1-Theme:Vitamin Dependant States

Ascorbic Acid

Biotin

Cobalamin

Folate

Niacin

Pyridoxine

Retinol

Riboflavin

Thiamine

J
Vitamin E
Which of the above options best fit the statements below?
A deficiency leads to nyctalopia.
Vitamin E

Incorrect - The correct answer is Retinol

A deficiency leads to Pellagra.

Ascorbic Acid

Incorrect - The correct answer is Niacin

A deficiency results in dermatitis and seborrhoea.

Retinol

Incorrect - The correct answer is Biotin

Retinal is another term for vitamin A. Deficiency results in ocular manifestations

and visual impairment, e.g. nyctalopia, photophobia, xerophthalmia and

keratoconjunctivits. Niacin is a constituent of coenzyme.essential for metabolism.

A deficiency results in Pellagra. Biotin is a constituent of co-enzymes involved in
CO2 transfer. .A deficient state results in dermatitis and seborrhea.

2-A 4-year-old girl is referred with behavioural problems. Her speech is

generally well-formed. However, she finds it difficult to sustain
conversations because she talks obsessively about her own interests. She
avoids eye contact. She plays on her own for hours with her dolls,
dressing and undressing them repeatedly. Attempts to play with others
results in tantrums. Born at 39+6/40, 3.18kg no neonatal problems. No
drugs, allergies. Fully immunised. No FH/SH of note.
On examination she is on the 50% for height and weight. There are no
specific abnormalities to find.
What is the most likely diagnosis?
(Please select 1 option)

Autism

Incorrect answer selected

Chronic secretory otitis media

Global developmental delay
Pervasive developmental disorder

This is the correct answer

Speech delay, isolated

This child has problems with reciprocal social interaction, with repetitive obsessive
play. Her speech is normal in form. These symptoms are characteristic of
Asperger syndrome. This is part of the spectrum of Pervasive Developmental
Disorders, and is regarded by some as 'high-functioning autism'. Such children
may be regarded as eccentric by their peers.

3-A 15-year-old boy plays competitive football. Following an accidental

clash of heads he initially seems to recover, but a few minutes later he has
a 5 minute generalised convulsion. This starts with eye-rolling, then
stiffness of all limbs, followed by rhythmic shaking and incontinence. He is
placed in the recovery position and an ambulance called. He is generally
fit and well. Full term normal delivery with no neonatal complications.
Immunisations up to date. There is no FH/SH of note.
On examination he is slightly drowsy but responds to voice. RR is 12/min
and HR 70/min. There are no abnormalities to find except bilaterally upgoing plantars. BM stix shows a glucose of 5.4 mmol/l.
What is the most likely diagnosis?
(Please select 1 option)

Drug ingestion
Extradural haematoma

Incorrect answer selected

Idiopathic epilepsy
Post-traumatic seizure

This is the correct answer

Subdural haematoma

The history suggests a brief generalised seizure following a minor head injury.
This is likely to have no long-term sequelae. A single episode cannot be
considered epilepsy. About 5% of children will have at least 1 seizure during their
lives, mostly related to fever. Fatigue, particularly with alcohol ingestion, is
another common trigger.

4-A 17-year-old woman presented six hours after taking 30 g of

paracetamol.
Which of the following factors is most likely to predict an increased risk of
hepatotoxicity from the paracetamol?
(Please select 1 option)

Anorexia nervosa

This is the correct answer

Consumption of 20 units of alcohol since taking the paracetamol

Incorrect

answer selected
Gilbert's disease
Ingestion of amitriptyline with the paracetamol
Smoking 20 cigarettes per day

High risk groups in paracetamol overdose include:

malnourished patients (anorexia nervosa/bulimia

nervosa)

patients taking enzyme inducing drugs (e.g.

carbamazepine, phenytoin, rifampicin and St
John's wort)

patients with induced liver enzymes due to

chronic ethanol abuse

human immunodeficiency virus (HIV) positive

patients.

See review in Clinical Medicine Vol 3 No 2 2003.

5-A 17-year-old girl with mild Von Willebrands disease is scheduled for
dental extraction. A previous dental extraction resulted in bleeding that
had required two unit transfusion. What is the most appropriate treatment
prior to dental surgery?
(Please select 1 option)

Cryoprecipitate
DDAVP

This is the correct answer

Fresh frozen plasma

Incorrect answer selected

High purity factor VIII concentrate

Recombinant factor VIII concentrate

DDAVP is the choice treatment for mild vonWillebrand disease, which

would include Type I, and the majority of Type II, although there is some
controversy in Type II B as it is thought that DDAVP can exacerbate
thrombocytopenia that can accompany this type of Von Willebrand's.
It is of no use in Type III severe Von Villebrand's disease. The history
tells us that she has mild disease.
You would not use cryoprecipitate or Fresh frozen plasma in these patients
in this era due to potential viral transmission risk from blood products. For
severe disease you would use a Von Willebrand factor concentrate, not
factor VIII concentrate.

6-What proportion of the total number of children born with some degree
of hearing impairment are detected by neonatal screening of babies
considered at 'high-risk' of having congenital hearing loss?
(Please select 1 option)

25%
50%

This is the correct answer

75%
95%

Incorrect answer selected

100%

A number of risk factors are associated with neonatal hearing loss.

Traditional newborn screening methods involve screening of only these
high-risk infants. The risk factors considered include: family history of
hearing loss, prematurity, low birth weight, neonatal jaundice, rubella or

non-bacterial intrauterine infection, anoxia, craniofacial deformity,

bacterial meningitis and Apgars score of 0-3.
Only half of the total number of children born with a hearing impairment is
detected by these high-risk screening programs. The other half has no
obvious risk factors to alert parents or professionals to the presence of the
hearing loss. For each child detected by high-risk screening, another child
goes home undetected. Universal newborn hearing screening is now being
introduced to ensure most children have their hearing loss detected from
birth.

7-Relating to fractures in children:(Please select 1 option)

The periosteum is thicker and more highly developed.

Correct

Bone is generally more brittle.

Healing is usually prolonged
Angulation and displacement of fractures are poorly tolerated.
Stiffness of adjacent joints is common following fracture immobilisation.

Fractures in children usually heal quicker than similar fractures in adults. The
bone is more elastic. Due to the remodelling potential of paediatric fractures
angulation and displacement, if not excessive, is usually well tolerated.
Immobilization of fractures is also well tolerated in general. The periosteum in
children is thick and can often be used as an aid to hold reduction.

