University of Zambia

School of Medicine
Department of Paediatrics and Child Health

Paediatrics: PED 510

GENERAL PAEDIATRICS PAPER

Tuesday 1st April 2014 10:00- 11:00

Directions
 This paper consists of 12 pages. Please read it carefully and ensure that it is complete
and correct. .
 Each question has five answer options from which you are to choose one (single best
answer)
 Answer all the questions on the Question paper.
 It is ESSENTIAL that you write your Computer Identification Number each page
 Time allowed: One 1 hour

Computer Number:

[Turn Over]

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1. A 3-year-old male child presents with shortness of breath, pedal edema and abdominal pain. Further history
reveals that he had suffered a chest infection at 6 months prior for which he was admitted to hospital for 5
days. His mother has been on Anti-retroviral therapy for one year now. On examination he is dyspneic,
febrile and a grade 4 pan systolic murmur radiating to the axilla. Which of the following statements
concerning this child is correct?

a. The chest infection was most likely due to group B streptococcus.

b. The pan systolic murmur is most likely due to mitral incompetence.
c. The patient will have to be placed on life-long prophylaxis with a penicillin
d. The murmur is most likely functional and not due to incompetent mitral valves
e. This condition can be prevented by a vaccine.

2. During your clerkship, while sitting in the emergency, you see a frantic mother rushing into the room
carrying her 3-year-old son whom she says is not responding to her when she calls his name out. Mum says
he woke up well in the morning and was playing with friends in the backyard near the rubbish pit who just
brought to mum in that state. On examination he has a GCS of 8/15, pinpoint pupils, lots of secretions in the
mouth and has soiled his pants with loose stool. No medications have been given to the child. Which of the
following statements below is true concerning this scenario?

a. The child requires pralidoxime immediately

b. Atropine is not a very useful drug in this situation
c. The child most likely just suffered a febrile convulsion and mum needs to be reassured.
d. A cranial CT be done immediately
e. It is important to take all of the child’s clothes off as part of management of this situation

3. Which of the following statements regarding examination of the respiratory system is correct?

a. Bronchial breathing in the 5th right intercostal in the subscapular region indicated a right middle lobe
pneumonia
b. A persistent wheeze with reduced breath sounds is diagnostic of asthma
c. A respiratory rate of 40/min is normal for a 5 year-old at rest
d. Pectus excavatum is mostly indicative of underlying lung pathology
e. The ribs of children are more horizontal than that of adults.
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4. You are sitting in a developmental clinic when you notice that a child, brought by her mother, gets upset
each time she pulls away a syringe on the doctors table that she keeps trying to reach for (object
permanence). She gets to sitting position without help and while in the room she says at least one word with
meaning. She is not able to walk more than two steps but stands unsupported. As they leave the room, she
waves bye-bye. Approximately, how old is this child?
a. 5 months
b. 7 months
c. 10 months
d. 13 months
e. 15 months

5. A 7-year-old boy presents with cyanosis, and acute shortness of breath. On further inquiry he has had
several similar episodes though not as severe as this one. He also has a history of episodes of turning blue
while feeding in infancy and it has also been noticed that from the age of 5, while playing with friends he
‘sit down’ occasionally and would feel better after several minutes. On examination, she is dyspneic,
cyanosed and has clubbed fingers and toes. Concerning the diagnosis, which of the following statements is
true?

a. Cyanosis is commonly present from birth in thus condition.

b. Heart failure occurs during the first 6 weeks of life
c. The most likely chest X-ray findings will be plethoric lung fields.
d. The ‘sitting down’ reported in the above scenario helps the patient by increasing systemic vascular
resistance.
e. Correction of the defect is only possible by heart transplantation

6. Results of investigations performed on cerebrospinal fluid from a febrile, irritable,4-year-old female with
seizures are as follows:
Appearance: Cloudy
WBC: 80 cells/mm3 (76%Polymorphs and 24% Lymphocytes)
RBC: 98 cells/mm3
Gram Stain: Gram negative coccobacilli
Ziehl-Nielson Stain: No organisms
Proteins: 0.6 g/L
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 Sugar: 2mmols/L
Which of the following statements is true regarding this statements?
a. A vaccine against the above organism is currently not offered under the Zambian immunization
program.
b. This kind of meningitis rarely presents with shock.
c. Sepsis is uncommon with this type of meningitis
d. The organism responsible for this picture is E coli.
e. Household contacts of this patient need not be identified.

