A.

Chlamydia
B. Cytomegalovirus
C. Group B Streptococcus
D. Haemophilus Influenza
E. Mycoplasma pneumonia
F. Parainfluenza
G. Respiratory syncytial virus
H. Rhinovirus
I. Staphylococcus aureus
J. Ureaplasma
Select the most appropriate pathogen from the above list that would account for the following
presentations:
1) The commonest cause of pneumonia
F. Parainfluenza
in the 2 month - 6month age group.
G. Respiratory syncytial virus

2) A 9 year old boy presents with a cough

D. Haemophilus Influenza
and fever. Chest x-ray demonstrates a
E. Mycoplasma pneumonia
reticular nodular pattern with high
adenopathy and a small pleural effusion.

3) A 5 year old boy presents with painful

E. Mycoplasma pneumonia
red swellings of his shins. Examination of
C. Group B Streptococcus
his throat reveals an exudative tonsillitis.

Comments:
The commonest cause of pneumonia in the 2month 6 month age group is Respiratory syncytial virus,
which results in bronchiolitis and occurs in epidemics. Mycoplasma pneumonia mainly affects older
children (between 5 and 15 years) resulting in community acquired pneumonias. Tonsillitis can occur at
any age although is frequently seen in the 4-7 age group. The majority of episodes are caused by viruses
although beta haemolytic streptococcal infection is also responsible and has systemic reactions such as
erythema nodosum, rheumatic fever and glomerular nephritis

The follwing are true of rabies virus infection:

A it can be carried by foxes for several weeks true
B it can be harmless to small animals false
C it is found only in the brain at autopsy false
D fatal infections always make dogs mad true
E it can have an incubation period longer than 6 months true

Comments:
Foxes usually die within 10 days of contracting rabies. The virus can be found in many tissues and is
transmitted through saliva.
Indications for tonsillectomy include:
A Persistently enlarged tonsils false
B Snoring true
C Peritonsillar abscess true
D Recurrent glue ear requiring grommet insertion true
E More than 3 episodes of tonsillitis requiring antibiotics true

Comments:

The indications for tonsillectomy are controversial. Undoubtedly, upper airway obstruction, particularly if
associated with hypoxaemia or apnoea, are a clear indication. In most cases, recurrent tonsillitis with
pus requiring antibiotic therapy would encourage the surgeon to remove the tonsils. This is particularly
the case if there has been a previous abscess. However, if there is no history of chronic tonsillitis, the
chance of a recurrence of quinsy is only about 10%, so isolated incision and drainage with antibiotics is

1
 all that is required.

Copyright

In polycythaemia rubra vera there may be:

A Pruritis due to deposition of bilirubin. true
B Increased total red cell volume. true
C Evolution to acute leukaemia. false
D Reduced plasma volume which contributes to the increased haemocrit. false
E Arthropathy as a recognised complication. true

Comments:

Polycythemia rubra vera is a myeloproliferative disorder in which erythroid precursors of affected people
do not require erythropoietin to stimulate growth.

Diagnostic criteria are:

Increased total red blood cell volume.
Arterial oxygen saturation greater than or equal to 92% (to distinguish from secondary
polycythemia).
Splenomegaly.
There may be thrombocytosis, leukocytosis and increased leukocyte alkaline phosphotase.

Treatment includes phlebotomy -/+ antiproliferative chemotherapy.

Complications:
Bleeding
Thrombosis
Malignant transformation: myelofibrosis, acute leukaemia

Prolonged survival is not unusual.

Regarding congenital Nephrotic Syndrome (Finnish type):

A It is characterised by cysts visible on ultrasound scan. false
B Presentation is usually within the first 3 months of life. true
C It may be associated with a small placenta. false
D It is inherited as an autosomal recessive disorder. false
E May be associated with respiratory distress in the newborn. true

Comments:

Congenital Nephrotic Syndrome is autosomal recessive, and commonest in Scandinavian genotypes.

There is dilatation of the proximal convoluted tubules visible on microscopy (microcystic disease).
Proteinuria is present at birth, and the children may be born prematurely with enlarged placenta,
respiratory distress, and separation of the cranial sutures. They usually present within the first 3 months of
life, and tend to have persistent oedema and recurrent infections resulting in death by the age of 5 years.
The disease is not steroid responsive, with renal transplantation the only hope. Antenatal diagnosis by
measuring alphafeta protein levels is possible on amniocentesis

A lesion of the sciatic nerve in the region of the buttock causes:

A Weakness of knee flexors false
B Weakness of knee extensors true
C Complete loss of sensation below the knee true

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D Weakness of dorsiflexion of the foot true
E Loss of the ankle jerk true

Comments:

The sciatic nerve is the largest nerve in the body, and arises from the sacral plexus (L4, 5, S1-3). It
passes through the greater sciatic foramen into the buttock and then descends through the posterior
aspect of the thigh supplying the hamstrings. At the level of the mid-femur it divides to form the tibial and
common peroneal nerves. The tibial nerve passes through the popliteal fossa to the posterior aspect of
the leg where it supplies the muscles and the skin. The common peroneal nerve winds around the neck of
the fibula and divides into the deep and superficial perineal nerves, which supply the skin and muscles of
the anterior aspect of the leg and the dorsum of the foot and toes. The saphenous nerve, arising from the
femoral nerve, supplies the antromedial aspect of the thigh and calf. Lesions of the sciatic nerve therefore
cause weakness of knee flexors, but not extensors, and there is incomplete loss of sensation below the
knee, particularly affecting the lateral and posterior parts of it. Plantar flexion is weak, but dorsal flexion is
unaffected. The ankle jerk is absent (L5, S1).

The following are recognised causes of recurrent cough in the pre-school child:
A Parainfluenzae infection true
B Exercise false
C Retropharyngeal abscess false
D Congenital ciliary dysmotility true
E Postnasal drip true

Comments:

Cough indicates irritation to nerve receptors in the pharynx, larynx, trachea or bronchi. Recurrent causes
include:

Asthma, sometimes exacerbated by allergic rhinitis and postnasal drip.

Infections: pertussis, RSV, mycoplasma.
Bronchiectasis: cystic fibrosis, Kartagener Syndrome.
Recurrent aspiration, especially in children with abnormal swallowing.
Habit cough or smoking.

Other: inhaled foreign body, TB

Recognised side effects of thiazides:

A Hypercholesterolaemia true
B Hypochloraemia true
C Impotence true
D Agranulocytosis true
E Peripheral neuropathy true

Comments:
Side effects of thiazides include:
Postural hypotension.
GI upsets.
Reversible impotence.
Electrolyte disturbance: hypokalaemia, hypomagnesaemia, hyponatraemia, hypochloraemic
alkalosis, hypercalcaemia, hyperglycaemia, hyperuricaemia, hypercholesterolaemia.
Rashes, photosensitivity.

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 Blood disorders, including exacerbation of SLE

Which of the following is/are true regarding testicular torsion.

A Occurs frequently in neonates. false
B May present with abdominal pain and vomiting and few testicular symptoms. false
C Radiological investigation with doppler ultrasound or isotope scanning is
invariably indicated. true
D Testicular viability is reduced if surgery is delayed more than 6 hours. true
E Contralateral orchidopexy should also be performed if a torsion is confirmed. true

Comments:
The commonest causes of the 'acute scrotum' in childhood are testicular torsion, torsion of an appendix
testis and idiopathic scrotal oedema. Testicular torsion can occur at any age but is most common in the
neonatal and peripubertal periods. It usually presents with severe testicular pain but this may be absent
and the testis should be examined in all boys with abdominal symptoms. If a torsion is clinically suspected
then radiological investigations have little to offer. None are diagnostic and may delay surgery. Testicular
viability is reduced with increasing time from the onset of symptoms. Following reduction of a torsion 3-
point fixation with an non-absorbable suture should be performed. The contralateral testis should also be
fixed.

The following are recognised symptoms of migraine:

A Hemiballismus true
B Hemianopia true
C Hemihypertonia false
D Hemiparesis true
E Convulsions false

Comments:

Migraine is a periodic disorder characterised by paroxysmal headache often unilateral accompanied by

visual or GI disturbance. Rarely, there may be unilateral sensory or motor symptoms. The aura may
include hemianopia, scitoma, or fortification spectra. The GI features include nausea, vomiting and
abdominal pain, and may overlap with cyclical vomiting and abdominal pain of childhood. Migraine may
be:

Common - without aura.

Classical - with visual, sensory or motor aura (10%).
Complicated - associated with other neurological phenomena such as ophthalmoglegia,
hemiparesis, parasthesia, or hemidysesthesia (altered sensation down one side) (1-2%).

Vertigo basilar migraine may give rise to cerebellar signs such as nystagmus and vomiting with
retching.

Regarding central cyanosis:

A It can be reliably diagnosed when >5g/l of desaturated haemoglobin are present. true
B If the haemoglobin is 6g/dl, the child will be pre-terminal before cyanosis appears. false
C Central cyanosis is indicated by circum-oral blueness. false
D It can be associated with a normal arterial PO2 in methaemoglobinaemia. true
E May be caused by right to left shunts. true

Comments:

Cyanosis is a bluish or purplish tinge of the skin or mucous membranes resulting from the presence of

4
>5g/dl of reduced haemoglobin in the blood perfusing the skin. It is, therefore, not detectable in patients
with severe anaemia, even if they are gravely hypoxaemic. Central cyanosis is usually detectable once
the oxygen saturation drops below about 80-85%. It may be respiratory or cardiac in origin.

Occasionally, cyanosis can be because of abnormal pigments such as sulphaemoglobin or

methaemoglobin. In this cases, arterial oxygen tension is normal.

