5th NATIONAL MCQ EXAMINATION

NATIONAL BOARD OF EVALUATION

INDONESIAN COLLEGE OF PEDIATRICS
JUNE 1, 2009

SELECT THE ONE BEST ANSWER , put your answers in The Answer Sheet
TIME ALLOCATION: 100 MINUTES
GASTRO-HEPATOLOGY

1. A girl aged 6 years old has experienced recurrent abdominal pain since the last 6 months. No abnormalities are evident on
physical examination. She complains of persistent or recurrent pain or discomfort centered in the upper abdomen (cranial to
the umbilicus). The pain is not associated with the onset of a change in stool frequency or stool form. She feels also early
satiety, bloating and nausea.
The most likely diagnosis is:
A. Functional dyspepsia
B. Irritable bowel syndrome
C. Abdominal migraine
D. Gastroesophageal reflux disease
E. Functional abdominal pain

2. A baby, 4 months of age has 5 bowel movements a day for the last 3 days, which is soft and contains blood and mucus. She
looks healthy, has a good appetite and no signs of dehydration. What is the most likely diagnosis?
A. Shigellosis
B. Salmonellosis
C. Cow`s milk allergy
D. Intussusceptions
E. Amebic colitis

3. A 3-year-old girl presents to the Emergency Department with fever, vomiting, and abdominal pain. She has right upper
quadrant tenderness and hepatomegaly. Her serum transaminases are elevated, but her total and direct bilirubin are only
slightly above normal. Several other children in her day care are sick with similar symptoms. Which of the following
statements is FALSE:
A. Most patients with this illness do not develop fulminant or chronic disease
B. Jaundice is common in young children with this illness
C. Highly effective vaccines exist against this disease
D. Most commonly transmitted by fecal-oral contact
E. This disease more commonly occur in a crowded community (urban)

4. A 3 week-old baby came to the emergency department with the main complaint of profuse non-bilious vomiting after feeds.
He was uneventfully born at term with a birth-weight of 3 kg. On physical examination, the BW was 2.5 kg along with
moderate dehydration and hypokalemia. The most probable diagnosis in this case is:
A. Gastroesophageal Reflux
B. Atresia Duodenum
C. Hirschprung Disease
D. Hypertrophic Pyloric Stenosis
E. Pancreas Annulare

5. In any infant or toddler who presents with acute abdominal pain, bilious emesis, and guarding, which of the following
imaging studies is the initial study of choice most likely to confirm your suspicions?
A. Magnetic resonance imaging
B. Ultrasonography
C. CT scan
D. Barium enema
E. Upper GI series
HEMATOLOGY

6. On a routine-screening of complete blood count, a 1 year-old is noted to have a microcytic anemia. Follow-up hemoglobin
electrophoresis demonstrates an increased concentration of hemoglobin A2. The child is most likely to have
A.. Iron deficiency
B. β-thalassemia trait
C. Sickle cell anemia
D. Chronic systemic illness
E. Lead poisoning

7. A 3 year-old boy develops pallor and recurrent epistaxis, There is no hepatosplenomegaly or lymphnode enlargement.
Laboratory finding shows hemoglobin level 3 g/dl, hematocrit 14%, red blood cell count 2,500.000/mm 3, white blood cell
count 11.000/mm3 and platelet count 180,000/mm3. The most likely diagnosis of the patient is:
A. Hemolytic anemia
B. Aplastic anemia
C. Post-hemorrhagic anemia
D. Leukemia
E. Iron deficiency anemia

8. A 5 year-old boy came with rashes like purpura in the lower extremities, lower trunk and buttocks. There was a history of
low grade fever for few days. There was no other complaint. Physical examination was unremarkable. Complete Blood Count
reveals slight leukocytosis and normal platelet count. Hemostatic function also reveals normal.
What is the most possible diagnosis in this child ?
A. Immune Thrombocytopenic Purpura
B. Secondary Thrombocytopenic Purpura
C. Systemic Lupus Erithematous
D. Henoch-Schönlein Purpura
E. Drug Allergy

9. A patient suffered from fever and chills 30 minutes during Packed Red Cell transfusion. There was no history of transfusion
before. In emergency situation like this, what should you do?
A. Give paracetamol and continue transfusion
B. Give paracetamol and antihistamin, and then continue transfusion
C. Stop the transfusion and change into washed erythrocyte transfusion
D. Stop the transfusion and change with another Packed Red Cell bag
E. Stop the transfusion, keep the intravenous line open with Physiologic Saline until the symptom resolved