7. Which of the following statements concerning immunization in Zambia?

a. The presence of a coryzal illness and fever of 37.9oc is a contraindication

b. Rota virus is first given at 6 weeks and the follow-up dose is at 10 weeks
c. PCV is given on the right thigh while the pentavalent vaccine is given on the left thigh.
d. PCV is given on the left thigh while the pentavalent vaccine is given on the right thigh.
e. A history of severe eczema

8. A 2-year old child with Cerebral Palsy (C.P) comes to the neurology clinic on Friday morning as follow up
for an admission for Hypoxic Ischemic Encephalopathy in neonatal life. He is unable to walk or sit
unsupported. He has never been hospitalized and he does not have swallowing problems. On examination
you find that boy has increased tone in the upper and lower extremities and is hyper-reflexic in the lower
extremities. Which of the following statements concerning this child is correct?

a. A cranial CT may show what may be interpreted as ‘enlarged ventricles’.

b. The head circumference will most likely be above the 75th percentile.
c. A lumbar puncture is mandatory as part of follow up of this case.
d. This child will most likely have sensorineural deafness
e. This type of C.P is not normally associated with feeding difficulty.

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9. A 13-year-old girl complains of headache over the past several days. She noted increased chest congestion
and coughing yesterday when walking outside in the cold air. She denies nasal congestion, rhinorrhoea,
emesis, or diarrhoea. Her mother declares her daughter is generally healthy with a history of only summer-
time allergies. Her vital signs, respiratory effort and chest examination are normal. Which of the following
is the most likely diagnosis?

a. Haemophilus influenza
b. Mycoplasma pneumonia
c. Respiratory syncytial virus
d. Staphylococcus aureus
e. Streptococcus pneumonia

10. An 11-year-old boy complains of cola-colored urine of several days’ duration. There is no change in the
frequency of urine and no dysuria. He does note that over the last two days there’s some slight facial
swelling upon waking up in the morning but this subsides by mid-day.. On physical examination he is
hypertensive but appears healthy. Urinalysis shows hematuria = 4+ and proteinuria = trace

Which of the following is the most useful next step in the evaluation of this patient?

a. Urea and creatinine levels

b. Urine culture
c. Urine microscopy
d. Abdominal ultrasound
e. Renal biopsy

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11. A 3-year-old boy who had a simple brief febrile seizure comes to OPD 1 day after his visit to AO1. He was
discharged after 6 hours of observation with no further seizures. He is currently afebrile, is happily pulling
at the doctors stethoscopebut is taking antibiotics for pharyngitis diagnosed the previous day. His mother
wants to know what to expect in the future regarding his neurologic status. Which is the most appropriate
statement to tell her?
a. He has no risk of further seizures because he was age 2 years at the time of his first febrile
seizure
b. He will need to take anti convulsant medication for 6 to 12 months to prevent further seizures
activity
c. You want to schedule an EEG and a magnetic resonance scan of his head
d. Although he does have a risk of future febrile convulsions, seizures of his type are generally
benign and he is likely to outgrow them.
e. This is an isolated disorder , and his children will not have seizures

12. A 2 year old child presents with anaemia to A01. As a 5th year medical student you take a detailed history
and and note that the child’s growth faultered at the age of 18 months after a bout of diarrhoea. You also
note that on physical examination, she is pale, has thin sparse hair, pedal oedema and dermatosis grade 3.
Which of the following statements concerning this child is correct?

a. Blood transfusion is done if Hb is 4g/dl or less

b. The amount of packed red blood cells required for transfusion is 7.5mls/kg
c. The amount of whole blood required for transfusion is 20mls/kg
d. Congestive cardiac failure rarely occurs after blood transfusion
e. Ferrous sulphate and folic acid should be always added right form bay 1

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13. The child in question 12 above is then admitted to A07 (malnutrition ward) and develops diarrhoea. Which
of the following statements is true in this regard?

