylline, and corticosteroids. One hour after admission, he appears exhausted. Determination of arterial blood gas and Ph values while the patient is in a 40% humidified oxygen atmosphere reveal a Ph of 7.15, PO2 of 60 mmHg and PCO2 of 60 mmHg.

The next step in the management of this patient would be

A. intravenous administration of sodium bicarbonateB. Intubation and mechanical ventilationC. intravenous administration of DexamethasoneD. Subcutaneous administration of epinephrine

36-A 10-year old boy with asthma has failed to respond to a home treatment program. He is admitted to the hospital and treated with intravenous administration of fluids, Aminophylline, and corticosteroids. One hour after admission, he appears exhausted. Determination of arterial blood gas and Ph values while the patient is in a 40% humidified oxygen atmosphere reveal a Ph of 7.15, PO2 of 60 mmHg and PCO2 of 60 mmHg.

The next step in the management of this patient would be

A. intravenous administration of sodium bicarbonateB. Intubation and mechanical ventilationC. Subcutaneous administration of epinephrineD. intravenous administration of Dexamethasone

37-A 6-year old boy is sent home from school because of an itchy scalp. On examination, you note small ovoid attachments to several otherwise normal hair shafts.

The most likely diagnosis isA. Normal hair

B. Seborrhea

C. Pediculosis capitis

D. Tinea Capitis

E. Trichorrhxi nodosa (kinky hair disease)

37-A 6-year old boy is sent home from school because of an itchy scalp. On examination, you note small ovoid attachments to several otherwise normal hair shafts.

The most likely diagnosis isA. Normal hair

B. Seborrhea

C. Pediculosis capitis

D. Tinea Capitis

E. Trichorrhxi nodosa (kinky hair disease)

38. Daily caloric and protein requirements per kg of body weight are greatest in the

A. Adult

B. Infants with malabsorption

C. Toddler

D. Adolescent

E. Infant born prematurely

38. Daily caloric and protein requirements per kg of body weight are greatest in the

A. Adult

B. Infants with malabsorption

C. Toddler

D. Adolescent

E. Infant born prematurely

39. In an infant who appeared healthy at birth, vomiting and diarrhea developed at 1 week of age. She gained weight poorly despite a change from breast milk to infant formula feeding at 2 weeks of age. At 3 weeks of age, she is brought to the emergency department where she is found to be lethargic and to have hepatomegaly. Of the following, the most likely diagnosis is

(A) Inspissated bile syndrome(B) Crigler-Najjar Syndrome C) Galactosem(D) Gilbert Syndrome(E) Dubin-Johnson Syndrome

39. In an infant who appeared healthy at birth, vomiting and diarrhea developed at 1 week of age. She gained weight poorly despite a change from breast milk to infant formula feeding at 2 weeks of age. At 3 weeks of age, she is brought to the emergency department where she is found to be lethargic and to have hepatomegaly. Of the following, the most likely diagnosis is

(A) Inspissated bile syndrome(B) Crigler-Najjar Syndrome C) Galactosem(D) Gilbert Syndrome(E) Dubin-Johnson Syndrome

40. A 12-year old boy is struck in the eye by a tennis ball. He is examined by an Ophthalmologist who finds the optic globe to be intact. He comes to you one week later and reports that he has double vision.

Of the following, the most likely diagnosis isA. GlaucomaB. Intraocular hemorrhageC. Fracture of the floor of the orbitD. Oculomotor nerve paralysisE. Sinusitis

40. A 12-year old boy is struck in the eye by a tennis ball. He is examined by an Ophthalmologist who finds the optic globe to be intact. He comes to you one week later and reports that he has double vision.

Of the following, the most likely diagnosis isA. GlaucomaB. Intraocular hemorrhageC. Fracture of the floor of the orbitD. Oculomotor nerve paralysisE. Sinusitis

41. A 14-month old infant has had a clear nasal discharge and a mild cough for about two weeks. Despite therapy with Amoxicillin, his condition has not improved. The cough has worsened and the infant has been vomiting at each feeding. The leukocyte count is 20,000/mm3 with 80% lymphocytes, 15% neutrophils and 5% band forms. X-ray study of the chest shows bilateral perihilar infiltrates with shaggy heart border.

The most likely diagnosis is

A. Acute bronchial asthmaB. Acute lympocytic leukemia with pulmonary infiltrationC. Influenza virus infectionD. PertusisE. Hemophilus influenzae pneumonia

41. A 14-month old infant has had a clear nasal discharge and a mild cough for about two weeks. Despite therapy with Amoxicillin, his condition has not improved. The cough has worsened and the infant has been vomiting at each feeding. The leukocyte count is 20,000/mm3 with 80% lymphocytes, 15% neutrophils and 5% band forms. X-ray study of the chest shows bilateral perihilar infiltrates with shaggy heart border.

The most likely diagnosis is

A. Acute bronchial asthmaB. Acute lympocytic leukemia with pulmonary infiltrationC. Influenza virus infectionD. PertusisE. Hemophilus influenzae pneumonia

42. A 10 years old male presents with acute sever asthma. On examination his peripheral pulse volume decreased during inspiration.

Which one of the following is the most likely explanation for this clinical sign?

A. The cardiac effect of high dose beta agonist bronchodilator drugs.

B. A falling heart rate on inspiration.

C. Peripheral vasodilatation

D. Myocardial depression due to hypoxia

E. Reduced left atrial filling pressure on inspiration

42. A 10 years old male presents with acute sever asthma. On examination his peripheral pulse volume decreased during inspiration.

Which one of the following is the most likely explanation for this clinical sign?

A. The cardiac effect of high dose beta agonist bronchodilator drugs.

B. A falling heart rate on inspiration.

C. Peripheral vasodilatation

D. Myocardial depression due to hypoxia

E. Reduced left atrial filling pressure on inspiration

43. A 4-year old child has a grade 2/6 high-pitched continuous murmur at the right base with maximum intensity in the right supraclavicular fossa. The murmur is not audible when he is in the supine position, and the intensity changes with rotation of the head. There is no thrill. The first and second heart sound are normal. Blood pressure is 94/64 mmHg in the upper extremities and 10 mmHg higher in the lower extremities.

The most likely source of the murmur is

A. Patent Ductus ArteriosusB. Arteriovenous fistulaC. Venous humD. Right pulmonary artery stenosisE. Aortic valvular insufficiency

43. A 4-year old child has a grade 2/6 high-pitched continuous murmur at the right base with maximum intensity in the right supraclavicular fossa. The murmur is not audible when he is in the supine position, and the intensity changes with rotation of the head. There is no thrill. The first and second heart sound are normal. Blood pressure is 94/64 mmHg in the upper extremities and 10 mmHg higher in the lower extremities.