Methaemoglobin: Fe3+ instead of normal Fe2+ in haemoglobin in some haemoglobin molecules. Two types:

Genetic (asymptomatic)
Acquired: ingestion of oxidant drugs such as analine dyes, GTN, dapsone. These give symptoms of
anaemia haemolysis.

Sulphaemoglobin: Acquired by ingestion of sulphonamides or phenaciten.

Recognised causes of haematuria include:

A Group A Streptococcal infection false
B Schistosoma japonicum infection false
C Sickle Cell Disease true
D Hypocalciuria true
E IgA nephropathy true

Comments:
Haematuria can be caused by non-glomerular or glomerular abnormalities:
Non-glomerular: infection (bacterial, viral, TB, schistosoma haematobium), trauma (genital,
urinary tract, kidneys), stones, tumours, Sickle Cell Disease, bleeding diathesis, renal vein
thrombosis, hypercalcinuria.

Glomerular: acute or chronic glomerular nephritis, IgA nephropathy, familial nephritis, thin
basement membrane disease.

Regarding childhood malignancies:

A A mediastinal mass is a frequent finding in T cell Acute Lymphoblastic
Leukaemia. true
B A bone marrow biopsy should always be performed to exclude leukaemia
before ITP is treated with steroids. true
C Cranial irradiation before the age of 3 years has a high neurocognitive
morbidity. true
D Children on chemotherapy are at high risk if exposed to measles or chickenpox. true
E The siblings of children on active treatment for cancer can be safely immunised
with the combined measles, mumps and rubella vaccine (MMR). true

Comments:

A mediastinal mass is typical of T cell acute leukaemia, and can also be a manifestation of T cell non-
Hodgkin's lymphoma.

Side effects of chemotherapy are extremely common and important. They include:

Infection from immunosuppression: neutropenia places children at risk of septicaemia, and there
are specific problems with gram negative organisms, coagulase negative Staph., PCP, and
disseminated fungal infections. Most viral infections are no worse than in other children, but
measles and varicella may be life-threatening. Zoster immunoglobulin may be helpful in non-
immune children who have been in contact with measles or varicella. Acyclovir is used to treat
established varicella infection, but no active treatment is available for measles. The use of live
vaccines in patients receiving chemotherapy should be avoided until at least 6 months to a year

5
 has elapsed following the completion of chemotherapy.
Bone marrow suppression: anaemia requires transfusion, and thrombocytopenia may result in
bleeding.
Gut mucosal damage: this may increase the risk of gram negative infection, and is associated
with painful mouth ulcers, which can prevent eating.

Specific side effects:

- Cardiotoxicity with Doxorubicin.
- Renal failure and deafness with Cisplatin.
- Haemorrhagic cystitis with Cyclophosphamide.
- Neuropathy with Vincristine.
Occasionally, leukaemia may present with thrombocytopenia alone. In patients presenting with a low
platelet count who are thought to have ITP, a bone marrow should be done if steroids are considered, as
they may suppress the leukaemia enough to delay diagnosis

Which of the following is/are true regarding osteoid osteoma

A It is a benign bone tumour false
B The femur and tibia are the commonest bones involved false
C Presents with severe pain that is typically relieved by aspirin false
D Radiologically appears as a radiolucent lesion surrounded by dense bone false
E Local excision or currettage is curative false

Comments:
Osteoid osteoma is a benign tumour that mainly affects young adults. The femur and tibia are the
commonest bones involved. Pain is often the presenting feature and relief by asprin is almost diagnostic.
Xray reveals a radiolucent nidus with a dense rim. Local surgery is curative

Which of the following statements is/are true?

A Babies are able to respond to sounds in utero true
B Full term babies are unable to follow a large object at birth with their eyes false
C A 6-week old infant would be able to follow a large object through an arc of 135
degrees false
D Growth velocity of head decreases with age true
E A 12-month old infant who keeps falling when starting to walk is likely to have
cerebral palsy false

Comments:
Evidence would suggest that fetuses can respond to sounds in utero. Term babies are able to follow
moving objects and by about six weeks this is well developed. Falling when endeavouring to walk at 12
months is perfectly normal.

Regarding diphtheria:
A It is predominantly spread from cutaneous lesions. false
B It is characterised by an inflammatory exudate forming a greyish membrane on
the buccal mucosa. true
C It produces a toxin which affects the myocardium, nervous and adrenal tissues. true
D 3 doses of toxoid provides 75% protection. true
E About 50 cases per year are seen in the UK. false

Comments:

Diphtheria is spread by droplets, through contact with soiled articles (fomites), and, in areas of poor
hygiene, from cutaneous spread. The inflammatory exudate forms a greyish membrane on the tonsils and
respiratory tract which may cause respiratory obstruction. Incubation is between 2 and 5 days, and
patients may be infectious for 4 weeks. The toxin affects the myocardium, nervous and adrenal tissues.

6
The immunisation has been tremendously successful, and most cases seen in the UK are imported from
the Indian subcontinent or Africa. Recently, there has been a worrying epidemic of diphtheria in Russia
and the newly independent states of the former Soviet Union. In 1995, 52,000 cases and 1,700 deaths
were reported.

The following conditions show a predisposition to developing hepatocellular

carcinoma:
A tyrosinaemia. false
B galactosaemia. false
C alpha-1 antitrypsin deficiency false
D hepatitis A. false
E beta-thalaessaemia. false

Comments:
Heptocellular carcinoma is found frequently in conditions where liver cirrhosis is an important feature.
Serum alpha-fetoprotein is raised in up to 80% of cases. Prognosis for children with this condition is poor.
From Hannam et al. MRCP (Paediatrics) Part 1 MCQs. page 139 WB Saunders. Reproduced with
permission.

The following statements apply to a cephalhaematoma in the newborn.

A It usually manifests immediately after birth. false
B The haematoma is formed beneath the periosteum. false
C A common site is over the parietal bone. true
D The treatment of choice is aspiration. false
E Mother can be told it will disappear by the age of four weeks. true

Comments:
It usually manifests several hours after delivery. The haematoma occurs as a result of damage to
capillaries beneath the periostium.They usually require no treatment, but may take up to 3 months to
resolve.

In a normal 6 month old child, the following reflexes are present:

A Grasp reflex false
B Ankle reflex true
C Startle reflex true
D Parachute reflex true
E Tonic neck reflex false

Comments:

The primitive reflexes appear and disappear in sequence during specific periods of development. Their
absence or persistence beyond a given time frame signifies significant dysfunction of the CNS. Some
primitive reflexes such as the rooting reflex, may reappear during old age or with specific degenerative
diseases involving the cerebral cortex. The moro reflex is obtained by placing the child in a semi-upright
position and allowing the head to fall backward momentarily with immediate resupport by the examiners
hand. There is a symmetrical abduction and extension of the arms with flexion of the thumbs followed by a
flexion and adduction of the upper extremities. An asymmetric response may signify a fractured clavicle,
brachioplexus injury or a hemiparesis. Absence of the moro reflex in a term newborn is ominous
suggesting significant CNS dysfunction. The grasp reflex is elicited by placing a finger or an object in the
open palm of each hand. The normal infant will grasp the object and with attempted removal, the grasp is
reinforced. The tonic neck reflex is produced by manually turning the head to one side while supine.
Extension of the arm occurs on that side of the body corresponding to the direction of the face, while

7
flexion develops in the contralateral extremities. An obligatory tonic neck response by which the infant
remains locked in the fencer's position, is always abnormal and implies a disorder of the CNS. The
parachute reflex is demonstrated by suspending the child by the trunk and suddenly producing forward
flexion as if the child were going to fall. The child spontaneously extends the upper extremities as a
protective mechanism. This appears before the onset of walking. Most primitive reflexes disappear
gradually and are absent by 2-3 months.

In a 2 year old boy with meningomyelocele:

A Prophylactic antibiotics are mandatory. false
B Detrusor instability is common. true
C Proteus urinary tract infections may occur. true
D Intermittent catheterisation is usually necessary. true
E Vesico-ureteric reflux is extremely common. true

Comments:

Neurogenic bladder dysfunction is usually caused by a congenital abnormality, such as

meningomyelocele, lipomeningocele, sacral agenesis, or other spinal abnormality. This can result in upper
tract deterioration and urinary incontinence. The lack of co-ordination between detrusor contraction and
sphincter relaxation (a brain stem function) results in functional bladder outlet obstruction, leading to high
intrabladder pressures, VUR, and rapid deterioration of the upper tracts. VUR is present in 30% of
neonates with myelomeningocele, and develops later in a further 20%. Urodynamic studies are necessary
for accurate evaluation of each case. If the bladder is atonic or sphincters are dennovated then bladder
pressure is low and VUR is unlikely. However, urinary stasis increases the chance of infection, and
intermittent catheterisation (and therefore the introduction of more unusual organisms causing urinary
tract infection) increases in frequency. Prophylactic antibiotics are almost always necessary.

Copyright
The following statements regarding classical phenylketonuria (PKU) are
correct:
A eczema is characteristically present in young children with the disease. false
B phenylalanine is not detectable in cord blood in newborn infants with
PKU. false
C dietary restrictions are stopped after the age of 10 years. false
D a pregnant woman with PKU will not put her baby at risk if she is on an
unrestricted diet. false
E vomiting is an early presenting symptom of the disease. true

Comments:
Classical PKU is the result of a deficiency of phenylalanine hydroxylase. Eczema is often present in
younger children, which disappears as the child grows older. Phenylalanine levels may rise to levels
that are detectable by the Guthrie test as soon as 4 hours after birth, even before the ingestion of
protein containing milk. It is recommended that a diet low in phenylalanine is continued for life. It has
been shown that changes in white matter on stopping dietary restrictions are reversible on resumption
of a low phenylalanine diet. It is essential that women with PKU should be on a diet low in
phenylalanine in the preconception period to avoid damaging a normal fetus. From Hannam et al.
MRCP (Paediatrics) Part 1 MCQs. page 19 WB Saunders. Reproduced with permission.