a. The frequency of loose motions is better than skin turgor in determining hydration status
b. Zinc sulphate is routinely prescribed in patients with severe malnutrition
c. ORS cannot be given in profuse diarrhoea
d. Intravenous fluids are only given in severe dehydration
e. 2 hourly F100 is usually alternated with ReSoMal in severe dehydration

14. During your one week rotation on the malnutrition ward, you are intrigued to learn that malnourished
children are fed in a unique way. Which of the following statements concerning feeding in the malnutrition
ward is correct?

a. F75 and F100 contain the same amount of sugar and CMV
b. F75 contains more sugar than F100 but F100 contains more calories
c. There are 2 forms of F75 in AO7, F75 RUTF and F75 milk
d. Transitioning to F100 can only be done in bay 3
e. Increase in F100 via a transition is 10mls/day from the third day

15. A 4 year old boy is referred from Mazabuka with an 8 month history of a painless abdominal mass. The
mass was found incidentally by the mother on is said to be increasing in size. A renal scan confirms that the
mass is arising from the kidneys. Concerning the most likely diagnosis, which of the following statements is
false?

a. The condition commonly presents as an abdominal massT

b. It is more common in pre-school aged childrenT
c. Histology of favourable prognosis normally presents with ‘canon balls’F
d. Bilateral renal masses at diagnosis is stage V T
e. Hypertension may be a finding and may be due to hyper-reninemiaT

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16. Nephroblastoma is a devastating malignancy in children. Which of the following statements is true?

a. Stage 4S carries an unfavorable prognosis.

b. When associated with opsomyoclonus, the primary tumour may be in the thorax.
c. The age of presentation is usually in the 5- 10 year age group.
d. ?It presents more commonly than Nephroblastoma in UTH.?
e. Urine tests are not useful in the diagnosis

17. Which of the following statements concerning Non-Hodgkins Lymphoma is false?

a. It is the most common of all lymphomasT

b. Is commoner in children with immunodeficiencyT
c. May transform to acute leukaemiaF
d. Involves the central nervous system more commonly than Hodgkin’s lymphomaT
e. Commonly presents with cervical lymph node enlargementT

18. A 10 year old boy presents to casualty with swelling of the right knee. Without taking a detailed history, the
surgeons aspirated blood from the knee. As you were present at the time, you take a detailed history and
note that his maternal uncle had a similar problem which was recurrent. Excitedly you make a diagnosis of
Haemophilia. Which of the following statements concerning your diagnosis is true?

a. The symptoms of the disease can begin to manifest intrauterine

b. The prothrombin time is prolonged F
c. 70% of patients have no family history F
d. Factor VIII antibodies occurs around 20% of patients T
e. It incidence has increased following the advent of the HIV pandemic F

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19. A 6 year old girl is admitted in vaso-oclussive crisis. She is a known Sickle Cell Disease patient who has
been followed up in the haematology clinic for 4 years now. Which of the following statements is true?

a. Sickle Cell occurs as a result of a substitution of valine by glutathione.

b. Functional asplenia typically starts at 8years of age.
c. Trans-cranial Doppler velocity >200cm/sec is a predictor for a stroke
d. Asthma is distinguished from acute chest syndrome by a good clinical examination.
e. Reticulocytosis is noted in Parvovirus B19 infection.

20. A 4 year old boy presents to AO1 with weakness of the lower limbs of 3 day duration. On further inqury
you elicit that he suffered a bout of diarrhoea 2 weeks prior and a stool culture isolated Campylobacter
species. Serial examination of the patient reveals an ascending paralysis, absent deep tendon reflexes but
sensation is intact. You make a diagnosis of acute flaccid paralysis. Which of the following statements
concerning the most likely cause of this paralysis is true?

a. It is characterized by progressive weakness ?T

b. Demyelination of peripheral nerves rarely occurs F
c. Facial nerves are often involved T
d. Deep tendon reflexes are lost early in most cases ?F
e. It may be associated with cardiac arrhythmia F