8-A post-marketing surveillance study of a new heart failure therapy to

the market was carried out on 10,000 subjects who had completed clinical
trials. Which one of the following most accurately reflects the information
generated from such a study?
(Please select 1 option)

Adverse events profile

This is the correct answer

Cost benefit analysis

Cost effectiveness
Comparative therapeutic efficacy

Incorrect answer selected

Drug potency

Post-marketing surveillance/observational studies (phase IV studies)

generally are designed to assess the potential side effects of new drugs
but under everyday conditions and with a minimum of intervention. In

contrast to the randomized controlled trials, PMS typically include patients

from more extreme age groups, patients with comorbidity or other risk
factors. In order to cover a wide spectrum of patients and to observe rare
events with sufficiently high probability, PMS enroll a large number of
patients, typically several thousands. Comparative efficacy has already
been undertaken in Phase III studies (RCTs) but can also be undertaken
as part of specific RCT studies later in the drugs development and potency
usually in phase I and II studies.

9-A 17 month old girl presents with eye-rolling followed by generalised

shaking of the limbs for 3 minutes. She has had a cold for 3d, but became
very warm this afternoon just prior to the episode. No previous history of
note, Full term normal delivery with no neonatal complications.
Immunisations up to date. There is no FH/SH of note.
On examination she alert though febrile at 39.8C, with flushed cheeks.
She has a crusty nasal discharge. Respiratory rate is 20/min and heart
rate 120/min. Chest is clear and urinalysis negative.
What is the most likely diagnosis?
(Please select 1 option)

Cerebral abscess
Encephalitis
Febrile convulsion, complex
Febrile convulsion, simple

Correct

Meningitis

The history is of a febrile child having a brief generalised convulsion with rapid
recovery. The likely precipitant is a viral URTI. The picture is typical of a Simple
Febrile Convulsion. Parents should be advised that the prognosis is excellent,
though 30% may have further febrile seizures. They should be told how to control
fever (strip down, antipyretics, room at 19C, and tepid sponge of head).

10-Theme:Drugs During Pregnancy

A

Aminoglycosides

Aspirin

Beta Blockers

Lithium

Phenytoin

Pethidine

Sodium Valproate

Sulphonamides

Thiazide diuretics

J
Warfarin
Select the drug from the above list of options that is most likely to be associated with the
following effects if taken during pregnancy:
This drug taken in early pregnancy may result in Ebstein's anomaly in 3% of cases.
Lithium

Correct

This drug may result in a neural tube defect in approximately 2% of cases.

Sodium Valproate

Correct

This drug, when taken in pregnancy may result in a baby being born with cranio-facial
abnormalities, growth impairment and learning difficulties.
Warfarin

Incorrect - The correct answer is Phenytoin

Lithium, a drug used in the treatment of bipolar affective disorder. If given

in early pregnancy is associated with a wide variety of cardiac defects with
approximately 8% having severe cardiac disease, Ebstein's anomaly being
the most common (3% of all cases).
Sodium Valproate tends to induce a neural tube defect in approximately
2% of pregnancies and therefore should be avoided. It is also associated
with abnormalities of the face and digits, compromising the foetal
Valproate syndrome.
Phenytoin is well known for causing the foetal hydantoin syndrome,
compromising cranio-facial abnormalities and learning difficulties as well
as growth impairment.

11-Features consistent with Henoch-Schnlein syndrome include

True / False

An onset at 3 years

Incorrect answer selected

Microscopic haematuria
Proteinuria

Correct

Correct

An urticarial rash over the face

Incorrect answer selected

A joint effusion with polymorphonuclear leucocytosis of the synovial fluid

Correct

Henoch-Schonlein purpura (HSP) peak incidence is at three years of age.

An urticarial rash can occur, and it usually presents on the face and legs,
though the typical non-thrombocytopenic purpura is much more common
in HSP.

12-A 5-year-old boy presents to Accident and Emergency complaining of

acute pain over his upper tibia. He is febrile and he refuses to move his
leg. A diagnosis of osteomyelitis is suspected.
What is the likely infecting organism?
(Please select 1 option)

Clostridium difficile
Haemophilus influenzae
Pseudomonas
Salmonella
Staphylococcus aureus

Correct

The commonest infecting organism in acute osteomyelitis in children over

the age of four years is Staphylococcus aureus.
With immunisation, cases of haematogenous osteomyelitis due to
Haemophilus influenzae have almost been eradicated.
Salmonella is the characteristic organism in sickle cell anaemia.
Pseudomonas infection is a common organism in haemodialysis patients
and intravenous drug addicts.

13-A 17-year-old primigravida complains of constipation and arthralgia

at 28 weeks gestation. A number of biochemical investigations are
performed, but which of these are clinically significant?
(Please select 1 option)

Detectable urinary human chorionic gonadotrophin

Free thyroxine 8.9 pmol/L (9-22)

Incorrect answer selected

Prolactin of 1000 mU/L (<450)

Serum alkaline phosphatase of 350 iu/L (50-110)
Serum corrected calcium 2.89 mmol/L (2.2-2.6)

This is the correct answer

This patient has symptoms suggestive of hypercalcaemia, which are

clinically significant.
Free T is at the lower end of the normal range which is often the case in
pregnancy and TSH is a better guide of thyroid function.
4

Hyperprolactinaemia is a normal finding in pregnancy, as is detectable

urinary human chorionic gonadotrophin.
It is also normal for serum alkaline phosphatase to rise by up to 4 times
normal due to increased placental production.

14-The following are risk factors for child abuse:

True / False

Infant separated from mother for more than 24 hours post-delivery.

Correct
Infant mentally or physically handicapped.
Macrosomic child
Maternal smoking

Correct

Correct
Incorrect answer selected

Less than 18 months between the birth of children

Correct

Unfortunately, child abuse is a common and important problem. About 4050,000 case conferences are held each year in England. In 1993, 37%
were for physical injury, 26% for neglect, 26% for sexual abuse, and 11%
for emotional abuse. Risk factors include:

Family history of violence.

Parent indifferent, intolerant or overanxious

towards the child.

Single or separated parent.

Socio-economic problems such as unemployment.

History of mental illness, drug or alcohol

addiction.

Parent abused or neglected as a child.

Infant premature or low birth weight.

Infant separated from mother for more than 24

hours post-delivery.

