Examination

Reproduction

and

Development

2008

2008-25-04
Multiple Choice Questions (MCQ)

Read the directions carefully and mark the correct option/options clearly with a cross or a
circle.

1.

A 3-year-old boy comes to ER with his father who is very anxious, because the child has just
fainted and had seizures. “His face was blue and I thought that he would die! I did the mouth
to mouth resuscitation”. The boy became very angry after a conflict with his little brother
who is 1 years old, he screamed and screamed after which he suddenly stopped breathing, fell
to the floor and started twitching in arms and legs, he was grey-blue in the face. After a short
period of time he woke up and was completely normal. When examining you find him
normally developed, with no symptoms at all. The situation fits best with the following:

Disorder of the heart rhythm

Temporal lobe epilepsy

Fever seizures

Breath holding spells

Benign epilepsy of children

2.

What is the shortest length of pregnancy (in weeks) when a cesarian-section of foetal
indication can be an alternative?

24

30

27

21

33
3.

The evaluation of the foetal weight is based on measuring the:

Abdominal diameter (AD)

All methods are used

Abdominal diameter (AD) + femoral length (FL) + biparietal diameter (BPD)

AD + FL + BPD + humerus length

AD + FL

4.

What/which tests are routinely performed at Maternity Clinics:

Cultures of Chlamydia

Smear

Lues serology

Serology of group B streptococci

All these examinations are routinely performed

5.

Which of the foetal presentations has the biggest diameter?

Occiput post presentation

Face presentation

Occiput ant presentation

Forhead presentation

Breach presentation
6.

What is the action mechanism of Mifepristone?

Antiestrogene

Antiprogesterone

Antitestosterone

Prostaglandine

7.

Which of the following alternatives corresponds best to the relapse risk after a conventional
prolapse surgery?

30%

10%

50%

70%

90%

8.

What symptoms are the most common in the case of endometriosis?

Dyphagia, dysmenorréa, ovulation pain

Dyspepsia, dysmenorréa, melena

Dyspareunia, dysmenorréa, infertility

Dyspareunia, dysmenorréa, dysesthesia

9.

Which remark corresponds best with GnRH analogs?

Risk for initial increase of pain because of endometriosis

Results first in down-regulation and then stimulation of the gonadotropin receptor

Risk of developing osteoporosis after 3 month of treatment

Risk of prolonged menopausal signs

10.

The sign of malignancy when examining an ovarial cyst in a premenopausal woman is:

Solid parts

Eco free cyst > 8 cm

Peritoneal fluid, fixated cyst

All of the alternatives, except eco free….

Septa, excrescences (?)

11.

At the well baby clinic you see Elsa who is 8 months old. She is still breast-fed and “does not
want to have any other food”. Which of the nutrients is she at risk of having a deficit of?

Vitamin C

Iron

Protein

Zink

Vitamin A
12.

What of the following combination of lab parameters can you see in the cases of hypertonic
dehydration?

Na 152, K 3,0, Cl 120, BE +10

Na 128, K 5,5, Cl 120, BE –10

Na 128, K 5,5, Cl 120, BE +10

Na 152, K 3,0, Cl 120, BE –10

13.

A 4 month old girl, gestational age 40 weeks, BW 3,3 kg, has been growing and developing
normally. In December she arrives at the ER because of respiration problems and cough
since one day. She has been wheezing had some apnoeic spells in the morning. Her sister who
is 4 years old has a common cold. Status: distance rhonki, crackles and intercostals
retractions, secretion from the nose and the respiratory frequency 65 breaths/min, she has
some fever, 38.2 C. Which of the below suggested diagnosis corresponds best to the
symptoms?

RSV-infektion

Chlamydia pneumoniae-infection

Obstructive bronchitis

Pertussis

Bacterial pneumonia

14.

Which of the following anamnestic circumstances is incompatible with (makes you unable to
set or keep) the diagnosis fever seizure at an 8-month-old child, who comes to you because of
a symmetrical seizure with a loss of consciousness during fever.

Hospital ward because of skull fracture at 2 month of age

No seizures in the family

Tonic-clonic seizure with cyanosis and unconsciousness

Hospitalised because of gastroenteritis with dehydration last month

The seizures started at 8 month of age

15.