21. While walking through the labour ward, you are called by a midwife to come and take a look at a funny
looking kid’. You examine the child and note that the child has low set ears, a simian crease, broad feet with
short toes and brushfield spots. Cardiac ECHO confirms congenital heart disease. Concerning the most
likely diagnosis, which of the following statements is true?
a. Mothers to affected children are always elderly. F

b. The palpebral fissures slope downwards. F

c. Brushfield spots are found in the cornea of the eye. F (IRIS IN DOWN SYN.)

d. Microglossia causes speech delay F

e. A single palmar crease is pathognomonic of the syndrome T

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22. During a Saturday round in P.I C.U, you notice a little boy who has periorbital edema. You take a history
and note that the swelling subsides as the day progresses. His urine output is reduced and on physical
examination, she has ascites with an abdominal girth of 39cm. His blood pressure is 140/100mmHg (above
the 95th percentile). Urinalysis shows blood 4+ and protein 3+. His serum albumin is 10 and his creatinine is
mildly elevated. What is his diagnosis?

a. Acute Glomerulonephritis
b. Nephrotic syndrome
c. Nephritic-nephrotic syndrome
d. Chronic Kidney Disease
e. Pyelonephritis

23. Which of the following investigations is least important in a child presenting with diabetic ketoacidosis?

a. Urea and electrolytes

b. Blood glucose
c. Arterial blood gases
d. FBC and ESR
e. Urinalysis

24. A 6-month old girl is seen in the neurology clinic and is noted to have a Moro, Gallant, and an asymmetric
tonic neck reflex. She doesn't support weight on her feet and in ventral suspension, she makes no attempt to
extend her head or lower extremities. What is your clinical assessment given these findings?
a. Persistence of the primitive reflexes for this age is normal
b. The patient is too young for postural reflexes
c. The patient most likely has developmental delay with an upper motor neuron lesion
d. The patient has hypotonia from neuromuscular weakness ?T
e. The patient can be seen at 2years of age for reassessment.

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25. Diarrhoea is a common condition in children and thus most facts about it must be known by all doctors.
Which of the following statements concerning diarrhoea is true?

a. Oral rehydration therapy is used to manage severe dehydration

b. The most common cause is enterovirus. infection.
c. Broad-spectrum antibiotics are usually indicated.
d. A degree of lactose intolerance may follow gastroenteritis.
e. Blood pressure is a sensitive indicator of dehydration
26. Concerning the diagnosis of HIV in children, which of the following statements is false?
a. Diagnosis may be presumptive in a given setting F
b. Breastfeeding should be discontinued in order to perform a diagnostic HIV test
c. Virological testing for HIV DNA should be done on whole blood or DBS
d. Both HIV DNA and HIV RNA virological testing can be done on DBS
e. All infants whose HIV status is confirmed should receive ART promptly

27. A 10-year old boy presents for the first time with difficulty in breathing and shortness of breath. He is not a
known asthmatic, but there is a family history of atopy. There are expiratory wheezes and a few crackles
on listening to his chest. He responds to salbutamol inhalers of 10 puffs that are needed every 2 hours. He
is admitted and given prednisolone at 40 mg once a day for 3 days. All of the following regarding follow
up management are false except:

a. Use salbutamol inhalers when needed

b. Inhaled steroids everyday
c. Regular salbutamol inhaler
d. Lung function test
e. Regular asthma clinic follow-up
28. Causes of acute stridor in a two-year old child include the following except:

a. Whooping cough
b. Epiglottis
c. Foreign body aspiration
d. Bronchiolitis
e. Laryngo-tracheo-bronchitis
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 29. Breast milk is considered to be the best milk for newborn babies. Compared to most formula milk products,
which of the following statements is true concerning breast milk?

a. It has higher caloric value. ?T

b. It has increased protection from HIV infection in HIV-positive mothers.
c. It has increased calcium content.
d. Has high levels of IgE
e. Decreased risk of haemorrhagic disease of the newborn .

30. A Babinski sign or an up going great toe on plantar stimulation is most diagnostic of an upper motor lesion in
which one of the following clinical settings?

a. A 6-month-old with up going toes on plantar stimulation.

b. A 12-month-old with up going toes on plantar stimulation.

c. An 11-month-old with an up going toe on one side and a down going toe on the other side.

d. A 16-month-old with up going toes on plantar stimulation.

e. A 9 month-old with down going toes on plantar stimulation

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