The following suggest Patau's Syndrome rather than Edward's Syndrome:

A Overlapping digits false
B Holoprose encephaly true
C Midline cleft palate false
D Rocker-bottom feet false
E Low-set ears false

8
Comments:

Clinical features of Edward's Syndrome: Small chin, low-set ears, overlapping digits, rocker-bottom feet,
cardiac and renal malformations. Clinical features of Patau's Syndrome: Structural defects of the brain,
scalp lesions, microphthalmia and other eye defects, polydactyly, cardiac and renal malformations.

Which of the following is/are true regarding osteoid osteoma

A It is a benign bone tumour true
B The iliac crest is the commonest site involved false
C Presents with severe pain that is typically relieved by aspirin true
D Radiologically appears as an osteosclerotic lesion false
E Local excision or currettage is curative true

Comments:
Osteoid osteoma is a benign tumour that mainly affects young adults. The femur and tibia are the
commonest bones involved. Pain is often the presenting feature and relief by asprin is almost diagnostic.
Local surgery is curative.

The following conditions may be detectable by growth monitoring:

A Hyperthyroidism true
B Hypothyroidism true
C Pseudohypoparathyroidism true
D XYY Syndrome true
E Insulin dependent diabetes mellitus false

Comments:

Benefits of growth monitoring include:

Early detection of conditions such as:

hypothyroidism.
growth hormone insufficiency.
syndromes: Turners, Russell-Silver, Noonan's, skeletal dysplasias.
growth impairment e.g. coeliac disease, inflammatory bowel disease or chronic renal failure.
intracranial tumours.
short normal children.
children with short stature.
Health promotion: impaired growth may be associated with child abuse or neglect for example.
Focus of interest for parents.

Public health aspects:

secular trend of increasing growth.
linking growth patterns in fetal life and early infancy with adult patterns of disease.

link between height and social circumstances

Long-acting 2 agonists:
A Can be used to prevent activity-induced symptoms without anti-inflammatory
therapy. true
B Become less effective over time (tolerance). true

9
C Are beneficial in acute viral croup. false
D Protect against allergen challenge for up to 48 hours. true
E Should not be used in association with erythromycin. false

Comments:
Long-acting 2 agonists, e.g. salmeterol, can be used twice daily to assist in prophylaxis in chronic
asthma as Step 3 of the British Thoracic Society Asthma Guidelines. There is no evidence that the
bronchodilator effect wanes with time, though there is debate that it may become less effective in
protecting against exercise or methocoline induced bronchospasm. Its duration of action is around 12
hours, and has gone completely by 36 hours. Aminophylline interacts with erythromycin, giving an
increased risk of toxicity. There is no evidence that salmeterol works in viral croup, though oral steroids
are highly effective.Copyright

Chest signs that are reliable diagnostically are found in:

A A neonate with meconium aspiration. true
B A 3 month old child following aspiration pneumonia. true
C A 4 month old child with bronchiolitis. true
D A 6 month old with lobar pneumonia. true
E A 2 year old with inhaled foreign body. true

Comments:

Unfortunately, clinical chest signs are remarkably unhelpful, and in general are less helpful the younger
the child. Although in meconium aspiration chest signs may be found such as coarse crepitations, the
diagnosis is usually on the basis of the general appearance of the child (meconium stained, meconium in
the oro-phayrnx or recovered from the lungs) associated with an appropriate chest x-ray. A 3 month old
with aspiration pneumonia normally presents with a sudden onset of respiratory distress, but focal signs
are often difficult to locate at this age. A child with bronchiolitis, however, has more generalised signs, and
a fairly typical clinical picture. Lobar pneumonia can easily be missed in a 6 month old child, and a chest
x-ray is, therefore, usually included as part of a septic screen. The diagnosis of inhaled foreign body may
be difficult even on x-ray in a 2 year old child

Diffusion capacity of carbon monoxide:

A Is a specific measure of lung perfusion. false
B Depends on the thickness of the alveolar wall. true
C Depends on the surface area available for gas exchange. true
D Is increased in cigarette smokers. true
E Is increased in emphysema. false

Comments:

By Fick's law, the volume of gas diffusing across a membrane equals A/T x D x difference in partial
pressure. In life it is impossible to measure accurately the area (A) or the thickness (T), and these are
subsumed into a single constant, the diffusion capacity for carbon monoxide. DL=volume of transferred
carbon dioxide divided by partial pressure difference between the alveoli and the capillary blood. Since
the capillary blood normally does not contain carbon dioxide this term disappears. Diffusion will be
increased in healthy compared with unhealthy lungs, where the thickness is likely to increase and the
surface area available for gas exchange to decrease. VQ imbalances can indirectly interfere with carbon
dioxide diffusion capacity by decreasing the available area of lung for gas exchange, but it is not a specific
measure of lung perfusion.

Copyright

The following are recognised treatments for complications of cystic fibrosis:

A DNAase to assist in reinflating collapsed lung segments. false

10
B Rectal pull-through and anastamosis for rectal prolapse. true
C Pancreatic transplant for diabetes mellitus. false
D Nebulised tobramycin for pseudomonas colonisation of the lower respiratory
tract. true
E Hypotonic saline drinks for hypernatraemic dehydration. false

Comments:

Human recombinant DNAase given as a single daily aerosol seems to improve pulmonary function,
decrease the frequency of chest exacerbations, and promotes a sense of well-being in patients with mild
to moderate disease with purulent secretions. This may be because, in the inflamed airway, the nuclei
from dead cells accounts for much of the viscidity of secretions. Rectal prolapse is usually idiopathic,
occurring between 1 and 5 years. Intestinal parasites, malnutrition, acute diarrhoea, ulcerative colitis,
pertussis, Ehler's Danlos Syndrome, meningocele, cystic fibrosis, and chronic constipation can also
predispose to it. Following defecation the prolapse usually resolves spontaneously, or through manual
reinsertion by the patient or parent. Nebulised tobramycin or gentamicin may be given when airway
pathogens are resistant to oral antibiotics, or where infection is difficult to control at home. Hypernatramic
dehydration should be treated in the usual way

Which of the following is true regarding rheumatoid arthritis

A Primarily affects the articular cartilage true
B Is associated with the HLA antigens DR4 and DW4 false
C Occurs more often in women true
D The cervical spine is commonly involved false
E Extra-articular manifestations occur in 20% of patients true

Comments:
Rheumatoid arthritis is a disease of the synovial membrane. It results in joint destruction, pannus
formation and periarticular erosion. DR4 and DW4 are associated with diabetes. The female to male ratio
is 3:1. The hand, elbows and knees are the commonest joints involved. Extra-articular manifestations
occur in 20% and include keratoconjuctivitis sicca, episcleritis, pulmonary nodules, pleural effusions,
pericarditis and subcutaneous rheumatoid nodules.

Distal renal tubular acidosis type IV:

A Is characterised by hyperchloraemic acidosis and hypokalaemia. true
B Is characterised by a large anion gap and aminoaciduria. false
C A decreased glomerular filtration rate. false
D Is characterised by the presence of hyponatraemia. true
E Is due to increased reabsorption of hydrogen ions. true

Comments:
Renal tubular acidosis is a clinical state of systemic hyperchloraemic acidosis resulting from impaired
urinary acidification. Three types exist:
Distal RTA (type I).
Proximal RTA (type II).
Mineralacorticoid deficiency (type IV) (a proposed type III was found to be a variant of type I).

Proximal RTA results from reduced proximal tubular reabsorption of bicarbonate, presumably owing to
deficient carbonic and hydrase production or hydrogen iron secretion. There is, therefore and increased
load of bicarbonate reaching the distal tubules, overwhelming the capacity of the distal tubule to reabsorb
it. Up to 25% of a normal filtered load of bicarbonate can be lost in the urine, and proximal RTA is
therefore more severe than distal RTA. Causes of proximal RTA include: cystinosis, Lowe's Syndrome,
galactosaemia, hereditary fructose intolerance, tyrosinaemia, Wilson's Disease, medullary cystic disease.
Distal RTA is a deficiency of hydrogen iron secretion by the distal tubule and collecting duct. There must
thus be a loss of bicarbonate in the urine of upto 10% of the filtered load. The urine pH cannot be reduced

11
below 5.8 despite severe systemic acidosis. The loss of sodium bicarbonate results in hyperchloraemia
and hypokalaemia.
Mineralacorticoid deficiency RTA may result from diseases of the adrenal gland (Addison's, CAH, primary
hypoaldosteronism) in which aldosterone production is deficient. In these disorders renal function is
normal, urine sodium wasting is common, and the plasma renin level is high.

The following are features in infantile autism:

A Auditory hallucinations. false
B Gaze avoidance. true
C Stereotyped movements. true
D Delusions of reference. false
E Can be confused with deafness. true

Comments:
Impairment of verbal and non verbal communication is characteristic of the disease as are stereotyped
movements. Schizophrenic features such as auditory hallucinations and delusions of reference must be
absent.