Which of the following child infections can result in complications like pancreatitis, arthritis,
orchitis or deafness?

Mumps

The 5th disease

Chicken pox

Measles

Rubella

16.

What can be the cause of a white pupil at examination of a newborn with an

ophthalmoscope?

All except ROP

All of these diagnoses

Congenital cataract

Retinoblastoma

Retinopathy of prematurity ROP

Congenital glaucoma

17.

In a case of a shunting heart vitium, for example a big VSD, a child may develop heart failure
during the first weeks of life. The symptoms are usually noticed at the Well Baby Clinic and
are important to recognize.

Which of the following combinations describe the symptoms best?

Feeding difficulties + tachypnoe + hepatomegaly

Tachypnoe + cyanosis + hepatomegaly

Hepatomegaly + cyanosis + failure to thrive

Hepatosplenomegaly + tachypnoe + failure to thrive

Pretibial edema + basal crepitation + tachypnoe
18.

If an adult shakes a baby (shaken baby syndrome) the result can be … (choose the best
alternative)

Direct damage of neurons

subarachnoidal hematoma

Retinal hematoma

All those pathologies

subdural hematoma

All those alternatives except direct damage of neurons

19.

What is applicable in the case of the breach presentation when an external correction of the
foetal position is planned?

Previous caesarean section is a contraindication for external correction of the foetal position

Placenta previa is a contraindication for external correction of the foetal position

Usually done at week 35

The measurement of the pelvis should be done first

Is not applicable for the woman who have previously given birth

20.

Lotta, 30 years, I-gravida, and I-para, with normal delivery 1991 seeks help now because of
bleeding after sex and intermenstrual bleeding. Which diseases you should think of first?

Endometriosis

Anovulatory bleeing

Endometric cancer

Cervix cancer

Myoma
21.

What is the minimum age (years) that permits a woman to apply for sterilisation in Sweden?

18

25

15

20

35

22.

What is the Pearl Index used for?

To describe how many pregnancies occur per 100 woman years of exposure

To describe how many pregnancies are prevented per 100 woman years of exposure

To describe how many pregnancies are aborted per 100 woman years of exposure

To describe how many pregnancies are prevented per 100 woman years of exposure

To describe how many pregnancies result in spontaneous abortion per 100 woman years of
exposure

23.

Which part of the foetal head is the leading part in normal delivery?

The big fontanel

Left or right parietal bone

Sutura sagitalis

The small fontanel

The face
24.

Which is the most common reason for blindness in children globally?

Deficit of vitamin A

Deficit of vitamin D

Iodine deficit

Trachoma (infection with Chlamydia trachomatis)

Measles

25.

A 4-year-old child develops a severe anaemia, elevated creatinine and urea during a
gastroenteritis. What of the following conditions has he/she most probably developed?

Reyes syndrome

Hemolytic crisis because of parvovirus

Autoimmune hemolysis

HUS

26.

Which of the carbohydrates is present in both breast milk and formula?

Lactose

Galactose

Sackarose

Pentose

Glucose
27.

Which of the congenital heart vitium have decreased arterial pulses in the legs when
compared to the arms?

VSD

Aortic coarctation

Pulmonary valve stenosis

Stenosis of the aortic valve

28.

In pubertas praecox the first pubertal sign shows before the age:

9-10 years for girls and 8 for boys

9 years for girls and boys

9-10 years for boys and 8 for girls

8 years for girls and boys

29.

Due to different localisations of brain tumour in children and in adults respectively, the
following early symptoms are more common in children

Seizures

Frontal headache

Vomiting in the morning

Ataxia

Change in personality
Short answer questions
Write short and clear- text! Please stick to the space available below the question.

1.

Emergency case. The parents are worried but the child feels fine. The patient is a 14 year old,
ambitious schoolgirl from a socially well-established family. She is the eldest of 2 siblings.
She is a swimmer at an advanced level, almost elite. She trains extensively and regularly. She
is 170 cm tall and weighs 46 kg. She is becoming more obsessively focused on training and is
very interested in her diet excluding all food that contains sugar or fat. Her menstruations
stopped 6 months ago. Her changed feeding behaviour began last autumn. Since last spring
she is exercising more (jogging and sit-ups) and she has also started vomiting after eating.
The mother is worried but the girl thinks she’s fine and that the mother is exaggerating.
Which diagnosis is the most probable one? (4p)

2.