The most likely source of the murmur is

A. Patent Ductus ArteriosusB. Arteriovenous fistulaC. Venous humD. Right pulmonary artery stenosisE. Aortic valvular insufficiency

44.Regarding steroid inhaler therapy for a 4-year old child with asthma, you should tell the mother

A. It is most effective with acute exacerbation

B. It should be administered every two hours when the child is having an acute episode of asthma

C. The primary value is in the prevention of episodes of asthma

D. It will not be of value in the management of the child’s exercise-induced episodes of asthma

E. The most common side effect is the development of oral candidiasis.

44.Regarding steroid inhaler therapy for a 4-year old child with asthma, you should tell the mother

A. It is most effective with acute exacerbation

B. It should be administered every two hours when the child is having an acute episode of asthma

C. The primary value is in the prevention of episodes of asthma

D. It will not be of value in the management of the child’s exercise-induced episodes of asthma

E. The most common side effect is the development of oral candidiasis.

45. A healthy 15-month old girl has been growing along the 25th percentile for length and weight. Her mother is concerned now because the infant is losing her appetite. Of the following , the most appropriate statement to make to the mother at this time would be

A. The infant’s weigh should be checked more often

B. This may be the first sign of a chronic illness

C. She will have to make an effort to find special foods the infant will eat

D. The decrease in appetite is normal, in response to a decelerating growth rate.

E. This is an early manifestation of the normal negativism of infants at this age.

45. A healthy 15-month old girl has been growing along the 25th percentile for length and weight. Her mother is concerned now because the infant is losing her appetite. Of the following , the most appropriate statement to make to the mother at this time would be

A. The infant’s weigh should be checked more often

B. This may be the first sign of a chronic illness

C. She will have to make an effort to find special foods the infant will eat

D. The decrease in appetite is normal, in response to a decelerating growth rate.

E. This is an early manifestation of the normal negativism of infants at this age.

46. A 10-month old infant has had a respiratory tract infection, fever and vomiting for two days. There is evidence of mild dehydration. Which of the following sets of laboratory data would be most consistent with these findings.

Sodium potassium Chloride Bicarbonate

A. 135 4.0 102 15B. 125 6.8 100 15C. 120 3.0 92 15D. 155 5.0 135 20E. 130 3.5 80 35

46. A 10-month old infant has had a respiratory tract infection, fever and vomiting for two days. There is evidence of mild dehydration. Which of the following sets of laboratory data would be most consistent with these findings.

A. 135 4.0 102 15B. 125 6.8 100 15C. 120 3.0 92 15D. 155 5.0 135 20E. 130 3.5 80 35

47. An infant seated in a high chair turns his body around to see you as you approach. You place two cube before him, he takes one in his right hand and the other in his left. When a third cube is presented, he bangs and pushes it with the first. You demonstrate a tower of two cubes and encourage him to take a tower, he hold one cube on top for a second but does not release it. You show him how to release a cube into a cup. He follows suit at once. You ask him for a cube in his hand, extending yours. He drops the cube in your hand. On the floor he walks with one hand held. When he leaves he waves bye-bye. The developmental age of this infant seems closes to

A. 6 monthsB. 9 monthsC. 12 monthsD. 15 monthsE. 18 months

47. An infant seated in a high chair turns his body around to see you as you approach. You place two cube before him, he takes one in his right hand and the other in his left. When a third cube is presented, he bangs and pushes it with the first. You demonstrate a tower of two cubes and encourage him to take a tower, he hold one cube on top for a second but does not release it. You show him how to release a cube into a cup. He follows suit at once. You ask him for a cube in his hand, extending yours. He drops the cube in your hand. On the floor he walks with one hand held. When he leaves he waves bye-bye. The developmental age of this infant seems closes to

A. 6 monthsB. 9 monthsC. 12 monthsD. 15 monthsE. 18 months

48. A 2-1/2 year old child has had cough for two weeks after having been hospitalized one month ago for pneumonia in the right lower lobe. X-ray study of the chest reveals persistence of pneumonia in the right lower lobe. Of the following , the most likely diagnosis is

A. Staphylococcal pneumonia

B. Foreign body aspiration

C. Cystic Fibrosis

D. Pneumonia due to Mycoplasma pneumoniae

E. Pneumonia due to respiratory synctial virus

48. A 2-1/2 year old child has had cough for two weeks after having been hospitalized one month ago for pneumonia in the right lower lobe. X-ray study of the chest reveals persistence of pneumonia in the right lower lobe. Of the following , the most likely diagnosis is

A. Staphylococcal pneumonia

B. Foreign body aspiration

C. Cystic Fibrosis

D. Pneumonia due to Mycoplasma pneumoniae

E. Pneumonia due to respiratory synctial virus

49. On routine examination of a 2-year old boy, you noticed a moderate degree of peritibial bruising. The finding of the physical examination are normal. Of the following , the most appropriate management at this time would be to

A. Order x-ray studies of the long bones

B. Order determination of the bleeding and clotting times

C. Re-assure the mother

D. Suggest limited activity for several days

E. Request a psychosocial consultation

49. On routine examination of a 2-year old boy, you noticed a moderate degree of peritibial bruising. The finding of the physical examination are normal. Of the following , the most appropriate management at this time would be to

A. Order x-ray studies of the long bones

B. Order determination of the bleeding and clotting times

C. Re-assure the mother

D. Suggest limited activity for several days

E. Request a psychosocial consultation

50. A full term, 3-week old infant is pale, irritable, restless, and feeding poorly. Pulse rate is 250/min, respiratory rate is 60/min. The liver edge is palpable 3 cm below the right costal margin. Findings on physical examination are otherwise normal. The most likely diagnosis is

A. SepsisB. Impending shockC. Congestive heart failure due to a structural

congenital heart lesionD. Paroxysmal atrial tachycardiaE. Sinus tachycardia

50. A full term, 3-week old infant is pale, irritable, restless, and feeding poorly. Pulse rate is 250/min, respiratory rate is 60/min. The liver edge is palpable 3 cm below the right costal margin. Findings on physical examination are otherwise normal. The most likely diagnosis is

A. SepsisB. Impending shockC. Congestive heart failure due to a structural

congenital heart lesionD. Paroxysmal atrial tachycardiaE. Sinus tachycardia

51. A 3-year old child is brought to you because her speech consist only of single words . She sat at 6 months, walked at 11 months and was toilet trained at 2 years of age. She dresses and undresses herself, except that sometimes she puts the shoes on the wrong feet. She responds to simple requests. Findings on examination except for speech are normal.

Which of the following statements concerning this clinical situation is true?

A. this child is probably mentally retarded and should be referred for an IQ test

B. The child’s hearing should be testedC. The child should be referred to a psychiatristD. The parents can be assured that nothing is wrong and that the

child will learn to talk in timeE. The parents should be instructed not to give the child anything

unless she asks for it using more than one word

51. A 3-year old child is brought to you because her speech consist only of single words . She sat at 6 months, walked at 11 months and was toilet trained at 2 years of age. She dresses and undresses herself, except that sometimes she puts the shoes on the wrong feet. She responds to simple requests. Findings on examination except for speech are normal.