The following are features of acute intermittent porphyria:

A positive Hoesch test. true
B photosensitivity. true
C autosomal recessive inheritance. true
D diagnosed by the presence of gamma aminolaevulinic acid and porphobilinogen
in the urine. true
E a lack of symptoms until after puberty. true

Comments:
The porphyrias are a group of illnesses caused by a deficiency of one of the seven enzymes involved in
haem biosynthesis. Acute intermittent porphyria is caused by porphobilinogen deaminase deficiency. It is
diagnosed by the presence of gamma aminolaevulinic acid and porphobilinogen in the urine. The Hoesch
test detects porphobilinogen in the urine by turning a cherry-red colour. Symptoms of the illness may start
prior to puberty. From Hannam et al. MRCP (Paediatrics) Part 1 MCQs. page 127 WB Saunders.
Reproduced with permission.

Recognised complications of chickenpox infection include:

A Pneumonitis true
B Pancreatitis false
C Subacute encephalitis false
D Cerebellar encephalitis true
E Erythema marginatum false

Comments:
Complications of chickenpox include:
Superinfection (Staph. and Strep.), which rarely results in varicella gangrenousum, arthritis,
osteomyelitis, and pneumonia.
Encephalitis/ cerebellar ataxia.
Reye's, hepatitis, or pancreatitis.
Thrombocytopenia.
Nephritis, nephrosis, or haemolytic uraemic syndrome.
Myocarditis or pericarditis.
Orchitis.

Pneumonitis (immunocompromised with lymphocyte count < 0.5x109/L, newborn or pregnant

12
Concerning obsessional neurosis:

A Patients have good insight. false

B Patients often give way to aggressive impulses. false
C The occurrence of depression is a recognised feature. true
D Inconclusive rumination is characteristic. false
E There is regularly a history of faulty training in excretory habits. false

Comments:

Obsessive Compulsive Disorder results in repetitive thoughts that invade consciousness, or repetitive
rituals or movements that do not obviously contribute to a high level of adaptation in any given situation.
At times of stress some children touch certain objects, verbalise certain words, or wash their hands
continuously. There is obsession with bodily wastes and secretions, the fear that something calamitous
will happen, or the need for sameness. The most common compulsions are hand washing, continual
checking of locks, and touching. These occur consciously, often causing great distress. There is often
external, ritualised behaviour in an attempt to involve their parents in their compulsions. This may be
measured using he Yale Brown Obsessive Compulsive Scale. Life time prevalence is 1%. Treatment
consists of behavioural therapy and pharmacotherapy.

The following are at increased risk of paralytic poliomyelitis from oral polio
vaccination:
A A 4 year old on chemotherapy for recently diagnosed ALL. true
B A 2 year old child who received a bone marrow transplant for X-linked Severe
Combined Immune Deficiency (SCID), 1 year ago. true
C A 3 year old boy with Di George Syndrome. true
D An 18 month old girl with IgG2 sub-class deficiency. true
E A 7 year old boy with tuberculosis. false

Comments:

Children with a defective immune response to live vaccines can suffer from severe manifestations, such
as BCG-osis, or paralytic polio from vaccine virus. At risk individuals include:

Patients on chemotherapy, or receiving generalised radiotherapy, or following organ or bone

marrow transplant, those receiving immunosuppression. These are at an increased risk for the
first 6 months following these procedures.
Those on Prednisolone >2mg/kg/day for >7 days, or >1mg/kg/day for one month. Occasional
children on lower doses of steroids may have significant immunosuppression, and in cases of
doubt, expert advice should be sought.
Patients with defective cell mediated immunity, including HIV infection, severe combined immune
deficiency, Di George Syndrome. Patients with minor antibody immunodeficiency are not at risk.

For all these individuals, an impaired response to inactivated vaccines may be expected.

The mucous membranes may be affected in the following conditions:

A dermatitis herpetiformis. true
B lichen planus. true
C pityriasis versicolor. false
D Kawasaki's disease. true
E Stevens-Johnson syndrome. true

Comments:

13
Mucous membranes (MM) may be affected by developmental disorders, infection, acute and chronic skin
conditions, genodermatosis, benign and malignant tumours. Dermatitis herpetiformis occasionally has MM
involvement, Lichen planus commonly affects the MM. Other important conditions affecting the MM are:
Kawasaki's disease, Stevens-Johnson syndrome, toxic shock syndrome, mucocutaneous candidiasis and
mucocutaneous leishmaniasis. Some specific conditions of the MM include: Fordyce disease (aberrant
sebaceous glands), geographic tongue, cheilitis, oral thrush and aphthous stomatitis. From Hannam et al.
MRCP (Paediatrics) Part 1 MCQs. page 165 WB Saunders. Reproduced with permission.

The following characteristics of headache suggest space occupying lesion:

A Headache worse lying down true
B Morning vomiting true
C Changes in personality true
D Outbursts of rage true
E Focal neurological signs true

Comments:

The cardinal feature of an intracranial space-occupying lesion is that the headache is made worse lying
down (whereas in migraine and in other headaches lying down assists it). Morning vomiting is
characteristic, and there may be changes in personality or school performance. There may be localising
neurological signs, and growth and visual fields may be affected in craniopharyngioma. Cerebellar signs
suggest a posterior fossa tumour and cranial nerve abnormalities, a brain stem tumour. Occasionally
cranial bruit may be heard in AV malformations. Papilloedema may be present, but can also represent
benign intracranial hypertension.

Copyright

According to the 1989 Children Act the following principles and provisions are
applicable if child abuse is suspected:
A an emergency protection order lasts for 8 days. true
B a child assessment order allows a child to be taken into local authority care. true
C the welfare of the child is paramount. false
D the length of an emergency protection order cannot be extended. false
E a child assessment order can be granted by a local authority. true

Comments:
In the 1989 Children Act it is stated that the welfare of the child is paramount. An emergency protection
order allows a child to be taken into care and lasts for 8 days. It may be extended at the discretion of the
court for a further 7 days. After 3 days the parent or the child may challenge the order. A child assessment
order allows medical or psychiatric examination to be carried out. A ful court order is necessary. If the
parents or carers do not cooperate, the assessment order may be converted to an emergency protection
order. From Hannam et al. MRCP (Paediatrics) Part 1 MCQs. page 81 WB Saunders. Reproduced with
permission.

Features of Downs syndrome include all of the following except:

Available marks are shown in brackets
1) A third fontanelle. [0]
2) Duodenal atresia. [0]
3) Ataxic gait. [100]
4) Increased incidence of hypothyroidism. [0]
5) Susceptibility to acute leukaemia [0]

Comments:
Cerebellar dysfunction is not a feature of Downs syndrome, however an Alzheimers like syndrome of
memory loss and cognitive decline develops when patients reach the mid thirties.

14
At first examination, a neonate is noted to have hypospadias:
A The defect occurs in the anterior penile area in 65% of cases. false
B Surgery should be undertaken around puberty when penile growth is complete. false
C A chordee is usually present. true
D The incidence of hypospadias is approximately 0.3% of male infants. true
E Circumcision should be performed to minimise the risk of urinary tract infection. false

Comments:
The abnormalities associated with abnormal opening of the urethral meatus include:
A hooded prepuce (foreskin formed completely only on the dorsum).
Chordee: ventral curvature, present only in the worst cases. The incidence is 0.3% of males, and
surgery is usually undertaken before the age of 2 in order to create a terminal urethral meatus,
and a straight erection.

The foreskin is essential for surgical correction, and should always be preserved

Which of the following statements are true of childhood asthma.

A over 90% of patients show exercise-induced bronchoconstriction false
B hypercapnia is the first physiological disturbance in status asthmaticus false
C infants are unresponsive to bronchodilators false
D spontaneous cure occurs before adolescence true
E cough may be the only symptom true

Comments:
Exercise induced symptoms occur in approximately 90% of cases of childhood asthma. Hypoxia is the
first typical feature of severe asthma with hypercapnia occurring late and is a particularly worrying sign
indicating the requirement for ventilation. As a consequence of immature bronchiole musculature, infants
are unresponsive to bronchodilators.

Erythema nodosum:
A is characterized by red, tender nodules over the forearm. false
B is a recognized feature of tuberculosis. true
C commonly occurs in inflammatory bowel disease. true
D may be associated with viral infections. true
E is characterized by target lesions. false

Comments:
Erythema nodosum is characterized by red tender nodules over the tibia but may also appear on the
thighs and forearms. Erythema nodosum is shiny and hot and can be surrounded by bruising. Causes
include idiopathic, viral infections, streptococcal infections, ulcerative colitis and Crohn's disease.
Erythema nodosum rarely occurs in inflammatory bowel disease. Target lesions refer to the rash seen with
erythema multiforme. From Hannam et al. MRCP (Paediatrics) Part 1 MCQs. page 7 WB Saunders.
Reproduced with permission.

Chikenpox is associated with the following:-

A pnemonitis true
B pancreatitis true
C subacute sclerosing panencephalitis false
D erythema marginatum false
E cerebellar encephalopathy true

15
Comments:
a-Commoner in adults, resolves with the rash however impaired pulmonary function may last months. b-
Mumps. c-Measles. d-Rheumatic fever. e-acute cerebellar ataxia - commonest extracutaneous site in
children. Appears 21 days after rash.

'Endogenous' rather than 'neurotic' depression is suggested by:

A Marked weight-loss. false
B Delusions of guilt. true
C The depression being worst in the morning. true
D Difficulty in falling asleep. true
E Psychomotor retardation. true

Comments:
Reactive depression is a mood neurosis precipitated by external events, where as an endogenous
depression is an internal state.Copyright

Which of the following statements is/are true regarding atopic eczema.