Another patient is a boy with problems at school. He comes He is referred to you for a
neuropsychiatric investigation. He is a 12-year-old boy who has just started 6th grade. He
doesn’t want to get up in the mornings. He has a stomach pain when he arrives at school. He
has a poor contact with his fellow students. He is the youngest of two siblings from a highly
performing family. He has an older sister with the highest degree in all subjects. He is easily
stressed at school. He can sometimes be aggressive when things are too much for him. He is
unfocused and motorically active during teaching in a full classroom. He has problems
reading. He has had the same teacher since first grade. He likes individual teaching. The
school thinks the problems are due to ADHD. On the first examination of the boy you find
him normally developed physically, relevant for a 12-year-old boy. He does not have age
adequate interests. He prefers to play with a 7-year-old boy next door. He cannot read an easy
text from a storybook. He draws immaturely and childish. He is depressed.
What explanation to the patients’ problems should first of all be considered? (2p)
3.

Two siblings wet themselves at night. Two brothers of 9 and 11 years, from a family seeking
asylum from the Middle east, is referred to you for investigation of enuresis at night. In the
family there are 2 parents and five children. The brothers have 3 younger sisters. The family
suffers from a lot of stress. They have recently moved from another community and from a
non-permanent housing to a more permanent one. They live in a small apartment where the
boys share a room. None of the boys are dry at night and wet themselves almost every night.
They are dry during daytime and urine tests/culture have been normal. Is a more thorough
investigation necessary and in that case, what kind of investigation? (2p)

4.

As a doctor on call on an outpatient clinic you meet a 16-year-old girl with diabetes since 2
years. She came in by ambulance after having a seizure in the bathroom while brushing her
teeth. She was awake at arrival but affected and pale.

a.)What treatment is necessary as soon as possible? Name the substance, approximate dosage
and how it’s administered.

b.) The patient woke up after the treatment you gave. After a few hours the patient is rather
fine mentally but tired. The mother is very aroused by the incident and requires an
explanation. “-How could this happen?”. Your questions to the patient give you the following
information: she takes a long-acting insulin analog Lantus in the afternoon at 17.00 and a
ultra-short acting insulin analog Humalog before the meals. Yesterday she took the Lantus as
usual and as she only ate a little bit dinner she only took 8 units of Humalog (compared to
usually 16 units). After this she cycled approx 2 kms to her friend, whose parents weren’t at
home and met up with some other friends. She drank a coke zero but she didn’t eat a lot at
night. When she came home at 23.00 she were supposed to eat an (delayed) evening
sandwich, but she wasn’t hungry. Therefore she also didn’t take any insulin. She usually takes
4 units together with the evening sandwich. She slept until 9.30 this morning and she just
made her way to the bathroom when everything went black.
What important issue in the medical history, not mentioned in the description, should you ask
in order to be able to answer the questioned what’s happened (Here one word is enough). (4p)
5.

Describe briefly some perinatal cirumstance (s) that is relevant (as a contributory cause) in a
6-months-old child who comes to the ER for obstructive respiratory problems! (1p)

6.

Which is the most characteristic a) find in a normal clinical examination and b) laboratory
finding – in the case of idiopathic nephrotic syndrome in children

7.

What disease can cause increased urine production, hypernatremia and dehydration? (1p)

8.

What type of diet (that the parents have chosen for some, non-medical reason) can cause a
lack of vitamin B12 and minerals in small children? (1p)

9.

A 4-year-old boy comes to you on an emergent visit, as he is tired and pale. You find a Hb of
80, WBK 4,2 and TPC 13. Which disease should you suspect?
10.

A 12-year-old girl seeks help on the school medical policlinic as she is tired and can’t manage
schoolwork the way she’s used to. Previously she was top of the class and very active in
sports. She has lost one kg of weight during the last three months. She feels anxious and has a
difficulty focusing. Off and on she has an abdominal pain and she has lost some appetite
during the last 6 months. She denies vomiting. Sometimes she has some loose stools.
Name three clinically relevant diagnostic possibilities and one test or examination that would
confirm that particular disease. (2p)

11.