ALLERGY- IMMUNOLOGY
10. A 3 month-old boy was admitted because he had red, raised, palpable wheals all over his body, along with cyanosis,
tachycardia, and breathing difficulty. He had been breastfed and his mother recently gave him cow’s milk formula 5 days
before admission.
What is the baby’s diagnosis?
A. Urticaria
B. Angioedema
C. Anaphylaxis
D. Asthma
E. Heart problems

11. The drug of choice for this patient is:

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

13.. A 5 year-old girl presented to you with purpura that spread over her buttock and lower
extremities. You noticed that the purpura was palpable. Assuming this case to be Henoch
Schönlein Purpura, you asked for laboratory investigation. What you expected to find is:
A. Prolonged clotting time
B. Prolonged APTT
C. Prolonged PTT
D. Thrombocyte count below the normal limit
E.Thrombocyte count exceeding the normal limit

TROPICAL / INFECTIOUS DISEASE

14. A 10-year-old girl presents with a history of sore throat for 4 days, along with breathing
difficulty of 1 day’s duration. On examination she is very ill-appearing. She has some
inspiratory stridor and thick white-gray material covering her tonsils and faucial pillars,
and she has swelling of her neck
What kind of treatment will you give for the patient at the time?
A. B2 agonist nebulization
B. Corticosteroid
C. Ceftriaxon injection
D. Immunization with DT
E. ADS 40.000 IU

15. A 14 year-old girl awakens with a mild sore throat, low-grade fever, and a diffuse
maculopapular rash. During the next 24 hours, she develops tender swelling of her wrists
and redness of her eyes. In addition, her physician notes mild tenderness and marked
swelling of her posterior cervical and occipital lymph nodes.Four days after the onset of
illness the rash has vanished. The most likely diagnosis of this girl’s condition is
A. Rubella
B. Rubeola
C. Roseola
D. Erythema infectiosum
E. Erythema multiforme
16. A 20 month- old baby has a three week history of diarrhea and recurrent fever. He is noted to have oral thrush. He was
hospitalized 3 times with the same complaint. At the moment he has a body weight of 7 kg, and appears moderately ill. His
head, ear, heart and lung exams are normal. His oral exam is significant for thrush. He has liver, spleen enlargement along
with anterior/posterior cervical and occipital lymphadenopathies.
Which one of the following is used as a screening test in HIV infection diagnosis?
A..Enzyme immunoassay
B. Polymerase chain reaction
C. Western-blot.
D. Immune fluorescence assay
E. Viral culture
 17. Which of the following vaccines is contra-indicated in HIV-infected children?
A. IPV
B. MMR
C. HIB
D. Pneumococcal
E. BCG

NEUROLOGY
18. A 5-year-old boy presents with a limp. This was preceded by a febrile illness, but there has been no preceding trauma. On
examination he has weakness of all muscle groups in his right lower limb. The limb is hypotonic, and deep tendon reflexes
cannot be elicited. There is no pain on movement of the joints nor is there tenderness. Sensory examination is normal. What
would be the most likely diagnosis?
A.. Guillain Barre Syndrome
B. Poliomyelitis
C. Diphtheritic Polyneuropathy
D. Chikungunya
E. Spinal tumour

19. What kind of examination would you suggest for the patient?
A. .Head CT scan
B. Stool culture
C. CK-MB examination
D. Serum electrolyte
E. Lumbal puncture
20. A 2 month-old baby came to the Emergency Department with seizures and unconsciousness. There was no history of fever,
cough or other illness. The baby was uneventfully born spontaneously with good condition and had only been breastfed.
Physical examination showed a very weak baby, along with pallor and bulging fontanella. CBC revealed Hb 7.2 g/dL normal
white blood count and platelet count. Haemostatic function revealed PPT 45” (control 11.3”) and APTT 53.1” (control 26.3”).
What is the most possible diagnosis of this baby?
A. Hemophilia
B. Von Willebrand disease
C. Acquired Prothrombin Complex Deficiency
D. DIC
E. ITP
21. A previously healthy 10-year-old girl has developed progressive weakness, areflexia,
paresis of extra-ocular muscles and respiratory insufficiency over a 2 week period. The
MOST LIKELY diagnosis is
A. Polymyositis
B. Myasthenia gravis
C. Acute spinal muscular atrophy
D. Guillain-Barré syndrome
E. Botulism