A Often presents in early childhood. true
B May be familial. true
C Is commonly associated with asthma. true
D Commonly requires treatment with oral steroids. false
E Can be confused with scabies. false

Comments:
The onset is commonly in infancy, and it is associated with a history of asthma, eczema and hayfever in
the family. Topical rather than oral steroids are used sparingly for unresolved symptoms.

Regarding neural tube defects:

A The neural tube is usually formed during the 6th-8th week following conception. false
B The risk is reduced in mother's whose diets are supplemented with Vitamin B12. false
C Spina bifida occulta may be accompanied by diastematomyelia. true
D Associated Arnold Chiari malformation may result in hydrocephalus. true
E Intermittent urinary caterterisation may be required. true

Comments:

Neural tube defects result from failure of fusion of the neural plate to form the neural tube during the first
28 days following conception, before many women realise they are pregnant. Incidence has fallen
dramatically partly due to screening and partly related to improved maternal nutrition. Folic acid
supplementation markedly reduces the risk. Anecephalics are normal detected on antenatal ultrasound
scan or because of raised alphafeta protein, and termination is usually performed. If not, they are born
stillborn or die shortly after birth. An encephalocele is an extrusion of the brain and meninges through a
midline skull defect, which although correctable surgically, is often associated with other cerebral
malformations. Spina bifida occulta is usually asymptomatic and an incidental finding on x-ray, but may be
associated with overlying lipoma birthmark or tuft of hair. There may be underlying diastematomyelia
which causes bladder or lower limb dysfunction as the child ages. Meningoceles contain CSF but not
spinal cord, and usually have a good prognosis following surgical repair. In the meningomyelocele, the
spinal cord is involved , and consequently, there is variable paralysis of the legs, with sensory loss
affecting particularly bladder and bowel dysfunction. Scoliosis is common, and hydrocephalus can occur
because of the Arnold Chiari malformation (herniation of the cerebellar tonsil through the foramen
magnum) causing CSF accumulation. Indwelling catheters or intermittent catheterisation may be required
for neuropathic bladder.

Hodgkin's Disease:

16
A Is the commonest lymphoma in the childhood. true
B Requires a laparotomy and splenectomy for complete staging. true
C Chemotherapy results in sterility for males. true
D Chemotherapy results in sterility for females. true
E Can be treated with radiotherapy alone. false

Comments:
Lymphomas account for 12% of all childhood cancers in the UK, and are the third commonest overall.
Non-Hodgkin's lymphomas predominate. The age incidence of Hodgkin's is bimodal, with an early peak in
the late 20's and the second peak after 50 years. There may be a familial occurrence, and EBV may be
implicated in pathogenesis. The cardinal histological feature is the Reed-Sternberg cell, which has 2
nuclei, and is diagnostic of Hodgkin's Disease. Sub-types include:
Nodular sclerosing (50%).
Mixed cellularity (40%).
Lymphocyte predominant (10%).
Lymphocytic depleted (rare).

Presentation is usually with painless enlargement of lymph nodes, especially cervical. These are firm,
non-tender and discrete. Mediastinal lymph node is common, producing cough or other symptoms of
airway compression.
Staging:
Stage 1: Iinvolvement of a single lymph node region or of a single extra-lymphatic organ or site.
Stage 2: Involvement of 2 or more lymphoid regions on the same side of the diaphragm, or
localised involvement of an extra-lymphatic organ or site and of one or more lymph node regions
on the same side of the diaphragm.
Stage 3: Involvement of lymph node regions on both sides of the diaphragm -/+ localised
involvement of extra-lymphatic organ or site or by splenic involvement.
Stage 4: Diffuse of disseminated involvement of one or more extralymphatic organs or tissues -/+
associated lymph node enlargement.

Stages are further categorised as A or B based on the absence or presence respectively of systemic
symptoms of fever -/+ weight loss. Both radiation and chemotherapy are highly effective. With modern
treatment more than 90% of patients achieve an initial complete remission. Pelvic irradiation can cause
sterility despite ovarian and testicular shielding. Second malignant tumours occur in about 10% of cases.

A 2 year old child should be able to

A name three colours correctly false
B use plurals false
C build a tower of five blocks true
D kick a ball on request true
E hop on one foot false

Comments:
A 2 year old child would be able to build a tower of 6-7 blocks and kick a ball without losing balance and
organise phrases of 2-3 words. Naming of three colours would be expected by aged 5, amd use plurals
would be expected by age 3. Hop on one foot should be achieved by aged 4.

The following strategies are important in promoting the development of

language:
A Practice at listening. true
B Making sure that children learn only from professionals. false
C Rhyming games. true
D Unstructured communication. false

17
E Carefully controlled manipulation of child/adult interactions. true

Comments:

A few children have difficulties with speech and language because of genetic or prenatal factors, others
are slow because of inadequate stimulation at home. In most cases neither of these apply. Individual
variation in maturation, learning style and temperament may account for much of the difference between
children. A carefully controlled manipulation of child/adult interactions, structured communication in groups
and day nursery, practice at speaking, listening, reading and writing, including rhyming games and
reading are thought to be helpful in promoting language development.

Copyright 2002 Dr Colin Melville

Antibodies cross the placenta causing disease in the fetus/neonate in the

following conditions:
A dystrophica myotonica. false
B diabetes insipidus. false
C hyperthyroidism. true
D myasthenia gravis. true
E idiopathic thrombocytopenic purpura. true

Comments:
Infants born to mothers with dystrophica myotonica are likely to be affected with the condition but not as a
result of antibody transfer. Mothers who have been thyrotoxic will have circulating IgG antibodies that may
affect the neonate. About 10% of infants born to mothers with myasthenia gravis are affected by an IgG
antibody. Autoimmune thrombocytopenia occurs in neonates of mothers who suffer from idiopathic
thrombocytopenic purpura. Mothers who are Zwb antigen negative can produce an IgG antibody to Zwa
antigen (present in 98% population). This can cause an isoimmune neonatal thrombocytopenia. From
Hannam et al. MRCP (Paediatrics) Part 1 MCQs. page 165 WB Saunders. Reproduced
Concerning Hodgkin's Disease:
A Is diagnosed by finding Reed-Sternberg cells in biopsy specimens. true
B Prognosis is poorer when nodular sclerosis is present. false
C Impaired cellular immunity is present. true
D It is associated with bone pain. false
E It is associated with autoimmune haemolytic anaemia. false

Comments:
The age incidence of Hodgkin's Disease is bimodal, with an early peak in the 20's and a second peak
after the age of 50. EBV may be implicated in pathogenesis. The cardinal histological feature is the
Reed-Sternberg cell. Sub-types include: nodular sclerosing (50%), mixed cellularity (40%),
lymphocyte predominant (5%), lymphocyte depleted (<10%). The commonest presentation is painless
enlargement of cervical or supraclavicular lymph nodes. Nodes are firm, non-tender and discrete.
Mediastinal lymph node enlargement is common, and 33% have non-specific symptoms such as
fatigue, pruritis, urticaria, pain that worsens with ingestion of alcohol, lethargy, and anorexia.
Unexplained fever, weight loss of at least 10% in the last 6 months, night sweats are systemic
symptoms useful in staging. Rare presentations include biliary obstruction, bone marrow involvement
(pancytopenia), spinal cord compression, and immune diseases such as autoimmune haemolytic
anaemia, thrombocytopenia or nephrotic syndrome. Cellular immunity is impaired. Staging is
important in prognostication. Treatment involves radiation and chemotherapy, and is highly effective.
Copyright 2002 Dr Colin Melville

The following confirm a urine infection in an infant:

A A bag urine specimen containing 300 white cells and >105 E. Coli per mm3. true
B White cells and 103 E. Coli per mm3 in a suprapubic aspirate. true
C Two bag urines growing >105 E. Coli. true

18
D Catheter specimen of urine containing 60 white cells and >105 E. Coli. true
E Positive nitrite in a bag urine specimen. false

Comments:
The diagnosis of a urinary tract infection is confirmed by a positive catheter or suprapubic aspirate of
urine. Bag urines are only useful in excluding infection if negative. Any number of gram negative bacteria
and an SPA indicates infection, though a small number of gram positive cocci may represent skin
contaminants. Even the absence of leukocytes does not exclude infection. In infancy, 33% will have
positive blood cultures, and a few may have meningitis concurrently. A negative nitrite test is a good way
of ruling out infection, but not diagnosing it.Copyright 2002 Dr Colin Melville

The following are characteristic of acute hepatitis B:

A Most patients present with splenomegaly. false
B It confers immunity to hepatitis A. false
C It commonly presents with distal joint arthritis. true
D There is increased infectivity in the presence of the e antigen. true
E Pruritis is an important early symptom. false

Comments:
Clinical features of hepatitis B are as follows:
1. Most are asymptomatic.
2. Symptoms: Lethargy, anorexia, arthralgia, rash (any type), papular acrodermatitis (Gianotti
Crosti), polyarthritis, glomerulonephritis, aplastic anaemia. 25 % have jaundice.

3. Complications: Acute fulminent hepatitis. Chronic hepatitis. Membranous glomerulonephritis.

Hepatitis E antigen is present in the acute phase and indicates a highly infectious state. Pruritis
is characteristic of chronic hepatitis.

Lesions in the following may cause weakness of finger movements:

A Contralateral motor cortex true
B Inferior cerebellar peduncle false
C Thalamus false
D Inferior parietal lobule false
E Pre-central area false

Comments:

Weakness of finger movements may result from lesions anywhere in the motor pathway form the cortex to
the fingertips. This includes the motor cortex (precentral area), the internal capsule, a path through the
brainstem to the decosation of the pyramids, the posterior columns, the anterior horn cells, the lower
motor neurone, or the motor N plates in the muscles cells.