Tora is 6 years old and since 5 weeks she has eczema on her hands that is itching a lot. The
mother treated it with hydrocortisone that she bought without prescription on the pharmacy,
but the condition did not improve. Then she asked a colleague who prescribed a stronger
corticosteriode, after which she was improved but not cured. They were supposed to use the
ointment for a week and as soon as they stopped using it, the condition worsened and the
eczema has now spread to the underarms and to the feet. You find an excoriated and slightly
infected eczema on the above-mentioned locations. The nature of the eczema is difficult to
evaluate because of excoriations.
What etiology should you consider exclude before giving advice about the future treatment?
(2p)

12.

A 30 year old woman who has allergy against pollen is expecting her first child. The husband
has asthma. She asks you how to decrease the risk for the child to develop any allergies.
Give her two medically scientifically grounded advice concerning this.(2p)

13.

Anna who is 28 years old is expecting her first child and the pregnancy has been normal until
week 31 when she wakes up in the middle of the night and notices a bleeding as a red stain on
the sheet, approx 5 cm in diameter. She calls her midwife and she advises her to contact the
delivery ward in order to do an examination. You work on the delivery ward as an intern.
What examinations should be done on the first visit? (1,5p)
14.

Name two examinations for differential diagnoses that should be done at severe hyperemesis
gravidarum (2p)

15.

Which diagnostic tests are used to confirm the diagnose bacterial vaginosis (name at least
two)?

16.

Name three contraceptive methods recommended for a woman with increased risk of vascular
trombosis? (1,5p)

17.

Name two types of functional cysts and their origin? (2p)

18.

Until what gestational age is free abortion available in Sweden? (1p)

19.

Which abortive method is the most appropriate one for a woman who wants to do an abortion
in week 14+3? (1p)
20.

What clinical symptoms in a baby suggest a maternal genital infection? Name at least three
different infections and the symptoms of the baby! (4p)

21.

How is left occiput anterior presentation diagnosed? (3p)

22.

You’re called to the delivery ward to evaluate a CTG registration. A multiparous woman in
gestational week 39 has three hours ago received an oxytocin infusion because of sparse
contractions. The CTG shows that the fetus HR is 170. After most contractions there is a
decrease in the fetal heart rate. According to the registration the contractions lasts approx 60
seconds and the interval between the contractions are approx 20 seconds. What do you do
initially? (2p)
23.

A previously healthy multiparous woman comes to the maternal policlinic in gestational week
19 because she feels that her heart rate is too high. She has no other symptoms from the heart.
In your examination you notice a regular HR of 92/min BP 100/60. Otherwise you find
nothing noticeable. You examine her with an EKG, which is normal except a sinus
tachycardia. Thyroid tests are without remarks. Hb 97 g/l. Name two clinically relevant
possible causes to the woman’s tachycardia! (2p)

24.

A woman with no previous pregnancies has delivered a baby by VE. The child weighed 4,4
kg. The placenta has passed and seems to be intact. The uterus is firm at palpation. The
fundus uteri is palpated 4 fingers below the belly button. After the placenta has passed the
patient has bled approx a litre and is still bleeding. What is the most probable bleeding
source? (1p)

25.

A woman with insulin treated DM type I comes to you at the Pregnancy check-up clinic
(MVC).

a) She is planning to try to become pregnant and wonders if you have any words of
advice? Name at least two! (2p)
b) What complications can arise during the pregnancy? Name two! (2p)
Preliminary evaluations

To the following questions below you are supposed to write a preliminary evaluation of 4-6
rows about the case. Only include the most important characteristics of the patient, the
medical history, the examination findings and lab-findings (if any blood samples are taken).
Then suggest one or several preliminary diagnosis and if there are several possible diagnoses
also reason what speaks for one or the other. Finally explain your initial measures and
whether you’re admitting the patient or not, what examinations you refer the patient to and
the initial treatment. You can use short sentences, but it must be possible to follow you
thoughts.

1.