Which of the following statements concerning this clinical situation is true?

A. this child is probably mentally retarded and should be referred for an IQ test

B. The child’s hearing should be testedC. The child should be referred to a psychiatristD. The parents can be assured that nothing is wrong and that the

child will learn to talk in timeE. The parents should be instructed not to give the child anything

unless she asks for it using more than one word

52. School phobias (school refusals) in grade-school children most commonly result from

A. Fear of a strict teacher

B. Concern about failing school

C. Fear of separation from parent

D. Desire to avoid unfriendly classmates

E. Inability to do school work

52. School phobias (school refusals) in grade-school children most commonly result from

A. Fear of a strict teacher

B. Concern about failing school

C. Fear of separation from parent

D. Desire to avoid unfriendly classmates

E. Inability to do school work

53. A 6-year old boy suffers major abdominal trauma in a motor vehicle accident. One hour later in the emergency department, blood pressure is 65/40 mmHg. Hemoglobin concentration is 6.0 g/dL. Arterial blood gas and pH analysis while the patient is breathing room air shows pH 7.47, PO2 45 mmHg and PCO2 30 mmHg, FiO2 is 0.21. An x-ray study of the chest reveals diffuse bilateral pulmonary infiltrates.

Which of the following will provide the greatest improvement in oxygen transport?

A. VasopressorsB. Intubation and ventilation with positive end-

expiratory pressure (PEEP)C. Administration of 100% oxygenD. Blood transfusionE. Diuretics

53. A 6-year old boy suffers major abdominal trauma in a motor vehicle accident. One hour later in the emergency department, blood pressure is 65/40 mmHg. Hemoglobin concentration is 6.0 g/dL. Arterial blood gas and pH analysis while the patient is breathing room air shows pH 7.47, PO2 45 mmHg and PCO2 30 mmHg, FiO2 is 0.21. An x-ray study of the chest reveals diffuse bilateral pulmonary infiltrates.

Which of the following will provide the greatest improvement in oxygen transport?

A. VasopressorsB. Intubation and ventilation with positive end-

expiratory pressure (PEEP)C. Administration of 100% oxygenD. Blood transfusionE. Diuretics

54. 7 years old female attends pediatric clinic and is noted to have scattered small, raised lesions on her trunk and axillary freckles. No family history of the same lesions.

What is the likely mode of inheritance of this condition?

A. Autosomal recessive.

B. X- linked recessive

C. Trinucleotide repeating

D. Autosomal dominant

E. multifactorial

54. 7 years old female attends pediatric clinic and is noted to have scattered small, raised lesions on her trunk and axillary freckles. No family history of the same lesions.

What is the likely mode of inheritance of this condition?

A. Autosomal recessive.

B. X- linked recessive

C. Trinucleotide repeating

D. Autosomal dominant

E. multifactorial

55. You are discusing with a resident who has just evaluated a 4-year-old who has classic varicella lesions and a history that is consistent with this diagnosis.he put small pox as D/D. Of the following, the MOST accurate statement about the tow pathologies is that

A. lesions of both varicella and smallpox follow a 7- to 10-day course from eruption to resolution

B. lesions of both varicella and smallpox frequently produce deep, pitted scars

C.varicella lesions are transient vesicles; smallpox lesions are persistent pustules until resolution of the illness

D.varicella lesions are concentrated on the face; smallpox lesions are concentrated over bony Prominences

E. varicella lesions appear in stages or crops; smallpox lesions are uniformly in the same stage of development

55. You are discusing with a resident who has just evaluated a 4-year-old who has classic varicella lesions and a history that is consistent with this diagnosis.he put small pox as D/D. Of the following, the MOST accurate statement about the tow pathologies is that

A. lesions of both varicella and smallpox follow a 7- to 10-day course from eruption to resolution

B. lesions of both varicella and smallpox frequently produce deep, pitted scars

C.varicella lesions are transient vesicles; smallpox lesions are persistent pustules until resolution of the illness

D.varicella lesions are concentrated on the face; smallpox lesions are concentrated over bony Prominences

E. varicella lesions appear in stages or crops; smallpox lesions are uniformly in the same stage of development

56. A 14-yeard old girl with hyperthyroidism did not respond to antithyroid medication. A subtotal thyroidectomy was performed. After the operation, she had a unilateral convulsion.

The best initial means to stop such a seizure is administration of

A. Paraldehyde, rectally

B. Diazepam, intravenously’

C. Phenobarbital, intramuscularly

D. Calcium, intravenously

E. Phenytoin, intravenously

56. A 14-yeard old girl with hyperthyroidism did not respond to antithyroid medication. A subtotal thyroidectomy was performed. After the operation, she had a unilateral convulsion.

The best initial means to stop such a seizure is administration of

A. Paraldehyde, rectally

B. Diazepam, intravenously’

C. Phenobarbital, intramuscularly

D. Calcium, intravenously

E. Phenytoin, intravenously

57. A 10-yeard old girl has a one-month history of progressive symmetrical weakness leading to an inability to walk. She appears ill and has generalized tenderness of the muscles. The face is swollen and the eyelids are discolored.

The laboratory test result most likely to be normal in this patient is

A. Serum aldolase activity

B. Anti-DNAse B titer

C. Muscle biopsy

D. Serum Creatinine kinase activity

E. Electromyography

57. A 10-yeard old girl has a one-month history of progressive symmetrical weakness leading to an inability to walk. She appears ill and has generalized tenderness of the muscles. The face is swollen and the eyelids are discolored.

The laboratory test result most likely to be normal in this patient is

A. Serum aldolase activity

B. Anti-DNAse B titer

C. Muscle biopsy

D. Serum Creatinine kinase activity

E. Electromyography

58. A 2-year old asymptomatic child is brought to the hospital 30 minutes after ingesting an unknown quantity of kerosene that had been stored in a soda bottle. From the amount of kerosene left in the bottle and the odor of the child’s clothing, it is subsequently estimated that a maximum of 10 ml of kerosene may have been ingested. Among the following, the treatment of choice one hour after ingestion would be

A. Induction of emesis with ipecac syrup, 30 ml orallyB. Gastric lavageC. Gastric lavage after placement of cuffed endotracheal

tubeD. Administration of olive oil, 60 ml orallyE. Observation only

58. A 2-year old asymptomatic child is brought to the hospital 30 minutes after ingesting an unknown quantity of kerosene that had been stored in a soda bottle. From the amount of kerosene left in the bottle and the odor of the child’s clothing, it is subsequently estimated that a maximum of 10 ml of kerosene may have been ingested. Among the following, the treatment of choice one hour after ingestion would be

A. Induction of emesis with ipecac syrup, 30 ml orallyB. Gastric lavageC. Gastric lavage after placement of cuffed endotracheal

tubeD. Administration of olive oil, 60 ml orallyE. Observation only

59. A 12-year old boy is referred to you by a family physician because of a pectus excavation deformity he has had since birth. Physical examination confirms the diagnosis of pectus excavatum. As a consultant to this boy, you should know that the most common indication for operative correction of pectus excavatum is

A. Development of congestive heart failure

B. Psychological discomfort with cosmetic appearance

C. Progressive pulmonary deterioration

D. Failure to thrive stinal problems

E. Associated gastrointestinal problems

59. A 12-year old boy is referred to you by a family physician because of a pectus excavation deformity he has had since birth. Physical examination confirms the diagnosis of pectus excavatum. As a consultant to this boy, you should know that the most common indication for operative correction of pectus excavatum is

A. Development of congestive heart failure

B. Psychological discomfort with cosmetic appearance

C. Progressive pulmonary deterioration

D. Failure to thrive stinal problems

E. Associated gastrointestinal problems

60. A 16 years old female presents with hypertension and increasing weight. Which of the following features would be most suggestive of cushing’s syndrome rather than simple obesity?