A 2 month old boy presents with possible meningitis. If the CSF findings are as
follows, the given interpretations are reasonable:
A 20 white cells/mm3 - normal false
B Glucose of 0.2mmol/L - TB meningitis false
C 250 lymphocytes - bacterial meningits false
D Protein of 2gm/L - viral meningitis true
E CSF glucose of 67% of blood glucose - viral meningitis false

Comments:

In the premature neonate, up to 25 mononuclear cells or 10 polymorphs may be seen in the CSF. In term

19
newborns, up to 20 mononuclear cells or 10 polymorphs may be seen. In the neonatal period, up to 5
mononuclear cells or 10 polymorphs may be seen. Thereafter, more than 5 mononuclear cells should be
considered abnormal. CSF protein levels are considerably higher in the premature or newborn infant, with
levels upto 3g/L in the former and 1.2g/L in the latter. In older children, levels above 0.4g/L should be
considered abnormal. CSF glucose levels are normally >50% of those in the blood. They are normal in
viral meningitis, reduced in bacterial meningitis, and may be extremely low in TB meningitis.

In children with Down's syndrome:

A the infant is usually hypertonic. false
B asthma is more common. true
C most mothers are over 35 years of age. true
D karyotyping is always indicated. true
E brachycephaly is characteristic. true

Comments:
Infants with Down's syndrome (trisomy 21) are commonly hypotonic at birth. Brachycephaly a consistent
clinical feature. Owing to cases of Down's syndrome where a translocation has occurred, karyotyping
should always be carried out in order to assess the recurrence risk in parents and other family members.
From Hannam et al. MRCP (Paediatrics) Part 1 MCQs. page 47 WB Saunders. Reproduced with
permission.

A 3 year old boy presents with fever and headache. He has received oral
Amoxycillin for 3 days. The following CSF findings exclude a partially treated
meningitis:
A Negative gram stain false
B A CSF glucose of 45% of blood glucose false
C A white cell count of 50 false
D A negative CSF culture false
E Negative Kernig's Sign false

Comments:

The assessment of children with suspected bacterial meningitis who have already received antibiotic
therapy is a diagnostic conundrum. This applies to about 25-50% of children, so it is an important
problem. Partial treatment may reduce the incidence of positive CSF gram stains to <60%, and it also
reduces the ability to grow the bacteria, particularly meningococcus. CSF glucose, protein, neutrophils
and bacterial antigen testing or PCR should be completely unaffected.

Renal damage is a recognised complication of infection with:

A Plasmodium falciparum true
B Schistosoma haematobium true
C Plasmodium malariae true
D Leptospira icterohaemorrhagica false
E Mycobacterium leprae false

Comments:
c-Immune complex injury during chronic or repeated infections.

Prolongation of PT, TT, and APTT in a newborn may be due to:

A Haemorrhagic disease of the newborn. true
B DIC. true

20
C Heparin in the tube. false
D Afibrinogenaemia. false
E Factor XIII deficiency. false

Comments:
The prothrombin time measures factors I, II, V, VII and X (extrinsic pathway), while the APTT measures
factors I, II, V, VII, IX, XI and XII (intrinsic pathway). The thrombin time is a measure of fibrinogen function
and concentration. Haemorrhagic disease of the newborn is due to vitamin K deficiency and hence
associated with a prolonged PT. Some laboratory APTT assays are also sensitive to the vitamin K
dependent clotting factors and hence the APTT may also be prolonged. Fibrinogen is normal in neonates
and hence the TT should not be prolonged. DIC and heparin affect all 3 assays. Afibrinogenaemia
prevents clot formation and as all 3 assays measure time to clot formation, it will affect all 3 assays.
Factor XIII deficiency is associated with abnormal clot solubility and all clotting tests are normal.Copyright

The following are associated with neonatal hypoglycaemia:

A Septicaemia false
B Respiratory distress syndrome false
C Rhesus incompatibility false
D Maternal beta blockers false
E Intravenous hydrocortisone false

Comments:
Neonatal Transient: Inadequate substrate (SGA, permaturity) Hyperinsulinism (IDM,
erythroblastosis fetalis) Septicaemia
Neonatal Persistent: Hyperinsulinism (Beckwith, nesidioblastosis) Hormone deficiency
(panhypopit, ACTH, GH, cortisol, adrenaline) Substrate limited (ketotic hypoglycaemia, MSUD)
Glycogen storage diseases Disorders of gluconeogenesis (alcohol, aspirin, hyperglycaemia)
Other: GIPUT

Disorders of fat (alternative fuel): 1st and 2nd carnitine deficiency, long medium and short- chain
fatty acid oxidation defects.

The following haematological disorders are inherited as autosomal recessive

conditions:
A Antithrombin III deficiency true
B Protein C deficiency true
C Glucose-6-phosphate dehydrogenase deficiency false
D Pyruvate kinase deficiency true
E Acute intermittent porphyria false

Comments:

Anti-thrombin 3 (AT3) is a plasma inhibitor protein that blocks the enzymatic activity of some serrin
proteases coagulation factors. The activity of this inhibitor in increased by heparin. AT3 is synthesised by
the liver, is not Vitamin K dependent, and can be consumed during DIC. Normal newborns have a
reduced activity. Congenital AT3 deficiency is an autosomal dominant. Treatment of thrombotic in these
events in these patients may be difficult.

Protein C is an inhibitor that once activated inhibits clot formation and enhances fibrinolysis. It is liver
synthesised and Vitamin K dependent. Protein C is converted to an active enzyme by a thrombin-
thrombomodulin complex on the endothelial cell surface. Activated protein C inhibits a plasminogen
activator inhibitor, which results in enhanced fibrinlysis, and, with protein S as a co-factor, inhibits the
clotting of the activated factors 5 and 8 by limited proteolosis. Activated protein C thus controls the
conversion of factor 10 to 10a and prothrombin to thrombin. Congenital deficiency is an autosomal

21
dominant trait. Acquired deficiency may occur in association with infection.

Glucose-6-phosphate dehydrogenase deficiency is the most important disease of the pentose phosphate
pathway, and is responsible 2 clinical syndromes: an episodic haemolytic anaemia induced by infections
or certain drugs, and a spontaneous chronic non-spherocytic haemolytic anaemia. The deficiency is X-
linked, and heterozygous females are resistant to falciparum infections. There are a large number of
abnormal alleles causing disease of vastly different severity.

Pyruvate kinase deficiency is a rare congenital haemolytic anaemia inherited as an autosomal recessive.
Generation of ATP within the red cell is impaired resulting in an abnormally high concentration of 2,3,DPG
in the red cell, which inhibits the enzymes of the pentose phosphate pathway. Clinical manifestations vary
from severe neonatal haemolysis, to a mild well compensated haemolysis first noted in adulthood.

Acute intermittent porphyria is an autosomal dominant disorder resulting from partial porphobilinogen
deaminase deficiency in the cytosol of all tissues including erythrocytes. Clinical expression of the disease
is linked to environmental or acquired factors such as nutritional status, drugs, steroid or chemicals. The
major abnormality is of the peripheral, autonomic or CNS. Major symptoms are abdominal pain, nausea,
vomiting, constipation or diarrhoea. In severe cases the urine develops a port wine colour due to the high
content of porphobilin, an auto-oxidation product of PBG. Hypertension and neuropathy are common, with
muscle weakness, cranial nerve abnormality and seizures.

Inability to do which of the following in a 20 month child is cause for concern?

A Speak in clear two to three word phrases false
B Walk unaided false
C Kick a ball false
D Build a tower of 8 blocks false
E cooperate with dressing true

Comments:
A and C should be present by 2 years. Walking unaided by 18 months. D should be present at 30 months.
Helping to dress should be present by this age.

Features which may be seen on the blood film of a patient with haemolysis
include:
A Polychromasia true
B Howell Jolly bodies false
C Elliptocytes true
D Target cells true
E Heinz bodies true

Comments:
The following are common abnormalities of red cell morphology:
Polychromasia: younger cells have a bluish tinge (basophilia), and are larger than average, and
may contain residual nuclear material (reticulocytes). The presence of many basophilic forms in
a blood film produces a multicoloured effect known as polychromasia.
Microcytosis indicates small red cells, anisocytosis variation in size, and macrocytosis a large
size. Poikilocytosis indicates altered shape.
Spherocytes may indicate hereditary spherocytosis, and may also be found in acquired
haemolytic anaemias, while elliptocytes are found in hereditary elliptocytosis.
Schistocytes are fragments of red cells, as seen in DIC or haemolytic uraemic syndrome.
In splenic dysfunction: target cells and red cells containing nuclear fragments known as Howell
Jolly bodies are seen. Pappenheimer bodies are iron containing inclusions, and when seen
together with Howell Jolly bodies suggest previous splenectomy or reduced splenic function.

Heinz bodies: are denatured haemoglobin which result from deficiencies of enzymes of the

22
 penthose phosphate pathway. This damages the red cell leading to haemolysis and removal of
them by the spleen.

The following are virtually diagnostic of physical abuse.

A Bruising on the pinna. true

B A bite radius less than 3cm. true
C Injuries inconsistent with the child's stage of development. true
D A history that is lacking in detail. true
E Torn frenulum. true

Comments:

Most injuries follow genuine accidents and must be differentiated from those which are inflicted
deliberately. In the history, it is important to visualise the event. In child abuse, the history may be
inconsistent with the injuries found, and there may be a delay in reporting the injury. The history may be
inconsistent from different people, and the reactions of parents may be inappropriately vague, elusive,
unconcerned, distressed or aggressive. A vague history may also be found if the parents are educationally
subnormal. The injuries may be recurrent and of different ages, and inconsistent with the child's stage of
development. Particular patterns of bruising may be helpful: Bruises on the face, back and buttock are
uncommon in accidental injury. Fingertip bruising around the trunk, spine, mouth or arms, and slap marks
to the face or buttocks are suggestive, as are bruises outlining a particular assault weapon, e.g. belt or
flex.