2008-01-03 kl 13. A 31-year-old woman comes to the delivery ward in Lund with abdominal
discomfort. When reading her chart you notice that she had a miscarriage in 2004 and that she
gave birth to her first child in 2005 in gestational week 31 via a caesarean section because of
child in breach position. There was no explanation found to the preterm delivery of the child.
She went into labour and the delivery could not be stopped. The child is now fine. There is no
record of diseases except recurrent urine infections.
She is now pregnant and the expected date of delivery is 2008-03-23. The pregnancy has been
without any complications so far. A week ago there was an ultrasound examination done of
the cervix, which was normal.
The last days she has had some discomfort in her abdomen but her son has had a
gastroenteritis. Today at 10 am the discomfort was accentuated and now it feels more like a
pressure downwards. There have been no signs of rupture of membranes or bleeding.
In the examination you feel that the stomach gets hard in relatively regular intervals. The BP
is 110/70, urine sample +/0, nitur test pos. Temp 37,8. The CTG shows a basal frequency of
approx 140, variation between 136-142. No direct accelerations but no decelerations. A vag
ultrasound shows a cervix of 1,4 cm and a funnelling of 7 mm.

What is your preliminary evaluation in this case?

Please continue if necessary on the back of the paper
2.

2007-09-11. A 47 year old woman comes to you with problems of persisting vaginal bleeding
and abdominal pain. In the chart you read that she has been through four deliveries in
1985,1987,1990 and 1992. All of the deliveries have been normal. She also had a miscarriage
in 1980 and a legal abortion in 1988. She had a spiral inserted after the abortion and after this
she had a salpingitits that was treated with antibiotics.
She has a copper spiral since her last partus.
The patient has had regular menstruations until mid May 2007. From mid June until
September she has had intermittent bleedings between the menstruations. She seeked help at
the end of July because of bleedings and the spiral was then removed, as there was a suspicion
that it caused the bleedings. As the bleedings didn’t stop she seeked emergent help again and
was then given an oral gestagen treatment for 10 days. Despite this the bleedings continued. A
hormone spiral was then prescribed an inserted in October. At a revisit in January–08 the
bleedings had continued. She then expressed that she was tired of the bleedings. Smear and
endometric biopsy are without signs of pathology.
General condition: Unaffected.
Abd: Soft and not tender.
Vag examination: Vulva without remarks. Bloody discharge in the vagina. Uterus is
anteflekted and slightly larger than an egg, with myomas, not tender, firm, movable. Nothing
palpable over the adnexas.
Vaginal ultrasound: Uterus generally myomatic with a thin endometrium. Spiral in situ. The
ovaries are bilaterally without remarks. No free fluid in the abdomen.
Lab: Hb 131 g/l, WBK 6,7 TRC 302.
The hormone spiral has not had any effect and because of this a hysterectomy and destruction
of the endometrium. The final plan is a vaginal hysterectomy with adnexas left and
information about the risk of conversion.

What is your preliminary evaluation in this case?

Please continue if necessary on the back of the paper
3.

A 13-year-old boy accompanied by his father comes to you on the school medical policlinic
and describes intermittent problems with heart palpitations, fainting sensation, dizziness and
chest pain during the last months. When the boy returns to class the father comes back and
shows you this pedigree, in which the boy has the position III:4. The sister is 11 years old and
healthy, “as far as we know”. The question concerns Marfans syndrome, a hereditary
mutation of the gene responsible for the synthesis of fibrillin. Affected people often develop a
widening of the aorta at a young age, often with the consequence of aortic rupture. They are
often tall and slender with hyperextensible joints (Abraham Lincoln). Recently the family was
informed about the occurrence of the condition at the mothers´ side of the family. The
grandmother died of a sudden “ heart stroke” and she has two siblings living with the disease,
who are quite handicapped. The boy’s mother was genetically tested in Holland, where the
pedigree was done. Nothing abnormally was discovered regarding her but the father is now
anxious to have his sons´ heart thoroughly examined and he does not want his son to
participate in the school gymnastics before all of his symptoms have been investigated.
Socially: The father sells cars. The mother works in a shop. The family lives in a flat with 4
rooms and a kitchen. The patient is in the 7th grade and likes physics and religion. He plays
basketball in his spare time.
Previous diseases: Arm fracture when he was approximately 6 years old. No other hospital
visits. Normal growth and development. Has had the chicken pox. He has grown a lot during
the last six months (almost 8 cm). Myopic.
Current situation: When the boy stands up, for example in a ticket line, he can have
symptoms of heart palpitations and dizziness, near fainting and the first time this happened
was 2 months ago. He has never fainted. Sometimes the heart palpitations occur during light
exercise (like walking in stairs) and when it happens he also has chest pain that is so severe
that he must stop. He has no problems during basketball training when he’s warmed up. He
has no sensation of decreased stamina. He has a lot of hand sweat and the hands are often
rather cold.
Medicines: None
Physical examination:
General condition: Unaffected. Age adequate appearance. Slender young man with tall legs,
big hands, long fingers and a relatively big nose. No signs overextension in joints. PH4,
testicles 4 cm.
Mouth and throat: No irritation. Teeth without pathology.
Lymph nodes/thyroid: No pathologic resistances.
Cor: No voussure. No fremissement. Regular heartbeats 88/min, soft systolic heart murmur
grade II with PM in I3 sin. No radiation. Clear splitting of the 2nd tone variating with
breathing.
Peripheral pulses: Well filled and similar in arms and legs.
BP: 110/70
Lungs: Physiol without remarks
Abdomen: Normal configuration, no scars. Liver, spleen not palpable. No tenderness. No
resistances.
Neur: Pupils of similar size and reacts appropriately to light. Eyemovements without remarks.
Extremity reflexes obvious and similar bilaterally. Babinskis´sign missing.
PBD: 13 year old boy with Marfans syndrome on the mothers side…
What is your preliminary evaluation in this case?
Please continue on the back of the paper
4.