NEPHROLOGY
22. A 6 year- old boy is being evaluated for high fever of unknown etiology, flank pain,
vomiting, toxic appearance. haematuria and leucocyturia. Voiding cystoureterography
reveals findings as a shown below. Which of the following is a working diagnosis option? :
 A. Urethritis
B. Cystitis
C. Pyelonephritis
D. Eneuresis
E. Nephritis
23. Which of the following is an appropriate treatment option? :
A. Intravenous antibiotics for 3 days
B. Intravenous antibiotics for 7 days
C. Oral antibiotics for 3 days
D. Oral antibiotics for 7 days
E. Oral antibiotics for 10 days
24. A 6-week old child is being evaluated for a fever of unknown etiology. As part of the
laboratory evaluation, a urine specimen was obtained that grew Escherichia coli with a
colony count of 2000/µL. These findings will be definite evidence of a urinary tract infection
if the sampled urine
A. Is the first morning sample
B. Is from an ileal loop bag
C. Is from a suprapubic tap
D. Is from a bag attached to the perineum of uncircumcised boy
E. Has a specific gravity of 1.008

ENDOCRINOLOGY
25. A pregnant woman has a low urinary estriol level. At delivery, her male infant develops
hyponatremia, hyperkalemia, and hypoglycemia. What diagnosis should you consider?
A. Inappropriate antidiuretic hormone
B. Congenital adrenal hypoplasia
C. Juvenille diabetes mellitus
D. Phenylketonuria
E. Hyperthyroid
26. An 8-year-old boy has short stature. He has begun to gain quite a bit of weight over the
last year, has little or no energy, sleeps more than normal, and complains of feeling cold.
His growth demonstrates that he has fallen from 50th percentile to the 5th percentile for
height, but his weight has increased to 90th percentile. On examination, he is obese, has
an immature facies, thin hair, and slow reflexes. Which of the following is the most
appropriate course of action for this child?
A. Measure thyroid function
B. Determine bone age
C. Order a growth hormone level
D. Reassure the mother that the child has normal prepubertal development
E. Chromosomal analysis
27. A normal-appearing 9-month-old boy is discovered on routine herniorrhaphy to have
bilateral Fallopian tubes and a rudimentary uterus. Biopsy of the gonads performed
during this procedure revealed normal testicular tissue. On examination today, his
phallus is normal in size and appearance, and his descended testes are both 2 mL in
volume. Of the following, the MOST likely sex chromosome complement for this child is:
A. XX
B. XX/XY
 C. XXY
D. XO/XY
E. XY

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

29. Abdominal breathing in the patient above should be viewed as a:

A. Normal finding for a toddler
B. Sign of impending respiratory failure
C. Sign of decreased perfusion to the respiratory center
D. Compensatory mechanism to increase the volume of air inhaled.
E. Compensatory mechanism to increase respiratory rate.

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

NUTRITION
32. A 3 year-old boy who suffers from diarrhea more than 6 times a day was brought to the clinic. No bloody stool was found. The
boy was slimmy, the ribs pronounce, the skin wasting, hyper-pigmented skin and edema on the feet. The boy’s face resembled
‘old man face’, along with ‘flag sign hair’. he had measles two months before. The boy’s weight is 9 kg and his height 90 cm. (using
gold standard CDC-2000).
What is the diagnosis of the child?
A. Kwashiorkor
B. Marasmus
 C.Marasmic-kwashiorkor
D. Failure to thrive
E. Stunting

33. A 2 year-old girl came with obvious pallor. On admission the body weight was 6 kg, she did not show any sign of respiratory
distress or cardiac emergencies. The hemoglobin level was 6 g/dL. Proper management would be:
A. Blood transfusion given as soon as possible
B. Immediate transfer to intensive or high care ward
C. Oral iron supplementation is allowed starting at second week of hospitalization
D. Immediately starting a high calorie diet of 200 KKal/ kg
E. High protein along with a low fat diet