Human breast milk:

A has a sodium concentration of >20 mmol/l. false

B is associated with prolonged neonatal jaundice, and if so breast feeding must be
discontinued. false
C in infant feeding decreases the likelihood of developing atopic disease in
childhood. true
D has a lower carbohydrate content than cow's milk. false
E has a lower casein to lactalbumin ratio than cow's milk. true

Comments:
It is important to know about the basic composition of milks and in particular the main differences between
human breast milk and unmodified cow's milk. In addition it is useful to know the composition of a
common formula milk and a special preterm formula. Unmodified cow's milk has a high sodium content
(>20 mmol/l), whereas in breast and standard formula milks this is low (approx. 6 mmol/l). Cows milk also
has a high concentration of potassium, calcium and phosphate. The preterm formulae have a higher
sodium content (approx. 14 mmol/l) and more calories, reflecting the increased sodium losses of preterm
infants and their greater calorific requirements. Breast , standard formula and preterm formula milks have
a higher carbohydrate and lower protein content than unmodified cow's milk. Breast milk is associated
with neonatal jaundice since it contains oestrogens (3-alpha, 20-beta-pregnanediol) and non-esterified
long chain fatty acids which inhibit glucuronyl-1-transferase. There is increasing evidence that breast
feeding decreases the likelihood of developing atopic disease, particularly if the mother avoids consuming
dairy products or other likely allergens. From Hannam et al. MRCP (Paediatrics) Part 1 MCQs. page 49
WB Saunders. Reproduced with

It is considered safe to breast feed when the mother is on the following drugs:

A amiodarone false
B warfarin false
C ciprofloxacin true
D rifampicin true

23
E sodium valproate false

Comments:
Amiodarone is present in the milk in significant amounts and should be avoided. Warfarin is safe but
phenindione should be avoided. High amounts of ciprofloxacin appear in the milk so should be avoided.
Rifampicin and sodium valproate are excreted in breast milk in too small quantities to be harmful. From
Hannam et al. MRCP (Paediatrics) Part 1 MCQs. page 157 WB Saunders

The following findings in the first week of life require investigation:

A erythema toxicum neonatorum. false

B subconjunctival haemorrhage. false
C a bulging fontanelle. true
D failure to pass meconium in the first 48 hours in a term infant. true
E a squint. false

Comments:
Erythema toxicum is a common rash of unknown aetiology which does not require investigation.
Conjunctival haemorrhages commonly result from birth trauma and frequently seen in the first week of life.
A bulging fontanelle can be due to raised intracranial pressure, meningitis, intracranial bleeds or
hydrocephalus. Most term infants pass meconium in the first 24 hours. Delay beyond this period can
occfur in cystic fibrosis, bowel atresia and Hirschsprung's disease. Full conjugate eye movement has
usually developed by 6 months. In the first weeks of life squints are common and are usually of no
consequence. From Hannam et al. MRCP (Paediatrics) Part 1 MCQs. page 27 WB Saunders.
Reproduced with permission.

A baby girl was born at 32 weeks gestation weighing 1.2kg. Primary

immunisations should be given as follows:

A DPT at a corrected age of 2, 3 and 4 months. false

B BCG at 6 weeks of age. false
C Hepatitis B vaccination at birth, 1 month and 6 months of age. false
D MMR at 9 months of age. false
E Hib at 2, 3 and 4 months of age. true

Comments:

Premature babies should be immunised at chronological rather than corrected age. They should receive
the normal immunisation schedule which consists of:

DPT, Hib and Polio at 2, 3, and 4 months of age.

MMR at 10 - 12 months of age.
Booster DT and Polio at 3 - 5 years of age, along with second dose of MMR.
BCG in infancy or between 10 and 14 years of age.
Booster DT and Polio at 13 - 18 years.

For children who are on the neonatal intensive care unit, oral polio vaccine should be deferred, with the
first dose being given on discharge from hospital, and the second and third doses being given at monthly
intervals thereafter.

A presumed male child of 6 years has apparent hypospadias and no palpable

testes. The following would be in favour of the child being female:-

A buccal mucosa chromatin -ve false

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B high urinary 17-ketosteroid excretion true
C pubic hair present false
D abnormally tall stature false
E retarded bone maturation false

Comments:
a - females have a barr body b,c,d - suggest CAH and virilization e - not a feature at this age, would
expect advanced bone age in a female.

The following are true regarding maternal depression:

A In low income, deprived populations, up to 40% of mothers are depressed. true

B The impact on girls is more than on boys. true
C Postnatal depression is easily recognised. false
D Acute purpural psychosis has an incidence of 1-2 per 1000 births. false
E Up to 2% of mothers are or become depressed within the 3 months of giving
birth. true

Comments:

Depression and mood disorders are common among mothers of young children, and in low income,
deprived populations, up to 40% of mothers are depressed, while one sixth have severe psychiatric
disturbance. Adverse effects on the child include an increased risk of accidents, a complex adverse
impact on behaviour, cognition and emotional development affecting particularly boys. The risk of SIDS
and child abuse are increased. Three patterns of postnatal depression are recognised:

Baby blues (usually transient and self-limiting) affecting 50% of mothers.

Acute purpural psychosis affecting 1-2 per 1000 births.
Depression with a large reactive component.

The first 2 are related to hormones and have no relationship to socio-economic status, while the third is
commoner in lower social classes. Identification may be extremely difficult, and up to 50% of cases are
missed unless formal enquiries are made. The Edinburgh Postnatal Depression Scale can be used as a
screening test, although it only picks up about 50% of cases. Loneliness may be a factor in some.

Regarding the red cell:

A Carbon Dioxide binds with reduced haemoglobin. true

B The oxygen affinity of haemoglobin is decreased in the presence of acidosis. true
C The oxygen affinity of fetal haemoglobin is greater than adult haemoglobin. true
D Carbonic anhydrase is present in all red cells. true
E Most carbon dioxide in venous blood is transported bound to albumin. false

Comments:
Carbon dioxide is carried in the blood in 3 forms:
Dissolved (10%).
Bicarbonate, whose formation is encouraged by carbonic anhydrase present in the red cell.
As carboamino compounds: hydrogen irons liberated from the bicarbonate reaction are bound to
haemoglobin which encourages the release of oxygen, since reduced haemoglobin is less acid
than the oxygenated forms.

Thus, the presence of reduced haemoglobin in the peripheral blood helps with the loading of carbon
dioxide, while the oxygenation which occurs in the pulmonary capillary assists in the unloading of it. The
fact that the deoxygenation of the blood increases its ability to carry carbon dioxide is often known as the

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Haldane effect.
Fetal haemoglobin contains g polypeptide chains in place of the b-chains of Hb A. Its resistance to
denaturation by strong alkali is used in its quantitations. Hb F is the predominant haemoglobin from 8
weeks gestation, and constitutes 90% of the total haemoglobin of the 6 month fetus. At birth 70% of the
total is Hb F, and synthesis decreases rapidly postnatally, such that by a year, only 2% is present. Hb F
has a greater oxygen affinity than Hb A, so the growing fetus is preferentially ourished by oxygen in utero.

Which of the following is/are correct of undescended testes

A 75% of undescended testes descend in the first year of life true

B Is associated with a reduced risk of testicular malignancy false
C Is associated with an increased risk of infertility true
D Surgery should be considered in the neonatal period false
E Laparoscopy is indicated for impalpable testes true

Comments:
Undescended testes affect 3% of full-term boys. However, the majority of these lie in the inguinal canal
and approximately 75% of undescended testes descend into the scrotum during the first year of life.
Undescended testes are associated with an increased risk of testicular malignancy which develops in 5%
of intra-abdominal testes. Overall, 80% of males with bilateral descended testes are fertile but only 30% of
men with bilateral undescended testes have normal fertility. Surgery should be performed during the
second year of life. Boys with a palpable testis should undergo a routine orchidopexy. Impalpable testes
should be assessed with laparoscopy.

The following statements are true:

A secretion of parathyroid hormone (PTH) is stimulated by increased ionized
calcium levels in extracellular fluid. false
B vitamin D increases calcium and phosphate mobilization from bone. true
C vitamin D increases calcium and phosphate absorption from the intestine. true
D PTH increases reabsorption of phosphate from the proximal renal tubule. false
E calcitonin is secreted by thyroid C-cells. true

Comments:
PTH is stimulated by low levels of ionized calcium in extracellular fluid. It leads to increased mobilization
of calcium and phosphate from bone and increases calcium from the distal renal tubule. PTH also inhibits
reabsorption of phosphate from the proximal renal tubule. The biologically active form of vitamin D (1,25-
hydroxycholecalciferol) increases mobilization of calcium and phosphate from bone and increases gut
absorption of calcium and phosphate. Calcitonin is secreted by thyroid C-cells and inhibits bone
resorption in response to increased calcium. From Hannam et al. MRCP (Paediatrics) Part 1 MCQs. page
141 WB Saunders. Reproduced with permission.