Mother less than 21 years old at the time of birth.

Step-parent or co-habitee present.

Less than 18 months between the births of

children.

Infant mentally or physically handicapped.

15-A 3-year-old girl is brought in by ambulance from a house fire. He

has extensive areas of peeling skin over the trunk and face, with
blackening around the mouth and nostrils. Full term normal delivery, no
neonatal problems. Immunisations up to date. No family or social history
of note.
On examination the temperature is 36.7C, respiratory rate 25/min, pulse
130/min. Capillary refill time of 3 seconds. 40% of 2nd and 3rd burns over
the trunk and face.
What is the most important part of management?
(Please select 1 option)

Analgesia

Incorrect answer selected

Bag and mask ventilation

Face mask oxygen
Intubation

This is the correct answer

IV fluid bolus

The picture is one of severe burns and smoke inhalation. Shock can occur
in the first few hours from loss of large amounts of plasma from denuded
skin. The airway should be secured by immediate intubation before it
becomes too oedematous and occludes completely. 100% O2 should be
given, as pulmonary oedema can be anticipated. Two large-bore cannulae

should be inserted and 20 ml/kg of N. saline given. Maintenance and

continuing losses should be calculated from the time of the fire.

16-In diabetic ketoacidosis:

True / False

bicarbonate should be given if pH is less than 7.20

corticosteroids should be given

Correct

Correct

initial fluid resuscitation should be with normal saline

the initial blood glucose level indicates the severity

Correct
Incorrect answer

selected
potassium often needs to be replaced

Incorrect answer selected

The treatment initially consists of fluid resuscitation with normal saline,

insulin infusion, replacement of potassium and treatment of the
precipitating cause. Bicarbonate should be considered only if the pH is less
than 7.0. The initial blood glucose is a poor indicator of severity. Steroids
may worsen hyperglycaemia.

17-Overwhelming septicaemia in post-splenectomy patients:

True / False

Can usually be prevented with prophylactic penicillin.

Is more common in children <5 years.

Correct

Correct

Is only a significant problem for two/three years post splenectomy.

Correct
Is due to hypogammaglobulinaemia.

Correct

Is less common if splenectomy is for traumatic rupture.

Correct

Because of the risk of post-operative sepsis, splenectomy should be

limited to specific indications. These include: splenic rupture, anatomic
defects, haemolytic anaemia, immune cytopaenia, metabolic storage
disease, secondary hypersplenism.
There is an increased risk of sudden overwhelming infection (sepsis or
meningitis). The risk is increased in children under 5, and is decreased in
splenectomies done for trauma, red cell membrane defects, immune
cytopaenias. Encapsulated bacteria (Strep. pneumoniae, Haemophilus
influenzae, neisseria meningitidus, Escherichia coli) are commonest. The
spleen is responsible for filtering the blood and for early antibody
responses. There is also an increased risk of malaria.

The operation should be postponed until the patient is over 5, and preoperatively, the child should be vaccinated with pneumovax, Hib, and
meningococcal A and C vaccines. In the case of trauma, splenic repair or
partial splenectomy may be possible. Post-splenectomy penicillin reduces
the risk of pneumococcal sepsis, but does not eliminate it. The appropriate
duration of prophylaxis is unknown.

18-The following may indicate underlying severe combined

immunodeficiency:
True / False

Platelet count of 40

Correct

Absolute lymphocyte count of 0.8 x 10 9/L

Generalised lymphadenopathy
Conjunctival telangiectasia
Failure to thrive

Incorrect answer selected

Correct

Correct

Incorrect answer selected

Severe combined immune deficiency is a clinical syndrome, with a vast

number of underlying potential causes. Other clinical categories include
combined immune deficiency, and T cell defects, where a secondary
problem with immunoglobulin formation is almost inevitable, given the
regulatory role of the CD4 cells and the cytokines they produce. In severe
combined immune deficiency, the immune deficiency involves the absence
of T and B cell function from birth.
Examples of each category include:

Severe: Adenosime Deaminase Deficiency (ADA),

X-SCID 1L2y deficiency, T+B+SCID, NK+ SCID.

Less Severe: Wiskott-Aldrich Syndrome, MHC

class I and II deficiency, Omenn's Syndrome,
ataxia telangiectasia, Hyper-IgE Syndrome, and
purine nucleoside phosphorylase deficiency (PNP
deficiency).

SCID: Clinical spectrum of great genetic diversity

where ID involves absence of T & B cell function
from birth

19-A 6-year-old girl presents with neck swelling and breathlessness,

worsening over 6 weeks. She has felt increasingly tired and unwell. Full
term normal delivery, no neonatal problems. Immunisations up to date.
No family or social history of note.
On examination the temperature is 36.7C, respiratory rate 25/min and
pulse 95/min. She looks unwell and has large rubbery enlargement of
glands in the right lateral neck area. She is slightly breathless at rest, with
stony dullness to percussion and decreased breath sounds in the right
base.
What is the most likely diagnosis?
(Please select 1 option)

HIV infection
Infectious mononucleosis
Kawasaki disease
Lymphoma
Tuberculosis

This is the correct answer

Incorrect answer selected

The history suggests pleural effusion and lymphatic infiltration. The most likely
diagnosis is a lymphoblastic lymphoma. A chest X-ray often shows a round lesion
arising from the mediastinum. Staging involves CT scans of the neck and thorax,
and detailed histology.Dissemination to the bone, marrow, skin and CNS is not
uncommon.

20-Which one of the following statements correctly applies to a child

being treated for leukaemia?
(Please select 1 option)

Meningeal leukaemia is completely preventable

Uric acid nephropathy occurs in remission

Incorrect answer selected

Male sex carries a favourable prognosis

Passive protection with hyperimmune gammaglobulin should be given for
measles

This is the correct answer

Treatment will usually result in infertility

Prophylactic intrathecal chemotherapy and cranial radiation does not

prevent meningeal leukaemia in all cases. Uric acid nephropathy occurs
when there are high levels of circulating blasts and cell breakdown is
occurring, eg during chemotherapy. Males have a worse prognosis and
receive a longer duration of treatment. Passive protection against measles
should be given, as the immune response to the vaccine will be

inadequate. Infertility is not common, however in males testicular relapse

may occur.