34. A 3 year-old boy came with a history of nausea, vomting, diarrhea, anorexia, fatigue and headache. He showed confusion and
appeared psychotic. Laboratory examination revealed hypercalciuria. This child most probably had a deficiency of
A. Vitamin A
B. Thiamin
C. Vitamin C
D. Vitamin D
E. Vitamin E
35. A 24 month-old girl was admitted to the emergency department the main complaint of high fever. Seven days before admission,
she got high fever, cough and cold. There was no history of vomiting and diarrhea. On clinical findings, she looked weak, the
respiratory rate was 54x/minute and Capillary Refill Time 10 seconds. There were fine moist rales on both lungs. The heart and
bowel sounds were within normal limits. The body weight was 10 kg, body length 85 cm, and the ideal body weight 11.9 kg; the
percent ideal body weight was 84%.When should enteral feeding be given or this patient?
A. As soon as possible after stable condition
B. After 72 hours
C. 48 – 72 hours
D. After the patient was conscious
E. As soon as possible after 24 hours

GROWTH AND DEVELOPMENT

An infant is brought by his mother to your well-baby clinic. He can move his head from side to side while following a moving object,
can lift his head from a prone position 45o off the examining table, smiles when encouraged and make cooing sounds. He cannot
maintain seated position. The most likely age of the infant is
A. 1 month
B. 3 months
C. 6 months
D. 8 months
E. 10 months
37. The mother has concerns about maintaining a safe environment for her child. In providing age-appropriate anticipatory
guidance, You tell her that
A. Pillows in the crib should be soft to provide a comfortable sleeping environment
B. She should set her water heater to 70oC to ensure the sterility, thereby decreasing the risk of infections
C. She can start to give solid food like pieces of apple or banana
D. Her baby should be placed on his back to sleep, as this decreases the risk of Sudden Infant Death Syndrome
E. She should give him small objects such as round pliable toys, to increase his fine motor development

38. A 3 ½ -year-old boy says only three single words, and these are poorly articulated. He uses gestures to communicate. There
are no other reported problems, gross and fine motor skills are normal for age and physical examination, including
tympanography, is normal. Which of the following is the MOST LIKELY explanation ?
A. Intellectual disability
B. Deafness
 C. Manipulative behaviour
D. Dysarthria
E. Autism

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

40. A 2-day-old is brought to ED after a generalized seizure lasting 3 minutes. If the seizure were related to birth trauma, the
most likely finding would be:
A. Subarachnoid hemorrhage
B. Epidural hematoma
C. Subdural hematoma
D. Focal brain contusion
E. Concussion

41. A 27-year-old gravida 1 para 0 female presents with a history of prolonged rupture of membranes and is presently in active
labor. Tocolytics are started, and despite medical intervention, a 30-week gestational infant is delivered. The baby
demonstrates nasal flaring, grunting, and intercostal retractions and is intubated. Positive pressure ventilation is initiated. A
chest radiograph reveals a fine granular appearance of the lung fields. The baby is hypotensive and poor perfusion is noted.
Initial arterial blood gas reveals pH 7.16, PCO2 50 mm Hg, PO2 55 mm Hg, and base excess -14.
Which of the following is the most appropriate intervention at this time?
A. Administer endotracheal surfactant immediately
B. Increase the ventilator settings to keep PaCO2 below 40 mm Hg
C. Administer 10 ml/kg 0.9% sodium chloride IV
D. Administer a dopamine infusion at 10 mgm/kg/min
E. Administer broad-spectrum antibiotics immediately

42. A patient presents in labour at a level 1 clinic. By her date and abdominal palpation she is 32 weeks pregnant. After a short
labour she delivers a male infant weighing 1400 gram. The New Ballard Score confirm the gestational age.
How would you classify this infant by weight for gestational age?
A. Low birth weight
B. Premature infant
C. Appropriate for Gestational Age (AGA)
D. Small for Gestational Age (SGA)
E. Large for Gestational Age (LGA)

CARDIOLOGY

43. A-five-year-old girl presents with fever for 8 days, weight loss, night sweats, a new heart murmur, splenomegaly, joint pains and
a history of having her teeth cleaned by a dentist 1 month prior to this visit. What is the most likely diagnosis for this patient ?
A. Kawasaki disease
B. Juvenile rheumatoid arthritis
C. Acute rheumatic fever
D. Infective endocarditis
 E. Systemic Lupus Erythematosus