Physiological jaundice in the full term newborn infant is associated with:

A Urobilinogen in the urine. true
B Large doses of Vitamin K. false
C Pregnanediol in breast milk. false
D Reticulocytosis. false
E Itching in the infant. false

Comments:
Physiological jaundice in the newborn occurs in 90% of infants and is a result of increased rate of red cell
breakdown and hence bilirubin accumulation secondary to impaired hepatic clearance

The following investigations are useful in locating an ectopic testis:

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A Radionucleotide scan true
B Ultrasound scan true
C Testosterone response to HCG false
D Abdominal x-ray false
E Chromosomes false

Comments:

If the testis is ectopic then it may be palpable outside the normal line of descent. However, in obese boys,
ultrasound may be useful in identifying its location. Radionucleotide scans and x-rays should be avoided,
and hormonal testing may be useful in cases of bilateral impalpable testes to detect the presence of
testicular tissue within the body. Laparoscopy is the investigation of choice if the testes are impalpable to
determine whether they are absent or intra-abdominal.

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The following diagnoses can be reliably made on antenatal ultrasound

performed before 20 weeks:

A Spina bifida occulta false

B Gastroschisis false
C Ventricular septal defect false
D Gestational age false
E Down's Syndrome false

Comments:

Gestational age can be reliably estimated if performed before 20 weeks, but after this the margin for error
increases. Multiple pregnancies can be identified. Up to 70% of major structural abnormalities can be
identified, and more detailed scans and specialist centres arranged. Fetal growth can now be reliable
measured from serial abdominal circumference by parietal diameter and femur length. Oligohydraminos
and polyhydraminos can also be diagnosed. Although specialist centres can reliably diagnose major
cardiac malformations, VSD can be very difficult to detect. Mutual fold thickness is being investigated as a
possible means of making a diagnosis of Down's Syndrome, but this is not generally available or
accepted.

Recognised features of infectious mononucleosis include:

A Palatal petechial haemorrhages true
B Aseptic meningitis true
C Vesicular rash on neck and trunk false
D Raised asparatate amino transferase true
E Splenomegaly true

Comments:
Incubation period of infectious mononucleosis is 30-60 days. Results of infection:

1. Asymptomatic (most)

2. Simple infection: fever, malaise, headache, myalgia, worsening sore throat abdominal pain.
Splenic enlargement in 50% to 2-3cm. 90% have lymphadenopathy and 10% liver enlargement.
Severe pharyngitis with exudate and petechiae is often present, and maculopapular rash will
occur in 80% given Amoxycillin.
3. Complications:

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 Splenic rupture with trauma (<0.2%).
Stridor or respiratory distress, which may be treated with steroids.
CNS: ataxia, fits, Alice in Wonderland Syndrome, Guillain Barre.
Haematology: Haemolytic anaemia, aplastic anaemia.

Other: Myocarditis, intesitial pneumonitis, pancreatitis, parotitis and orchitis.

A 7 year old girl presents with acute cough and wheeze, and is given nebulised
salbutamol. The following are indications for admission to hospital:
A A peak flow rate of 80% of that predicted for height. true
B Continuing cough. true
C Respiratory rate of 40/min. true
D Saturation of 90% in air. true
E She looks tired. true

Comments:

Patients should be given nebulised bronchodilator therapy, and admitted if:

1. They have not responded clinically.

2. They are exhausted.
3. Their peak flow is markedly reduced (severe is defined as <50% of predicted or best value, and
life-threatening as <33% of predicted or best value).

4. The oxygen saturation is reduced below 92%.

In a normal term baby at birth:

A Occipito-frontal head circumference is greater than maximum chest

circumference. true
B The prepuce (in boys) is usually not retractile. false
C Stepping reflex is present. true
D A palpable spleen tip is always pathological. false
E The epiphysis of the femoral head is usually present. false

Comments:
Occipital-frontal head circumference should be smaller than chest circumference. In a normal term baby
at birth the prepuce is not retractile, but 50% of boys have a retractile prepuce by the age of ten and over
90% following puberty. The stepping reflex and other types of reflexes, , including the moro or startle
reflex, walking or stepping, tonic neck reflex and the palmar and plantar grasp are present and most of
these from birth. Spleen tips may be identified in normal newborns. The femoral epiphysis may develop
and ossify later.

Hypoxaemic respiratory failure (Type I):

A Can be caused by respiratory muscle weakness and fatigue. false

B Is found in mountain sickness. true
C Can lead to pulmonary hypertension. false
D Can lead to CO2 retention if treated with 100% oxygen. false
E Can lead to ventricular failure. false

Comments:

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Hypoxaemia can occur because of 3 mechanisms:

Hypoventilation: muscular dystrophy, e.g. Werdig-Hoffman, Guillain-Barre, drugs, myasthenia

gravis.
Diffusion impairment: pneumonia (bacterial, viral, TB).
VQ inequality: obstructive airways disease, restrictive airways disease.

ARDS and hyaline membrane disease in addition to lung infections cause both diffusion impairments and
VQ inequality. In the case of VQ imbalance and hypoventilation, CO2 usually rises (type II respiratory
failure). In these cases, the patient relies more and more on hypoxia to maintain respiratory drive, an
excess of oxygen can be counterproductive. Hypoxia is a potent pulmonary vasoconstrictor, and can lead
to pulmonary hypertension. The brain and myocardium are also particularly sensitive to hypoxia.

In childhood offensive loose stools may be caused by:

A increased secretions of pancreatic enzymes. false
B Bodian-Schwachmann syndrome. true
C biliary atresia. true
D cystic fibrosis. true
E abetalipoproteinaemia. true

Comments:
A decrease or absence of pancreatic enzyme secretion may cause loose, offensive stools. Chest
infections or respiratory signs are suggestive of cystic fibrosis. Bodian-Schwachmann syndrome presents
with failure to thrive in the absence of respiratory symptoms, persistent neutropenia, thrombocytopenia,
raised fetal haemoglobin and minor liver enzyme abnormalities. Growth retardation, skeletal dysostoses
and bone marrow hypoplasia may also be present. Abetalipoproteinaemia results from a defective
production of apoprotein B by the intestinal cells leading to defective synthesis of low-density lipoproteins,
very low-density lipoproteins and chylomicrons (CLM). Absence of CLM results in fat malabsorption,
deficiency of fat-soluble vitamins and steatorrhoea. Very low cholesterol (<1.3 mmol/l), low triglyceride
and acanthocytes on the blood film are found. From Hannam et al. MRCP (Paediatrics) Part 1 MCQs.
page 105

With regard to malaria:

A Proguanil is recommended as prophylaxis for areas of Chloroquine resistance. false
B Congenital malaria can resemble neonatal sepsis. true
C Primaquine should not be given to glucose-6-phosphate dehydrogenase
deficient patients. true
D Self treatment with Pyrimethamine-Sulfadoxine (Fansidar) is appropriate. true
E Negative blood films exclude the diagnosis. false

Comments:

Malaria results when red cells are invaded by any of the few species of plasmodia carried by the female
Anopheles mosquito. Incubation is around 2 weeks, and the species of plasmodia are vivax, ovale,
malariae and falciparum. Vivax and ovale cause 48 hourly fevers (benign tertian), and can recrudesce if
treatment is inadequate. Malariae causes a quartan fever every 72 hours. Falciparum causes malignant
tertian fever every 48 hours or so, but this less predictable. Congenital malaria is rare because of relative
placental protection. Blackwater Fever is caused by falciparum malaria and severe haemolysis occurring
in non-immune (usually Caucasian subjects). Non-immune subjects have more serious illness and higher
fevers. High tolerance occurs, particularly in Africans due to repeated infections. Blood film is not 100% in
diagnosis.

Treatment:
a) Prophylaxis - Proganuil, Pyrimethamine (sometimes as Fansidar), or Chloroquine.
b) Treatment - 1. Chloroquine or Quinine. 2. Supportive therapy.
c) Primaquine for vivax or ovale to prevent relapse, but remember G6PD deficiency is a contraindication

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to its use (Asians and Mediterraneans in particular).
d) Primaquine to kill gametocytes in falciparum.

The following statements are correct:

A insulin is derived from C-peptide. false
B glucagon stimulates insulin release. true
C C-peptide levels are increased in endogenous hyperinsulinaemia. true
D insulin decreases absorption of glucose from the gut. false
E catecholamines antagonize the actions of insulin. true

Comments:
Insulin is derived from proinsulin, which is cleaved to form insulin and C-peptide. C-peptide can be
measured to distinguish between endogenous hyperinsulinaemia and exogenously administered insulin.
Insulin inhibits glucagon release, whereas glucagon stimulates insulin release. Insulin has no effect on the
absorption of glucose from the gut. Catecholamines inhibit the action of insulin. From Hannam et al.
MRCP (Paediatrics) Part 1 MCQs. page 127 WB Saunders. Reproduced with permission.

Regarding Guthrie card testing:

A It is done at 7 days in the breast fed infant. true
B It should be delayed till 14d if the child is exclusively on TPN. false
C It may be affected by concurrent antibiotic administration. false
D The card contains information about the patient's post code. false
E Hypothyroidism can be screened for by measuring TSH alone. true

Comments:

The Guthrie card was originally introduced for PKU screening using a specific strain of bacillus subtilis.
For this reason, results of PKU screening are affected by concurrent antibiotic administration. The
thresholds have been set for fully fed infants, so children should be on a full enteral intake. Those on TPN
should have card collection delayed until fully orally fed. In most European programmes, TSH is
measured by radioimmunoassay. This fails to detect the extremely rare secondary hypothyroidism due to
hypothalamopituitary disease (1:100,000). However, it is extremely effective at picking up primary
hypothyroidism (1:4000 births), mainly due to dysgenetic or ectopic thyroid tissue. The card does contain
information about the patient's postcode. In one study this was ingeniously used to map breast feeding
rates at a week of age to individual postcode sectors.

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