A. Moon face.

B. Acanthosis Nigricans

C. Abdominal striae.

D. Proximal myopathy

E. Buffalo Hump

60. A 16 years old female presents with hypertension and increasing weight. Which of the following features would be most suggestive of cushing’s syndrome rather than simple obesity?

A. Moon face.

B. Acanthosis Nigricans

C. Abdominal striae.

D. Proximal myopathy

E. Buffalo Hump

61. A 24 month old boy presents with high fever of 6 days duration, tender neck, red eyes and cracked lips. In the second week he developed maculopapular erythematous rash and blanching.

What is the most likely diagnosis

A. Kawasaki disease

B. Stevens-Johnson syndrome

C. Acute toxoplasmosis

D. Meningococcal sepsis

E. Measles.

61. A 24 month old boy presents with high fever of 6 days duration, tender neck, red eyes and cracked lips. In the second week he developed maculopapular erythematous rash and blanching.

What is the most likely diagnosisA. Kawasaki diseaseB. Stevens-Johnson syndrome C. Acute toxoplasmosisD. Meningococcal sepsis E. Measles.

62. A 15 years old female underwent a renal transplant. She was concerned about the effects of long-term Cyclosporin treatment.

Which on of the following is a common adverse effect of this

A. Alopecia. B. Paraesthesiae. C. Hepatotoxicity D. Nephrotoxicity. E. Bone marrow depression

62. A 15 years old female underwent a renal transplant. She was concerned about the effects of long-term Cyclosporin treatment.

Which on of the following is a common adverse effect of this

A. Alopecia. B. Paraesthesiae. C. Hepatotoxicity D. Nephrotoxicity. E. Bone marrow depression

63. A 7 years old male presented with a strongly positive Mantoux test. Which one of the following statements regarding his immune reaction is correct?

A. The reaction typically develops within 24 hours

B. It is a cell mediated immune response

C. The area of induration will be less than 10 mm in diameter

D. The response is mediated by B lymphocytes

E. If a skin biopsy were taken, immunohistochemistry would show immune complex deposition.

63. A 7 years old male presented with a strongly positive Mantoux test. Which one of the following statements regarding his immune reaction is correct?

A. The reaction typically develops within 24 hours

B. It is a cell mediated immune response

C. The area of induration will be less than 10 mm in diameter

D. The response is mediated by B lymphocytes

E. If a skin biopsy were taken, immunohistochemistry would show immune complex deposition.

64. The mechanism for Alo-immune thrombocytopena in the newborn infant is

A. Production of antifetal platelet antibodies by the mother

B. Production of antiplatelet antibodies by the fetusC. Transfer of antimaternal platelet antibodies across

the placentaD. Impairment of megakaryocytic function caused by

autoantibodiesE. Platelet aggregation secondary to occult infection

64. The mechanism for Alo-immune thrombocytopena in the newborn infant is

A. Production of antifetal platelet antibodies by the mother

B. Production of antiplatelet antibodies by the fetusC. Transfer of antimaternal platelet antibodies across

the placentaD. Impairment of megakaryocytic function caused by

autoantibodiesE. Platelet aggregation secondary to occult infection

65. A 5-year old girl is brought to your office by her mother who reports that the child is one of four children in her nursery school class who have similar rashes. Two days ago the patient had a low grade fever with the temperature reaching 38 C . The cheeks became red. She denied having sore throat. Today she has a generalized, discrete maculopapular rash.The most likely diagnosis is

A. RubellaB. MeaslesC. Scarlet feverD. Erythema infectiosumE. Pityriasis rosea

65. A 5-year old girl is brought to your office by her mother who reports that the child is one of four children in her nursery school class who have similar rashes. Two days ago the patient had a low grade fever with the temperature reaching 38 C . The cheeks became red. She denied having sore throat. Today she has a generalized, discrete maculopapular rash.The most likely diagnosis is

A. RubellaB. MeaslesC. Scarlet feverD. Erythema infectiosumE. Pityriasis rosea

66. Stridor, tachypnea and wheezing develop suddenly in a 10-year old girl who has received an injection of contrast medium for intravenous pyelography. Large urticarial lesions appear over the face , chest and extremities.

Of the following agents, you should first administer

A. Diphenhydramine

B. Epinephrine

C. Theophylline

D. Corticosteroids

E. Antibiotics

66. Stridor, tachypnea and wheezing develop suddenly in a 10-year old girl who has received an injection of contrast medium for intravenous pyelography. Large urticarial lesions appear over the face , chest and extremities.

Of the following agents, you should first administer

A. Diphenhydramine

B. Epinephrine

C. Theophylline

D. Corticosteroids

E. Antibiotics

67. Fever and a swollen eye have been present for one day in a 5-year old boy following an upper respiratory tract infection. There is no history of trauma. The boy is irritable and has proptosis and chemosis of the left eye.

Among the following, the most likely diagnosis is

A. Corneal foreign body

B. Retinoblastoma

C. Post-septal orbital Cellulitis

D. Hyphema

E. Battered child syndrome

67. Fever and a swollen eye have been present for one day in a 5-year old boy following an upper respiratory tract infection. There is no history of trauma. The boy is irritable and has proptosis and chemosis of the left eye.

Among the following, the most likely diagnosis is

A. Corneal foreign body

B. Retinoblastoma

C. Post-septal orbital Cellulitis

D. Hyphema

E. Battered child syndrome

68. A 2-yeard old boy is brought to you because his mother has never noted his testes. On physical examination the testes are not palpable in the scrotum. The penis is normal.

Which of the following would be indicated at this point?

A. Examination with the patient in a squatting positionB. Administration of human chorionic gonadotropinC. X-ray studies to determine bone ageD. Determination of the plasma testosterone

concentrationE. Assurance of the mother that the testes will ultimately

descend

68. A 2-yeard old boy is brought to you because his mother has never noted his testes. On physical examination the testes are not palpable in the scrotum. The penis is normal.

Which of the following would be indicated at this point?