21-Theme:Abdominal Pain
A

Acute gastro-enteritis

Appendicitis

Constipation

Diabetes Mellitus

Henoch Schonlein Purpura

Mesenteric Adenitis

Nephroblastoma

Pancreatitis

Sickle Cell crisis

Wilm's Tumour

Select one option from the list above that is most suitable for the following
patients
A 12-year-old boy with a 3 week history of coryza is brought to A&E complaining of severe
abdominal pain. He has swollen ankles and palpable lesions on his buttocks, which do not
disappear with pressure.
Henoch Schonlein Purpura

Correct

Henoch Schonlein purpura also known as anaphylactoid purpura has an unknown

aetiology. Children present with abdominal pain, possibly melaena due to
haemorrhage and oedema of the gut wall. They may have a flitting arthritis
affecting large joints. The nephritis presents with microscopic haematuria and
proteinuria and the macular, papular, purple rash is rather characteristic with
buttocks and extensive surfaces of the legs and arms being affected.

A 10-year-old girl has just returned from Thailand. She is brought to history of severe diarrhoea
associated with abdominal pain. Her mother, a known diabetic, has similar symptoms.

Acute gastro-enteritis

Correct

relates to a child with gastroenteritis. In the developed world gastroenteritis is

very common and usually mild. 60% of cases are due to viruses for example
Rotavirus. In bacterial gastroenteritis; fever is common and children present with
colicky abdominal pain, vomiting, diarrhoea and possibly dehydration.

A 12-year-old girl with a 2 month history of weight loss and increased appetite weight loss is
brought to Casualty with severe abdominal pain. She denies any history of vomiting or excessive
exercise. Her mother says that the child has been wetting her bed over the past 4 months.
Diabetes Mellitus

Correct

describes a child with diabetes mellitus. The commonest metabolic / endocrine

problem in childhood. Diabetes mellitus results from low Insulin levels resulting in
abnormal metabolism of carbohydrate, protein and fats. Children present with
polyuria, polydipsia and polyphagia. Children sometimes complain of abdominal
discomfort and there is a history of weight loss.

22-Regarding screening programmes:

True / False

For hypothyroidism uses B. subtilis.

Incorrect answer selected

For haemaglobinopathies involves electrophoresis.

For cystic fibrosis is universal.

Correct

Incorrect answer selected

For Down's syndrome has virtually eliminated the condition.

Correct

For neural tube defect has virtually eliminated the condition.

Correct

Screening tests (Cochrane and Holland) should be:

Simple, quick and easy to interpret.

Acceptable.

Accurate.

Repeatable.

Sensitive.

Specific.

The yield of a screening programme is defined as the number of new

previously unsuspected cases per 100 cases screened. Screening
programmes for PKU and congenital hypothyroidism are well established.
They are thought to be extremely cost effective. In congenital
hypothyroidism, the level of TSH at the time of diagnosis is an important
prognostic marker. If it is very high, impairment of neurological
development may not be fully reversible. Screening for PKU uses a
bioassay, bacillus subtlis strains that grow only in high concentrations of
phenylalanine. Antibiotics may interfere with this test. The 2 most
important haemoglobinopathies are sickle cell disease and thalassaemias.
About 3.3% of the UK population belongs to a racial group at significant
risk. Screening should be universal in districts where the ethnic groups
concerned make up more than 10% of the antenatal clinic population.
Screening procedures usually involve either electrophoresis of a blood
spot from the Guthrie card, or using separate capillary specimens. The
argument for screening for cystic fibrosis is less clear, but it will soon
become universal. Screening for Down's Syndrome using the triple test
identifies approximately 60% of cases antenatally. Screening for neural
tube defects using alpha-fetoprotein has dramatically reduced the
incidence of open spina bifida. Closed forms continue to be born.

23-Regarding cerebral palsy:

True / False

The incidence is 2 per 100 live births.

Visual impairment occurs in 50%.
Hearing loss is present in 5%.
Epilepsy is present in 40%.

Correct

Incorrect answer selected

Correct

Correct

Learning impairment is present in 30%.

Correct

Cerebral palsy is a disorder of movement and posture due to a nonprogressive lesion of the motor pathways in the developing brain. The
clinical manifestations tend to evolve with age. The incidence is 2 per
1000 live births, and other problems are common and are reflecting more
widespread damage to the brain. These include:

Learning impairment in 60%.

Epilepsy in 40%.

Squints in 30%.

Hearing loss and visual impairment in 20%.

Speech and language disorders.

In addition, there may be considerable behavioural problems.

24-Which of the following is conditions is associated with mutation in

fibroblast growth factor receptor 3 (FGFR3) gene?
(Please select 1 option)

Retinoblastoma
Achondroplasia

This is the correct answer

Neurofibromatosis type 1
Huntington disease
Marfan syndrome

Incorrect answer selected

Mutations in the fibroblast growth factor receptor 3 cause achondroplasia.

Neurofibromatosis type 1 is caused by a mutation of the neurofibromin
gene (which may act as a tumour suppressor) on chromosome 17q.
Marfan patients have mutations of the chromosome 15 gene encoding
fibrillin, a connective tissue protein.

25-A drug which undergoes high first pass metabolism

True / False

is excreted largely unchanged in the urine

Correct

can only be administered parenterally

Correct

is extensively metabolised by the liver

Correct

has a high extraction ratio

Correct

the extraction ratio is reduced in chronic liver disease

Correct

First pass hepatic metabolism implies extensive metabolism following absorption

of from the gut. Absorption of these agents is usually excellent (drugs may be
lipo or hydro- philic) and can be administered orally with increase of the dose (eg
oestrogens, MST, ISDN). The extraction ratio depends upon liver function and is
usually high (more drug removed following first pass).

26-Theme:Presentation of infectious disease in childhood

Chicken Pox

Herpes simplex

Infectious mononucleosis

Measles

Mumps

Mycoplasma

Pertussis

Rubella

I
Tuberculosis
For each presentation of infectious disease choose the single most likely diagnosis from the
list of options.
Commonly causes an acute gingivostomatitis.
Herpes simplex

Correct

Herpes simplex - the majority of children have benign manifestations of primary

infection with Herpes simplex, for example a gingival stomatitis. The virus is
readily spread by direct contact especially to damaged skin e.g. eczema.

Causing an acute parotitis

Mumps

Correct

Mumps infection is now uncommon due to the vaccination. It is caused by a

paramyxovirus and usually causes minimal symptoms. The most common
manifestation being an acute parotitis although severe infection with mumps may
result in meningoencephalitis plus deafness.