A 3-year-old girl comes to the ER in November with a left side limping.

Her: There is an aunt with Reumatoid arthritis (mothers side) and one (fathers side) with
psoriasis.
Socially: Fist child to parents who live together.
Previous: Six months ago she had a swelling of the right knee, but with more discrete
symptoms and they never seeked help then. The condition healed spontaneously in 5 weeks.
Obstructiveness and they use beta 2 stim in a Nebunette inhalator.
Current: Two weeks ago the parents noticed that the left knee was slightly more swollen
compared to the right. Has had a cold since 3 days and a slight temp 38,5 but no fever
previously during the episode. No signs of obstructiveness. The parents have noticed that
when she tries to squat she fails. She has not complained about pain at rest and she has been
playing as usual but with a slightly limited ability to move. She does not fully extend her knee
joint. The general condition is good.
They spend their summers in the Swedish archipelago and she has had tic-bites every
summer. They have not noticed any ring formed skin lesions. No other current infections
during the last months.
Clinical examination:
General condition: Unaffected at rest. Running nose, clear mucus. Temp 38 C.
Mouth and throat: Slight redness in the throat.
Ears: Eardrums without remarks, normal reflex. No redness.
Cor: Normal rhythm. No murmurs.
Lungs: Without remarks
Skin: No rash.
Joints:.Hydrops in the left knee, both below and above the patella, medially and laterally.
Warm compared to the right knee. No redness. Has a flexion defect of approx 20 degrees.
Cannot fully extend, with approx 10 degrees extension defect. No signs of synovitits or
hydrops in the other joints, neither large or small. Full motion in all other joints.

Write a preliminary evaluation that contains: Probable diagnosis (2p) differential diagnoses
(at least two, 1 p each) and a plan with referrals to the tests and emergent examinations that
you want her to take/do.
Please continue if necessary on the back of the paper
SOLO question

In this question you´re supposed to show the quality of your clinical thinking by formulating
clearly how you perceive a case. Start by mentioning in important diagnostic scenarios that
are dangerous or/and call for immediate action. Then mention situations that are frequent in
the described situation in health care in Sweden. Be selective concerning what you bring up,
in the way that the most important stand out clearly! Avoid listing a lot of distant possibilities
and instead name a few highly relevant! Keep your answer inside the space and write clearly!

A 24 year old woman, 1-gravida , comes to your maternity clinic in the primary health care in
gestational week 27+4. The mid-wife has a week ago noticed a suspected decreasing of the
symphysis-fundus measure, that is confirmed after the measurement today. The patients BP
was 130/85 last week and today the BP is 150/100. How should this be dealt with; today – and
onwards? What immediate risks are there for the mother and child? If you take the right
action and everything turns out fine until partum, what risks for the child remain after birth, as
a consequence of the mothers’ present condition?