A. Examination with the patient in a squatting positionB. Administration of human chorionic gonadotropinC. X-ray studies to determine bone ageD. Determination of the plasma testosterone

concentrationE. Assurance of the mother that the testes will ultimately

descend

69. A 1-year old infant is admitted to the hospital because of bacterial meningitis. He is treated with intravenous administration of antibodies in 5% glucose with 30 mEq/L of sodium chloride at 5 ml/kg/hour. Six hours after therapy is initiated, he has a generalized tonic clonic seizure. Physical examination reveals a lethargic but responsive infant. Temperature is 39.30C , Pulse rate is 108/min, and blood pressure is 92/78 mmHg.

Which of the following would be the most appropriate at this time?

A. A second examination of the cerebrospinal fluidB. Computed tomography (CT scan) of the headC. Determination of serum electrolyte concentrationsD. Bilateral subdural tapsE. Intravenous administration of Phenobarbital

69. A 1-year old infant is admitted to the hospital because of bacterial meningitis. He is treated with intravenous administration of antibodies in 5% glucose with 30 mEq/L of sodium chloride at 5 ml/kg/hour. Six hours after therapy is initiated, he has a generalized tonic clonic seizure. Physical examination reveals a lethargic but responsive infant. Temperature is 39.30C , Pulse rate is 108/min, and blood pressure is 92/78 mmHg.

Which of the following would be the most appropriate at this time?

A. A second examination of the cerebrospinal fluidB. Computed tomography (CT scan) of the headC. Determination of serum electrolyte

concentrationsD. Bilateral subdural tapsE. Intravenous administration of Phenobarbital

70. A 4-week old girl was found shortly after birth to have a cardiac murmur. Her color is now good and weight gain has been satisfactory. Pulse rate is 160/min and respiratory rate is 70/min. Her mother has noted that the infant sweats despite normal ambient temperature and that she sleeps poorly.

The infant most likely hasA. Pneumonia

B. Sepsis

C. Paroxysmal Atrial tachycardia

D. A left to right shunt circulation

E. A Septal defect that has begun to close

70. A 4-week old girl was found shortly after birth to have a cardiac murmur. Her color is now good and weight gain has been satisfactory. Pulse rate is 160/min and respiratory rate is 70/min. Her mother has noted that the infant sweats despite normal ambient temperature and that she sleeps poorly.

The infant most likely hasA. Pneumonia

B. Sepsis

C. Paroxysmal Atrial tachycardia

D. A left to right shunt circulation

E. A Septal defect that has begun to close

71. A woman who is positive for hepatitis B surface antigen (HbsAg) but negative for hepatitis Be antigen (HbeAg), delivers at term. After careful bathing, the BEST management for this woman’s infant would be to:

A. Administer gamma globulin intramuscularly immediately and at 1 month of age.

B. Administer HBIG and HB vaccine immediately and HB vaccine again at 1 month and 6 months of age.

C. Administer hepatitis B immunoglobulin (HBIG) if cord blood is positive for HBSAg.

D. Administer hepatitis B (HB) vaccine immediately and at 1 month and 6 months of age

E. Advise mother that breast feeding is contraindicated.

71. A woman who is positive for hepatitis B surface antigen (HbsAg) but negative for hepatitis Be antigen (HbeAg), delivers at term. After careful bathing, the BEST management for this woman’s infant would be to:

A. Administer gamma globulin intramuscularly immediately and at 1 month of age.

B. Administer HBIG and HB vaccine immediately and HB vaccine again at 1 month and 6 months of age.

C. Administer hepatitis B immunoglobulin (HBIG) if cord blood is positive for HBSAg.

D. Administer hepatitis B (HB) vaccine immediately and at 1 month and 6 months of age

E. Advise mother that breast feeding is contraindicated.

72. The parents of an 18-month old boy bring the infant to you as a new patient. They state that he has been constipated since early infancy. He has been managed with fair success with glycerin suppositories and laxatives. Physical examination discloses no distention of the abdomen. A copious amount of fecal material is palpated in the large bowel. The rectal ampulla is empty.

The management of choice would be to

A. Continue the present treatment regimen

B. Continue the present treatment regimen but add more bulk to the diet

C. Prescribe mineral oil

D. Order a barium enema examination

E. Discontinue all medications and observe the patient

72. The parents of an 18-month old boy bring the infant to you as a new patient. They state that he has been constipated since early infancy. He has been managed with fair success with glycerin suppositories and laxatives. Physical examination discloses no distention of the abdomen. A copious amount of fecal material is palpated in the large bowel. The rectal ampulla is empty.

The management of choice would be to

A. Continue the present treatment regimen

B. Continue the present treatment regimen but add more bulk to the diet

C. Prescribe mineral oil

D. Order a barium enema examination

E. Discontinue all medications and observe the patient

73. 10 years old boy presented with fever, headache and neck stiffness for 24 hours. He had an identical illness requiring admission to hospital at 8 year of age

Of the following, the most likely immune defect is

A. B lymphocytes.

B. Complement pathway.

C. Immunoglobulin production.

D. Neutrophil count.

E. Neutrophil function.

73. 10 years old boy presented with fever, headache and neck stiffness for 24 hours. He had an identical illness requiring admission to hospital at 8 year of age

Of the following, the most likely immune defect is

A. B lymphocytes.B. Complement pathwayC. Immunoglobulin productionD. Neutrophil countE. Neutrophil function

74. A 2-month old boy is hospitalized because of cough and rapid respirations. The infant has been well since birth except for a mild mucoid conjunctivitis. Length and weigh are at the 15th percentile. An x-ray study of the chest reveals hyperinflation and bilateral interstitial pneumonia. His temperature is 38.0C and his respiratory rate is 56/min. Leukocyte count is 10,000/mm3 with 60% Neutrophil, 5% band forms, 35% lymphocytes, and 10% eosinophils. The serum IgM concentration is markedly increased.

The most likely diagnosis isA. PertussisB. Pneumonia due to Chlamydia TrachomatisC. Pneumonia due to Myoplasma pneumoniaeD. Pneumonia due to Hemophillus InfluenzaeE. Pneumonia due to Staphylococcus Aureus

74. A 2-month old boy is hospitalized because of cough and rapid respirations. The infant has been well since birth except for a mild mucoid conjunctivitis. Length and weigh are at the 15th percentile. An x-ray study of the chest reveals hyperinflation and bilateral interstitial pneumonia. His temperature is 38.0C and his respiratory rate is 56/min. Leukocyte count is 10,000/mm3 with 60% Neutrophil, 5% band forms, 35% lymphocytes, and 10% eosinophils. The serum IgM concentration is markedly increased.