Causing an exudative tonsillitis.

Infectious mononucleosis

Correct

Glandular fever is also called infectious mononucleosis. It is caused by EpsteinBarr virus and usually presents with an exudative pharyngitis or tonsillitis and
cervical lymphadenopathy. It may cause a transient impairment of cellular and
humeral immunity, which is usually self limiting

27-Recognised findings in bulimia include:

True / False

Calluses on the dorsal surface of the hand.

Dental inspection may be helpful.
Hypokalaemia

Correct

Correct

Correct

Body mass index <16

Correct

Abnormal perception of body size

Incorrect answer selected

Bulimia is defined in the Diagnostic and Statistical Manual of Mental

Disorders (DSM-IV) as:
1. Recurrent episodes of binge eating (rapid consumption of
a large amount of food in a period of less than 2 hours).
2. A fear of not being able to stop eating during binges.
3. Regular self-induced vomiting, use of laxatives, or
rigorous dieting or fasting to counteract the effects of
binge eating.
4. A minimum average of 2 binge eating episodes per week
for at least 3 months.
5. Self-evaluation unduly influenced by body weight and
shape, but the disturbance not as excessive as anorexia
nervosa. Their BMI is usually within the normal range. If
abnormal then anorexia with bulimic features is the likely
diagnosis.

28-Medulloblastoma:
True / False

Can metastasise outside the CNS.

Correct

Can metastasise down the neuroaxis.

Correct

Are common in Gorlin's Syndrome.

Correct

Can be successfully treated with chemotherapy.

Can respond to radiotherapy.

Correct

Correct

Medulloblastoma accounts for 20% of brain tumours. It nearly always

arises in the midline of the posterior fossa. It presents with ataxia plus
raised intracranial pressure. The tumour may seed throughout the CNS,
and via the CSF, and up to 20% have spinal metastases at diagnosis.
Treatment is with total CNS radiation after maximal surgical resection, and
has a 5 year survival of 50%. Chemotherapy may be beneficial in
completely resected cases and those with intraspinal metastases.
Gorlin Syndrome (nevoid basal cell carcinoma syndrome) is AD, with a
defect on chromosome 9. It includes a wide spectrum of defects involving
skin, eyes, CNS, endocrine system and bones.

Skin: early onset basal cell carcinoma.

Eyes: cataract, glaucoma, coloboma, strabismus,

blindness.

CNS: falx calcification, fits, mental retardation,

partial agenesis of the corpus callosum,
hydrocephalus, nerve deafness, medulloblastoma.

Endocrine: hypogonadism, with absent or

undescended testes.

Bones: anomalous rib development, spina bifida,

kyphoscoliosis.

29-Theme:Mood disorders
A

Adjustment disorder with prolonged depressive reaction

Adjustment disorder with brief depressive reaction

Bipolar affective disorder

Depressive conduct disorder

Persistent depression with cyclothymia

Persistent depression with dysthymia

Post-schizophenic depression

Recurrent depression with psychotic symptoms

Recurrent depression with somatic symptoms

For each scenario choose the most likely diagnosis.

A 12-year-old girl presents with irritability, loss of interest in her hobbies, poor concentration at
school and weight gain of 10 kg over the past two and a half years.
Recurrent depression w ith somatic symptoms

Incorrect - The correct answer is Persistent depression with dysthymia

This girl is depressed for no identifiable reason. There are no "highs", so

she has persistent depression with dysthymia.

A 13-year-old boy presents with feelings of worthlessness and decreased school performance.
His father committed suicide six months previously.
Adjustment disorder w ith prolonged depressive reaction

Correct

This boy is depressed following bereavement, so has an adjustment

disorder with prolonged depression.

A 15-year-old girl presents following an overdose. She feels that her teachers are picking on her
all the time, and she hears their voices criticising her for poor school performance.
Depressive conduct disorder

Incorrect - The correct answer is Post-schizophenic depression

This girl has primary schizophrenic symptoms and lowered mood.

Depression is a mood disorder, which ranges in severity. Major depression

may be biologic or psychotic. Chronic depression lasts more than one
year.
Both genetic (positive family history) and environmental factors may play
a part.
In 50% of cases other conditions co-exist, e.g.

conduct disorder

anxiety

ADHD

school refusal.

30-Theme:Large anterior fontanelles

A

Achondroplasia

Apert's syndrome

Athyrotic hypothyroidism

Hallermann-Streiff syndrome

Hypophosphatasia

Pyknodysostosis

Rubella syndrome

Russell-Silver syndrome

Trisomy 13

Vitamin D dependent rickets

Which of the listed conditions best fits the features below?

Cleft palate and hypotelorism.
Trisomy 13

Correct

Patau syndrome (trisomy 13) is associated with midline defects including

hypotelorism, cleft palate, microphthalmia and cyclopia in some cases.

Acrocephaly and syndactyly.

Apert's syndrome

Correct

Apert's syndrome is one of the craniosynostoses (premature fusion of the

cranial sutures). It is characterised by syndactyly of fingers and toes.

A fatal metabolic condition of infancy associated with bony abnormalities and low serum alkaline
phosphatase.
Hallermann-Streiff syndrome

Incorrect - The correct answer is Hypophosphatasia

Hypophosphatasia is a genetic abnormality of alkaline phosphatase, which

leads to a spectrum of bony disorders, resulting in a fatal prognosis.

31-Theme:Treatment of Diarrhoeal illness

A

Metronidazole

Gluten free diet

No action

Steroids

Cow's milk free diet

Pancreatic enzyme supplements

Vitamin D

High fibre diet

Breast milk allergy

Praziquantel

Select one option from the list above that is most suitable for the following
patients:

A 6 month old baby has diarrhoea and failure to thrive, which mother feels has been brought on
by the introduction of weaning. On examination he appears wasted, with loose buttock folds.
Gluten free diet

Correct

Likely coeliac disease, which can be confirmed by coeliac antibodies and biopsy,
and respond to gluten-free diet.

A 13-year-old Irish girl complains of diarrhoea. She is Iron deficient and denies any history of GI
upset after eating rice or potatoes. She has high anti-reticulin antibodies
High fibre diet

Incorrect - The correct answer is Gluten free diet

refers to Coeliac disease where a gluten free diet is appropriate. High reticulin or
more specifically now anti-TTG antibodies are expected. The diagnosis is
confirmed by jejunal biopsy.