44. A one month-old is seen after turning blue when feeding. Auscultation of the heart reveals a harsh grade III systolic ejection
murmur over the pulmonic area that radiates to the back. Arterial blood gas shows a normal pH, PaCO2, and Pa02 at rest. The
ECG demonstrates right axis deviation and right ventricular hypertrophy. The chest x-ray film reveals a large heart with a
reduced main pulmonary artery segment. Which of the following congenital heart disorders is consistent with these findings?
A. Atrial septal defect
B. Coarctation of the aorta
C. Tetralogy of Fallot
D. Patent ductus arteriosus
E. Ventricular septal defect

45. A 4-year-old boy was referred for dyspnea on exertion. Poor weight gain, cold sweat on the forehead .There is distended neck
veins and tachycardia. The CXR showed cardiomegaly with increased pulmonary vascular marking.The ECG showed LVH. What
is the diagnose ?
A. Infective endocarditis
B. Congestive heart failure
C. Cardiomyopathy
D. Cardiogenic shock
E. Septic shock

46. A 6-year-old boy was referred for prolonged fever and swelling , severe pain and redness of ankles. The precordium is
normal except for a mild thrill in the apex. S1 and S2 are normal, but a harsh holosystolic murmur is heard in the apex. The
abdomen is soft and there is no organomegaly. What is the diagnosis ?
A. Juvenile rematoid arthritis
B. Acute rheumatic fever
C. Myocarditis
D. Infective endocarditis
E. Cardiomyopathy

RESPIROLOGY

47. A 7 month- old boy was brought to the hospital with the chief complaint of difficulty in breathing since 3 hours prior to
admission. He started to have cough, rhinorrhea and fever 2 days before. Physical examination revealed that the baby was
alert, appeared distressed,with no evidence of cyanosis. Heart rate was 112 times per minute, respiration rate 60 times per
minute, the body temperature was 38,5 C. Lung auscultation appeared wheezing; no rhales or crackles was evident. The
patient then underwent Chest X Ray, Peripheral Blood Smear, and Blood Gas Analysis.
Working diagnosis of the case is
A. Pneumonia
B. Bronchopneumonia
C. Acute Bronchitis
D. Bronchiolitis
E. Acute asthma attack

48. The result of CXR or BGA is predicted as:

A. Diffuse infiltrate on CXR and Hypoxemia , Metabolic acidosis on BGA
B. Hyperaeration on CXR and Hypercapnia, Respiratory Acidosis on BGA
C. Emphysematous lung , alveolar infiltrate on CXR and Metabolic Acidosis on BGA
D. Alveolar infiltrate on CXR and No hypoxemia, only metabolic acidosis on BGA
E. Pleural effusion on CXR and hypoxemia, respiratory acidosis on BGA
49. A 13 year-old girl, was admitted to the hospital due to chronic cough and difficulty of breathing since 2 days ago. She
complained that this condition recurs almost every month, with each attack typically lasting for 1 or 2 days, especially at
night. The mother had a history of having allergic rhinitis, while the father was a heavy smoker. On physical examination the
child looked slightly dyspneic, with increased expiration time. Diffuse wheeze was heard over both lungs. She was able to
communicate to the physician, with clear and uninterrupted sentences. All other vital signs were normal.
Proper initial prompt treatment of this case:
A. Administration of broad spectrum antibiotics
B. Inhalation therapy with B2 Agonist.
C. Simultaneous steroid and aminophyllin intravenously
D. Oral mucolitic to dissolve mucus
E. Antitussive to depress coughing

50. A 3-year-old boy was brought to pediatric clinic for consultation. His father suffered from haemopthysis and has been
treated with antituberculous drugs since a week ago. The child was symptomless with normal body weight. Tuberculin skin
test result was 12 mm, and the chest x-ray doesn’t show any suggestion for tuberculosis. Which of the following answers is
the most appropriate management in this child?
A. Primary chemoprophylaxis with isoniazid for 3 months
B. Primary chemoprophylaxis with isoniazid + rifampin for 3 months
C. Secondary chemoprophylaxis with isoniazid for 6 months
D. Secondary chemoprophylaxis with isoniazid + rifampin for 6 months
E. Give isoniazid, rifampin, and pyrazinamide for 2 months, follow with isoniazid and rifampin for 4 months

GOOD LUCK
from
SOETJI-WATI-SUMA (Kolegium IKA)