The most likely diagnosis isA. PertussisB. Pneumonia due to Chlamydia TrachomatisC. Pneumonia due to Myoplasma pneumoniaeD. Pneumonia due to Hemophillus InfluenzaeE. Pneumonia due to Staphylococcus Aureus

75. In infants with serious dehydration, the clinical signs of tachycardia , poor turgor and cool distal extremities result primarily from

A. metabolic acidosis

B. Starvation

C. Hypovolemia

D. Cortisol deficit

E. Oliguria

75. In infants with serious dehydration, the clinical signs of tachycardia , poor turgor and cool distal extremities result primarily from

A. metabolic acidosis

B. Starvation

C. Hypovolemia

D. Cortisol deficit

E. Oliguria

76. An infant who has not yet passed meconium begins vomiting when he is 36 hours old. His abdomen has doughy distension. The rectum is empty on examination, no meconium was seen on the examiner’s finger. An x-ray study of the abdomen shows distended intestinal loops, but fluid levels are not present. The abdomen has a granular, ground glass appearance with flecks of calcium scattered throughout.

The most likely diagnosis is

A. Aganglionic megacolon (Hirschsprung’s disease)B. Intestinal AtresiaC. Meconium plug syndromeD. Ruptured appendixE. Cystic fibrosis, Meconium ileus and peritonitis

76. An infant who has not yet passed meconium begins vomiting when he is 36 hours old. His abdomen has doughy distension. The rectum is empty on examination, no meconium was seen on the examiner’s finger. An x-ray study of the abdomen shows distended intestinal loops, but fluid levels are not present. The abdomen has a granular, ground glass appearance with flecks of calcium scattered throughout.

The most likely diagnosis is

A. Aganglionic megacolon (Hirschsprung’s disease)B. Intestinal AtresiaC. Meconium plug syndromeD. Ruptured appendixE. Cystic fibrosis, Meconium ileus and peritonitis

77. Your 4-yeard old patient who is receiving L-asparaginase and vincristine therapy for acute lymphocytic leukemia played for one hour with a child who has had a varicella rash for 2 hours. The patient’s mother does not recall that her child has had varicella in the past.

Of the following, the most appropriate course of management would be to

A. Discontinue chemotherapy for about three weeks and observe

B. Discontinue Chemotherapy for about three weeks and administer zoster immune globulin

C. Discontinue chemotherapy for about three weeks and administer live attenuated varicella vaccine

D. Continued chemotherapy and administer acyclovirE. Continue chemotherapy without changing the regimen

77. Your 4-yeard old patient who is receiving L-asparaginase and vincristine therapy for acute lymphocytic leukemia played for one hour with a child who has had a varicella rash for 2 hours. The patient’s mother does not recall that her child has had varicella in the past.

Of the following, the most appropriate course of management would be to

A. Discontinue chemotherapy for about three weeks and observe

B. Discontinue Chemotherapy for about three weeks and administer zoster immune globulin

C. Discontinue chemotherapy for about three weeks and administer live attenuated varicella vaccine

D. Continued chemotherapy and administer acyclovirE. Continue chemotherapy without changing the regimen

78. Which of the following has the most potential for the subsequent development of malignancy?

A. Mongolian spot

B. Strawberry hemangiomas

C. Giant pigmented nevus

D. Nevus flammeus

E. Café-au-lait spot

78. Which of the following has the most potential for the subsequent development of malignancy?

A. Mongolian spot

B. Strawberry hemangiomas

C. Giant pigmented nevus

D. Nevus flammeus

E. Café-au-lait spot

79. Which of the following is a feature of Neurofibromatosis?

A.  Cushing’s syndrome.

B. Haemangiomas of the retina.

C. Infantile spasm.

D. Scoliosis.

E. Shagreen patch.

79. Which of the following is a feature of Neurofibromatosis?

A.  Cushing’s syndrome.

B. Haemangiomas of the retina.

C. Infantile spasm.

D. Scoliosis.

E. Shagreen patch.

80. The mother of a previously healthy 2-year old boy seeks medical advice because her child is not using his left arm. No definite precipitating event can be established but the mother recalls that the boy and his father were playing rather roughly the evening before he stopped using the arm. The most likely diagnosis is

A. Fractured clavicleB. Colles fractureC. Subluxation of the radial headD. Epiphyseal fracture of the upper extremityE. None of the above

80. The mother of a previously healthy 2-year old boy seeks medical advice because her child is not using his left arm. No definite precipitating event can be established but the mother recalls that the boy and his father were playing rather roughly the evening before he stopped using the arm. The most likely diagnosis is

A. Fractured clavicleB. Colles fractureC. Subluxation of the radial headD. Epiphyseal fracture of the upper extremityE. None of the above

81. A 12 years old girl presented with acute Guillain-Barre syndrome and has developed worsening proximal muscle weakness. Which one of the following tests should be used to monitor her respiratory function?

A. Arterial blood gas.

B. Vital capacity.

C. FEV1/FVC ratio.

D. Peak expiratory flow rate.

E. Chest expansion

81. A 12 years old girl presented with acute Guillain-Barre syndrome and has developed worsening proximal muscle weakness. Which one of the following tests should be used to monitor her respiratory function?

A. Arterial blood gas.

B. Vital capacity.

C. FEV1/FVC ratio.

D. Peak expiratory flow rate.

E. Chest expansion

82. 8 years old boy presents with hypertension. Which of the following statements concerning hypertension in the young is true?

A. Sodium nitroprusside is useful for the long-term treatment of sever cases.

B. Abnormalities are frequently seen on DMSA scan.

C. It is defined as systolic blood pressure above the 99th centile for age.

D. Headache is the usual presenting feature

E. Aortic coarctation is the commonest secondary cause.

82. 8 years old boy presents with hypertension. Which of the following statements concerning hypertension in the young is true?

A. Sodium nitroprusside is useful for the long-term treatment of sever cases.

B. Abnormalities are frequently seen on DMSA scan.

C. It is defined as systolic blood pressure above the 99th centile for age.

D. Headache is the usual presenting feature

E. Aortic coarctation is the commonest secondary cause.

83. A child with chronic renal failure has persistent acidosis with an increased anion gap. Increased serum concentration of which of the following substances would likely contribute most to this finding?

A. Lactic acid

B. Protein

C. Urea

D. Inorganic acids

E. Keto acids

83. A child with chronic renal failure has persistent acidosis with an increased anion gap. Increased serum concentration of which of the following substances would likely contribute most to this finding?

A. Lactic acid

B. Protein

C. Urea

D. Inorganic acids

E. Keto acids

84. A 6-month old infant with tachypnea, dyspnea prolonged expiration and an overly expanded chest probably has

A. Obstruction in the upper respiratory tract (larynx or above)

B. Obstruction in the lower respiratory tract (below the larynx)

C. Obstruction in both the upper and lower respiratory tracts

D. Extensive exudative disease involving the lung parenchyma

E. An intracranial lesion stimulating the respiratory center

84. A 6-month old infant with tachypnea, dyspnea prolonged expiration and an overly expanded chest probably has

A. Obstruction in the upper respiratory tract (larynx or above)

B. Obstruction in the lower respiratory tract (below the larynx)

C. Obstruction in both the upper and lower respiratory tracts

D. Extensive exudative disease involving the lung parenchyma

E. An intracranial lesion stimulating the respiratory center

85. 17 years old boy presented with a non-blanching rash over his legs, a swollen knee and painless frank Haematuria. Investigations revealed:serum creatinine: 210 uml/L (60-110). Urine dipstick analysis: blood +++., protein +. Urine culture: negative. Ultrasound of the kidneys was normal.