A 10-year-old boy presents with faecal urgency and bloody diarrhoea. He is also under the care
of ophthalmologists for a chronic iritis.
Steroids

Correct

relates to inflammatory bowel disease, Crohn's disease and ulcerative colitis

respectively. In Crohn's disease the colonoscopy will reveal cobbled stone mucosal
appearances with fistulae where as in ulcerative colitis crypt abscesses are
present.

32-Theme:WEAKNESS IN THE LOWER LIMBS

A

Guillain-Barre syndrome

Transverse Myelitis

Multiple sclerosis

Chronic fatigue syndrome

Spinal tumour

Dermatomyositis

Congenital myopathy

Duchenne muscular dystrophy

Fascioscapulohumeral dystrophy

J
Spinal abscess
For these children with lower limb weakness select the most likely diagnosis

A 4-year-old boy is brought to clinic by his mother who feels he has weak legs and is finding
climbing the stairs difficult. He walked independently at 20 months and has received speech
therapy for a mild speech delay. On examination his lower limb reflexes are normal, his muscles
are well developed distally although weak proximally.
Duchenne muscular dystrophy

Correct

DMD occurs in boys and presents with delayed walking i.e.> 18months. Speech
delay, cardiomyopathy, scoliosis and calf pseudohypertrophy are also features.

A 12-year-old girl presents with a 5 day history of progressive weakness in her legs and is now
unable to walk. She has been passing urine frequently and with difficulty. On examination there
is power with gravity eliminated in her legs, very brisk ankle and knee jerks and upgoing plantar
responses. Her bladder is palpable up to the umbilicus. Sensation is reduced to touch below T5,
vibration and position sense are preserved 3 weeks previously she had a presumed viral illness.
MRI brain is normal but shows swelling and increased signal over the spinal cord T5-7 on T1weighted images. Lumbar puncture shows 33 lymphocytes and monocytes per microlitre and
protein 570 mg/L in the CSF.
Spinal abscess

Incorrect - The correct answer is Transverse Myelitis

The features are suggestive of a lower motor neurone lesion which could also be
caused by a spinal tumour / abscess however the MRI would demonstrate these
latter pathologies. The CSF lymphocytosis and increased protein may be seen in
transverse myelitis. Transverse myelitis has unknown aetiology but has been
postulated to have a viral or mycoplasma origin.

A 14-year-old girl has been off school for 4 months with headaches, tiredness and weakness of
her legs. In the initial weeks of her illness she had a low-grade fever, sore throat and cervical
lymphadenopathy. A blood count showed atypical lymphocytes and liver function tests show a
raised AST. These were re-checked 1 month later when they had normalised and thyroid
function, urine culture urea & electrolytes were also normal. It is difficult to get her full cooperation for examination but there are no objective signs of weakness and reflexes are all
present, symmetrical with downgoing plantar responses.
Chronic fatigue syndrome

Correct

The previous viral illness and subsequent lethargy with no consistent abnormal
investigations suggest chronic fatigue syndrome.

33-The following are notifiable diseases in England and Wales

True / False

Acute encephalitis
Dysentery

Correct

Correct

Pulmonary tuberculosis
Chickenpox

Correct

Correct

Kawasaki Disease

Correct

Notifiable infections include:

Bacterial: anthrax, diphtheria, leptosporosis,

pertussis, plague, Brucellosis, tetanus, typhus,
cholera, dysentery, food poisoning, paratyphoid
fever, typhoid, leprosy, tuberculosis, meningitis,
meningococcal infection, ophthalmia neonatorum,
erysipelas, scarlet fever.

Viral: acute encephalitis, AIDS, hepatitis B,

measles, mumps,rubella, poliomyelitis, rabies,
varicella (encephalitis- chickenpox isn't) , yellow
fever.

Protozoal: malaria.

Chicken Pox is notifiable in Scotland.

34-A 3-year-old girl presents with a 3 day history of bloody diarrhoea,

followed by pallor, and reduced output of smoky coloured urine. Full term
normal delivery with no neonatal complications. Immunisations up to
date. There is no FH/SH of note.
On examination she is apyrexial, Respiratory rate is 15/min and pulse is
95/min. She appears pale and has a few petechiae over the abdomen.
Blood pressure is 110/90 mmHg.
What is the most likely diagnosis?
(Please select 1 option)

Benign familial haematuria

Haemolytic uraemic syndrome
Haemorrhagic cystitis

Correct

Post-streptococcal glomerulonephritis
Urinary tract infection

The history of bloody diarrhoea followed by reduced output of blood-stained urine

and petechiae strongly suggest Haemolytic Uraemic Syndrome, now the
commonest cause of acquired renal failure in childhood. This is the triad of
intravascular thrombosis, thrombocytopaenia and acute renal failure. 85% are
associated with (bloody) diarrhoea, with Escherichia coli 0157:H7, and Shigella
being the commonest culprits.

35-Theme:Infections
A

Measles

Rubella

Chicken pox

Herpes simplex

Mumps

Glandular fever

Pertussis

Polio myelitis

Hepatitis A

For each description below choose the single most likely infection from the
list of options.
Caused by a gram negative pleomorphic bacillus.
Pertussis

Correct

Whooping cough is not uncommon in infancy. It typically presents with apnoeic

episodes or cyanotic episodes during infancy. In the older child upper respiratory
tract infections and a paroxysmal cough with a whoop is characteristic.

Is caused by a paramyxovirus which can cause orchitis.

Mumps

Correct

Mumps and measles are caused by a paramyxoviruses, but only mumps causes
orchitis.

This infection is most often associated with post-viral fatigue.

Glandular fever

Correct

Glandular fever virus infects the B lymphocytes which results in an immunodeficiency which is usually self limiting.

36-A 14-year-old girl presents with a history of cough and

breathlessness on exercise. She has seasonal rhinitis, and admits to have
started smoking. Clinical examination is unremarkable.
What is the most likely diagnosis?
(Please select 1 option)

Gastroesophageal reflux
Allergic rhinitis
Sinusitis
Asthma

Correct

Croup

A typical history of asthma in later childhood, with exercise-induced

symptoms and a general deterioration on commencement of smoking.
Unfortunately this is all too common these days.

37-The following are recognised causes of post-neonatal hypoglycaemia:

True / False

Tricyclic overdose
Urea cycle defects

Correct
Correct

Congenital adrenal hyperplasia

Incorrect answer selected

Medium chain Acyl coenzyme-A dehydrogenase deficiency

Correct

Intravenous Salbutamol

Correct

The major causes are:

METABOLIC:

a) Ketotic hypoglycaemia.

b) Liver disease: Reye's Syndrome, acute liver

failure.

c) Inborn errors of metabolism (glycogen storage

disease, galactosaemia, MCAD deficiency, organic
acidaemia, tyrosinaemia, hereditary fructose
intolerance).

d) Poisoning: alcohol, aspirin.

a) Growth hormone.

b) ACTH: panhypopituitarism.

c) Cortisol: Addison's Disease, congenital adrenal

HORMONAL:

hyperplasia.

d) Hyperinsulinsim: Nesidioblastosis, Beckwith's,

insulinomas, exogenous insulin.

38-In Henoch-Schnlein purpura:

True / False

The rash is usually on buttocks and extensor surfaces

The platelet count is decreased

Correct

Correct

Some patients develop minimal change nephrotic syndrome

Incorrect

answer selected
Abdominal pain is common

Correct

The purpuric spots do not blanch on pressure

Correct

The rash is on the back and thighs. It is a non thrombocytopenic purpura.

The resulting glomerulonephritis is membranoproliferative rather than
minimal change nephropathy.
Abdominal pain and bloody stools may occur.
The purpuric spots are vasculitic and do not blanch on pressure.

Abdominal pain is one of the cardinal symptoms of HSP. According to a

study quoted in emedicine: "Abdominal pain was more common in
children than adults (70.2% vs 28.9%)" Henoch-Schnlein Purpura at
eMedicine

39-A 7-year-old girl presents with right ear pain and fever, worsening
over the past few days.
Symptoms began seven days ago with severe ear pain and fever, which
was treated with paracetamol. The following morning the pain resolved
and a purulent discharge mixed with blood was noted on her pillow. Four
days later the pain is throbbing and her ear is tender.
She was born at term weighing 3.68kg and there were no neonatal
problems. She is fully immunised, and there is no FH/SH of note.
On examination she has a fever to 39.7C, and her right ear is displaced
downwards and forwards. She is extremely tender behind the right ear,
and has a purulent discharge from the ear canal. Her pulse is 100/min and
respiratory rate is 15/min.
What is the most likely diagnosis?
(Please select 1 option)

Cholesteatoma
Mastoiditis

Correct

Otitis media, acute

Otitis media, recurrent
Otitis media with effusion

The history suggests acute otitis media with perforation, followed by acute
mastoiditis (acute mastoid osteitis).
This can be confirmed by CT scan of the mastoid.
Pneumococcus and H. influenzae are the commonest cause.
Most resolve with antibiotics, but some require surgical drainage

40-Marasmus:
True / False

is commoner in twins

Correct

is due to protein deficiency

Correct

may be associated with severe chronic bowel disease

the risk of superadded infection is high during recovery

Correct
Incorrect

answer selected
the recovery of older children is much greater than younger

Correct

Starvation, can coexist with kwashiokor. The risk of infection is high at any time in fact if the child has no clinical sign of infection, the WHO recommends 5 days of
oral cotrimoxazole therapy. Read more

41-Theme:Apgar score
A

10

Select the most appropriate Apgar score for the following babies.
A baby is born with a pink appearance all over, a respiratory rate of 30/min, a pulse of 125/min
actively moving his limbs and is crying
10

Correct

This is a full house:

normal appearance - pink (2)

pulse - heart rate above 100 (2)

grimaces - crying (2)

activity - moving all four limbs (2)

respiration - 30/min normal, crying (2).

A baby is born with a blue complexion, a heart rate of 96/min, has some flexion of muscle tone,
grimaces when stimulated with suction and has irregular respiration
5

Incorrect - The correct answer is 4

In this case:

appearance being blue (0)

pulse is less than 100 (1)

grimace when stimulated (1)

activity - flexion (1)

respiration - irregular (1).

A baby is born with peripheral extremities that are blue but is centrally pink, has a heart rate of
106 on the monitor, coughs when stimulated, moves all limbs and has some irregular respiratory
effort.
7

Incorrect - The correct answer is 8

On this occasion:

appearance of blue peripheries (1)

pulse - more than 100 (2)

grimace - coughs when stimulated (2)

activity - moving limbs (2)

respiration - irregular respiratory effort (1).

The Apgar score is a simple test to assess newborn health and was
devised by Virginia Apgar in 1952. The baby is evaluated on five simple
clinical scores from 0-10.

Appearance

Pulse

Grimace

Activity

Respiration.

42-A girl aged 5 years attending normal school presents to the

outpatient clinic with bilateral enlargement of the breasts. Bone age is 5.8
years and height is on the 90th centile.
There has been no vaginal bleeding:
Which of the following is correct:
(Please select 1 option)

The diagnosis is unlikely to be precocious puberty

Correct

It is desirable to check her karyotype in making a diagnosis

Lateral skull X-ray should be requested
Menarche will likely take place in 3 years
She will need to be treated with Clomiphene

The diagnosis is unlikely to be precocious puberty as elevated gonadal

steroid levels increase height velocity and the rate of skeletal maturation
as well causing feminisation and breast development.
The condition is more suggestive of premature thelarche. Karyotypic
anomalies are not relevant. If central (LHRH dependent) precocious
puberty is suspected then MRI would be of value rather than cranial
ultrasound to identify hypothalamic lesions and other CNS lesions.
However pelvic ultrasound showing normal uterine volume is the most
sensitive discriminator between premature thelarche and true precocious
puberty. Puberty and menarche should take place at the normally
expected timing( 11-13y).
LHRH agonists are used in the treatment of precocious puberty of all types
and not clomiphene, an estrogen antagonist.

43-Regarding osteosarcomas

True / False

Affects the epiphyses of long bones

Correct

Are most commonly seen around the knee and in the proximal humerus
Correct
Haematogenous spread can result in pulmonary metastases
Is exclusively a disease of adolescence and early adult life

Correct
Correct

x Ray shows a 'sunburst' appearance due to soft tissue involvement

Correct

Osteosarcomas affect the metaphyses of long bones. They are most

commonly seen around the knee and in the proximal humerus.
They often occur in young adults but are also seen in the elderly in
association with Paget's disease.
They usually present as bone pain and a palpable lump. x Ray shows
periosteal elevation (Codman's triangle) and a 'sunburst' appearance due
to soft tissue involvement.
Early haematogenous spread occurs and the five year survival rate is
approximately 50%.