Which glomerular abnormality is most likely to be present at renal biobsy

A. Foot process fusion.

B. Linear deposition of IgG on the basement membrane.

C. mesangial proliferative and focal lesions

D. Thickening of basement membranes.

E. Mesangial deposition of IgA

85. 17 years old boy presented with a non-blanching rash over his legs, a swollen knee and painless frank Haematuria. Investigations revealed:serum creatinine: 210 uml/L (60-110). Urine dipstick analysis: blood +++., protein +. Urine culture: negative. Ultrasound of the kidneys: normal.

Which glomerular abnormality is most likely to be present at renal biobsy

A. Foot process fusion.

B. Linear deposition of IgG on the basement membrane.

C. mesangial proliferative and focal lesions D. Thickening of basement membranes.

E. Mesangial deposition of IgA

86. A mother reports that her 11-month old son who was previously sleeping through the night now awakens several times during each night.

This most likely represents

A. A normal developmental stageB. Putting the infant to bed too earlyC. HungerD. Inconsistent bedtimeE. Family disturbance

86. A mother reports that her 11-month old son who was previously sleeping through the night now awakens several times during each night.

This most likely representsA. A normal developmental stage

B. Putting the infant to bed too early

C. Hunger

D. Inconsistent bedtime

E. Family disturbance

87. Hyperpnea, lethargy and fever have developed in a 2 year old girl with rheumatoid arthritis. She is not dehydrated or disoriented. There is no nuchal rigidity on physical examination. The lungs are clear. Findings on x-ray study of the chest are normal. Blood oozes from a venipuncture site. Urinalysis reveals reducing substance but no ketones. An aunt has diabetes mellitus.

The most likely diagnosis is

A. Diabetic KetoacidosisB. Reactive airways diseaseC. Gastroenteritis with acidosisD. Salicylate intoxicationE. Oranophosphate ingestion

87. Hyperpnea, lethargy and fever have developed in a 2 year old girl with rheumatoid arthritis. She is not dehydrated or disoriented. There is no nuchal rigidity on physical examination. The lungs are clear. Findings on x-ray study of the chest are normal. Blood oozes from a venipuncture site. Urinalysis reveals reducing substance but no ketones. An aunt has diabetes mellitus.

The most likely diagnosis isA. Diabetic Ketoacidosis

B. Reactive airways disease

C. Gastroenteritis with acidosis

D. Salicylate intoxication

E. Oranophosphate ingestion

88. A young woman with rheumatoid arthritis receives Prednisolone 15 mg every other day throughout pregnancy. Her newborn infant will most likely

A. be small for gestational age

B. Have a cleft palate

C. Have a cushingoid appearance

D. Have adrenal insufficiency

E. Have no evident ill effects

88. A young woman with rheumatoid arthritis receives Prednisolone 15 mg every other day throughout pregnancy. Her newborn infant will most likely

A. be small for gestational age

B. Have a cleft palate

C. Have a cushingoid appearance

D. Have adrenal insufficiency

E. Have no evident ill effects

89. An infant weighing 5 kg has Hyponatremia with shock and convulsions. The serum sodium concentration is 118 mEq/L . He is treated with 42 ml of (5.85%) sodium chloride solution intravenously over a 30-minute period. At the end of that time, the predicated serum sodium concentration would be closest to

A. 130 mEq/LB. 160 mEq/LC. 146 mEq/LD. 152 mEq/LE. 140 mEq/L

89. An infant weighing 5 kg has Hyponatremia with shock and convulsions. The serum sodium concentration is 118 mEq/L . He is treated with 42 ml of (5.85%) sodium chloride solution intravenously over a 30-minute period. At the end of that time, the predicated serum sodium concentration would be closest to

A. 130 mEq/LB. 160 mEq/LC. 146 mEq/LD. 152 mEq/LE. 140 mEq/L

90.Thalassemia major has been diagnosed in a 2-yeard old girl who weighs 12 kg. Her hemoglobin concentration is 4 g/Dl. To increase her hemoglobin concentration to 10 g/dL by transfusion with packed erythrocytes having a hemoglobin concentration of 22 g/dL the approximate volume of packed erythrocytes needed would be

A. 100 ml

B. 250 ml

C. 125 ml

D. 150 ml

E. 500 ml

90.Thalassemia major has been diagnosed in a 2-yeard old girl who weighs 12 kg. Her hemoglobin concentration is 4 g/Dl. To increase her hemoglobin concentration to 10 g/dL by transfusion with packed erythrocytes having a hemoglobin concentration of 22 g/dL the approximate volume of packed erythrocytes needed would be

A. 100 ml

B. 250 ml

C. 125 ml

D. 150 ml

E. 500 ml

91. Routine physical examination of a 4-year old boy reveals enlargement of the upper and lower left limbs.

Which of the following conditions is associated with this physical findings?

A. lymphoma

B. Wilms tumor

C. Rhabdomyosarcoma

D. Neuroblastoma

E. Acute lymphocytic leukemia

91. Routine physical examination of a 4-year old boy reveals enlargement of the upper and lower left limbs.

Which of the following conditions is associated with this physical findings?

A. lymphoma

B. Wilms tumor

C. Rhabdomyosarcoma

D. Neuroblastoma

E. Acute lymphocytic leukemia

92. An afebrile 2-week old infant has cough and tachypnea. X-ray study of the chest shows a radiolucent area in the left upper lobe causing a slight mediastinal shift to the right.

The most likely diagnosis is

A. Cystic fibrosisB. Congenital lobar emphysemaC. Pulmonary sequestrationD. Lung abscessE. Pneumomediastinum

92. An afebrile 2-week old infant has cough and tachypnea. X-ray study of the chest shows a radiolucent area in the left upper lobe causing a slight mediastinal shift to the right.

The most likely diagnosis is

A. Cystic fibrosisB. Congenital lobar emphysemaC. Pulmonary sequestrationD. Lung abscessE. Pneumomediastinum

93. An 18-month old boy who was circumcised as a newborn infant has had pain on urination for one day. Today his mother noticed blood on his diaper.

Physical examination shows a crusted meatal ulcer. Bag collected urine contains 6 erythrocytes/hpf and no bacteria smear. Further management would most appropriately include

A. Local application of petroleum jelly and advice to the mother regarding prevention of primary irritant contact dermatitis

B. Obtaining a clear catch urine specimen for culture and colony count

C. Treatment with sulfisoxazole and plans for subsequent intravenous urography

D. Referral to a urologistE. Immediate intravenous pyelography

93. An 18-month old boy who was circumcised as a newborn infant has had pain on urination for one day. Today his mother noticed blood on his diaper.

Physical examination shows a crusted meatal ulcer. Bag collected urine contains 6 erythrocytes/hpf and no bacteria smear. Further management would most appropriately include

A. Local application of petroleum jelly and advice to the mother regarding prevention of primary irritant contact dermatitis

B. Obtaining a clear catch urine specimen for culture and colony count

C. Treatment with sulfisoxazole and plans for subsequent intravenous urography

D. Referral to a urologistE. Immediate intravenous pyelography

94- A 2-year-old boy presents with a 3-day history of diarrhea and vomiting. He has been able to tolerate small amounts of fluids. He is moderately dehydrated, with dry mucous membranes and a heart rate of 145 beats/min.

Of the following, the BEST management for this patient's fluid status is

A. hospitalization with intravenous fluids and a restrictive bland diet

B. hospitalization with intravenous fluids and gut rest for 24 hours

C. oral rehydration therapy at home followed by a diet of fruits, vegetables, and meats

D. oral rehydration therapy at home followed by a clear liquid diet for 24 hours

E. oral rehydration therapy at home followed by a restrictive bland diet

94- A 2-year-old boy presents with a 3-day history of diarrhea and vomiting. He has been able to tolerate small amounts of fluids. He is moderately dehydrated, with dry mucous membranes and a heart rate of 145 beats/min.

Of the following, the BEST management for this patient's fluid status is

A. hospitalization with intravenous fluids and a restrictive bland diet

B. hospitalization with intravenous fluids and gut rest for 24 hours

C. oral rehydration therapy at home followed by a diet of fruits, vegetables, and meats

D. oral rehydration therapy at home followed by a clear liquid diet for 24 hours

E. oral rehydration therapy at home followed by a restrictive bland diet

95. Increased blood concentration of free erythrocyte protoporphyrin in chronic lead poisoning is the result of

A. Impaired renal excretion of protoporphyrin

B. Impaired binding of protoporphyrin with iron to produce heme

C. Increased synthesis of protoprophyrin

D. Increased hemoglobin breakdown

E. Increased binding of heme to the globin molecule in hemoglobin synthesis

95. Increased blood concentration of free erythrocyte protoporphyrin in chronic lead poisoning is the result of

A. Impaired renal excretion of protoporphyrin

B. Impaired binding of protoporphyrin with iron to produce heme

C. Increased synthesis of protoprophyrin

D. Increased hemoglobin breakdown

E. Increased binding of heme to the globin molecule in hemoglobin synthesis

96. A mother brings her 10-month-old son to the emergency department because he has been vomiting for the past 10 days. The child has not experienced any diarrhea. On physical examination, he is lethargic and has dry mucous membranes, reduced tears, a full anterior fontanelle, and 2-second capillary refill. After a second intravenous bolus of 20 mL/kg of normal saline, the boy extends his arms and legs forcefully for 10 seconds. Of the following, the MOST appropriate next step in the management of this child is administration of

A. additional intravenous normal saline bolus of 20 mL/kgB. intravenous fosphenytoin bolus at 20 mg/kg phenytoin

equivalents over 10 minutesC. intravenous prochlorperazine of 5 mgD. rapid intravenous lorazepam of 0.05 mg/kg E. intravenous dexamethasone of 1 mg/kg

96. A mother brings her 10-month-old son to the emergency department because he has been vomiting for the past 10 days. The child has not experienced any diarrhea. On physical examination, he is lethargic and has dry mucous membranes, reduced tears, a full anterior fontanelle, and 2-second capillary refill. After a second intravenous bolus of 20 mL/kg of normal saline, the boy extends his arms and legs forcefully for 10 seconds. Of the following, the MOST appropriate next step in the management of this child is administration of

A. additional intravenous normal saline bolus of 20 mL/kgB. intravenous fosphenytoin bolus at 20 mg/kg phenytoin

equivalents over 10 minutesC. intravenous prochlorperazine of 5 mgD. rapid intravenous lorazepam of 0.05 mg/kg E. intravenous dexamethasone of 1 mg/kg

97. The parents of a child who has Down syndrome and a 47,XX+21 karyotype come to you for counseling about future pregnancies. Of the following, their risk for giving birth to another child who has trisomy is CLOSEST to

A. no greater than the general population at risk

B. 1% added to the mother's age-related risk

C. 5% added to the mother's age-related risk

D. 10% added to the mother's age-related risk

E. 25% added to the mother's age-related risk

97. The parents of a child who has Down syndrome and a 47,XX+21 karyotype come to you for counseling about future pregnancies. Of the following, their risk for giving birth to another child who has trisomy is CLOSEST to

A. no greater than the general population at risk

B. 1% added to the mother's age-related risk

C. 5% added to the mother's age-related risk

D. 10% added to the mother's age-related risk

E. 25% added to the mother's age-related risk

98. An 8-year old boy is brought to your office because he has fever, bilateral knee pain, and a limp. The patient is a black child with generalized lymphadenopathy, an enlarge spleen and a swollen, tender knee. Laboratory studies reveal a hemoglobin concentration of 5 g/dL and a leukocyte count of 2500 mm3 with 80% lymphocytes.

Which of the following studies would be most helpful in confirming the diagnosis?

A. Erythrocyte sedimentation rate

B. Heterophil titer

C. Coagulation profile

D. Examination of a bone marrow aspirate

E. X-ray study of the knee

98. An 8-year old boy is brought to your office because he has fever, bilateral knee pain, and a limp. The patient is a black child with generalized lymphadenopathy, an enlarge spleen and a swollen, tender knee. Laboratory studies reveal a hemoglobin concentration of 5 g/dL and a leukocyte count of 2500 mm3 with 80% lymphocytes.

Which of the following studies would be most helpful in confirming the diagnosis?

A. Erythrocyte sedimentation rate

B. Heterophil titer

C. Coagulation profile

D. Examination of a bone marrow aspirate

E. X-ray study of the knee

99. In an infant, chronic hypervitaminosis A is most often manifested by

A. Follicular hyperkeratosis

B. Excessive growth of hair

C. Lymphocytic leukocytosis

D. Nephrocalcinosis

E. Thickening of the periosterum of the long bones

99. In an infant, chronic hypervitaminosis A is most often manifested by

A. Follicular hyperkeratosis

B. Excessive growth of hair

C. Lymphocytic leukocytosis

D. Nephrocalcinosis

E. Thickening of the periosterum of the long bones

100. A diagnosis of Kawasaki Syndrome has been made in a 6-year old girl. Four days after hospitalization, abdominal pain and distention develop. These developments are most likely due to;

A. Hydrops of the gallbladder

B. Enterocolitis

C. Intussusception

D. Volvulus

E. Hepatic Haematoma

100. A diagnosis of Kawasaki Syndrome has been made in a 6-year old girl. Four days after hospitalization, abdominal pain and distention develop. These developments are most likely due to;

A. Hydrops of the gallbladder

B. Enterocolitis

C. Intussusception

D. Volvulus

E. Hepatic Haematoma