44-Characteristic features of idiopathic diffuse interstitial fibrosis of the

lung (HAMMAN-RICH) include:
True / False

Cyanosis on exercise

Correct

Inspiratory crackles on auscultation

Hypercapnia

Correct

Incorrect answer selected

Decreased FEV1/FVC ratio

Correct

Decreased gas transfer factor

Incorrect answer selected

This is a rare, chronic and often fatal disorder only occasionally seen in
infants and children. There is an uncontrolled inflammatory process
leading to progressive fibrosis. Clinically, there is progressive pulmonary
insufficiency resulting from interstitial fibrosis and alveolar-capillary block.
The onset is insidious with dyspnoea on exercise, later at rest. Gradually,
anorexia, weight loss, fatigue ability followed by cyanosis, clubbing, cor
pulmonae and right sided heart failure occur. Inspiratory crackles may be
heard. There is no increase in airway resistance, but vital capacity,
compliance and diffusion capacity are decreased. The spirometry shows a
restrictive defect, with an increased FEV1:FVC ratio.

45-Diffusion capacity of carbon monoxide:

True / False

Is a specific measure of lung perfusion.

Correct

Depends on the thickness of the alveolar wall.

Correct

Depends on the surface area available for gas exchange.

Is increased in cigarette smokers.
Is increased in emphysema.

Correct

Incorrect answer selected

Correct

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

46-The following are compatible with a diagnosis of Werdnig-Hoffmann

Syndrome:
True / False

Fasiculation of the fingers

Brisk tendon reflexes

Incorrect answer selected

Correct

Pseudohypertrophy of the arm and leg muscles

Incorrect answer

selected
Intercostal recession

Correct

Positive Gower's sign

Correct

Spinal muscular atrophy type 1 (Werdnig-Hoffmann Disease) is an

autosomal recessive degenerative disorder of the anterior horn cells,
which leads to progressive weakness and wasting of skeletal muscles. It
presents in early infancy. There may be diminished fetal movements, and

arthrogryposis noted at birth. Typical signs include fasiculation of the

tongue, intercostal recession, lack of antigravity power and the hip
flexors, and absent deep tendon reflexes. Death is from respiratory failure
by 12 months of age. Despite being very floppy, the child is usually very
alert.

47-A 3-year-old girl has a fit in association with a temperature of 39C:

True / False

A lumbar puncture is indicated.

Correct

The risk of future epilepsy is 1%.

Correct

An EEG is indicated if the fit is tonic clonic.

Correct

Fits lasting longer than 5 minutes should be thoroughly investigated.

Correct
The commonest precipitating infection is a Streptococcal throat infection.
Incorrect answer selected

Febrile seizures occur in 3-4% of young children, particularly between 9

months and 5 years. Occasionally, a febrile convulsion may signify a
serious underlying acute infectious illness such as bacterial meningitis.
Typically, the seizure is generalised tonic clonic and lasts less than 10
minutes. Atypical seizures last longer than 10 minutes, may have focal
features, may recur or be associated with a positive family history of
epilepsy, occur below 9 months of age, or be associated with delayed
development or abnormal neurological examination. The incidence of
epilepsy in uncomplicated cases is 1%, increasing to 9% when several risk
factors are present. If any doubt exists with regard to the possibility of
meningitis, an LP is indicated (if safe). The commonest precipitants are
viral infections of the upper respiratory tract, roseola, and acute otitis
media.
Copyright 2002 Dr Colin Melville

48-A 2-year-old boy presents with fever and knee pain for 18 hours. He
has previously been well.
He had a full term normal delivery with no neonatal problems. His
immunisations are up to date. There is no family or social history of note.
On examination the temperature is 38.9 C, with respiratory rate 24/min
and pulse 100/min. He is alert and well perfused. His left knee is swollen,
warm, red and exquisitely tender. It is held partly flexed.
o

What is the most likely diagnosis?

(Please select 1 option)

Haemophilia A
Juvenile rheumatoid arthritis
Osteomyelitis
Reactive arthritis
Septic arthritis

Correct

The short history, fever, location and clinical findings all point to a septic
arthritis.
This can be confirmed by blood culture and needle aspiration of the joint.
The common organisms are Staph. aureus and Gram negative Bacilli, with
Guillain-Barr syndrome (GBS) in less than 3/12 infants.
Treatment is with intravenous antibiotics, with resolution followed by
settling white cell count, erythrocyte sedimentation rate and C reactive
protein.

49-A 5-year-old girl presents with vomiting and diarrhoea. This began
two days ago. The vomiting is now settling, but the diarrhoea has
contained admixed blood and some slime.
She was a healthy term infant, with no previous medical problems, nor
adverse FH/SH.
On examination she has a temperature of 38.6C and is quiet. She has a
dry mouth and reduced skin turgor. Respiratory rate is 25/min and heart
rate 100/min. No rash. Her peripheries are cool and capillary refill time 4
seconds.
What is the most likely diagnosis?
(Please select 1 option)

Campylobacter gastroenteritis

This is the correct answer

Crohn disease
Escherichia coli0157:H7 infection
Salmonella typhi infection
Viral gastroenteritis

Incorrect answer selected

This child has acute bloody diarrhoea (dysentery) accompanied by

significant dehydration (5-10%).
This is most likely due to a bacterial gastroenteritis. The commonest
offending organism is Campylobacter followed by Salmonella and Shigella.
Escherichia coli 0157:H7 causes occasional outbreaks and may be
associated with haemolytic uraemic syndrome.
Occasional imported cases of typhoid are seen, and foreign travel is
important to enquire about.
In this country undercooked frozen food (barbeques and takeaways) are
the commonest culprits.

50-A 18-year-old girl presents with anxiety and palpitations.

Her mother had been treated for an overactive thyroid gland having
received radioiodine and was now on thyroxine replacement therapy.
On examination she had a pulse of 104 bpm with a fine tremor and lid lag.
There was no goitre palpable.
Investigations revealed:
Serum free T4

33 pmol/L (10-22)

Plasma thyroid stimulating hormone (TSH)

<0.05 (0.4-5)

Serum antithyroid peroxidase (anti TPO) titre

40 U/L (<50)

What is the most likely cause of her symptoms?

(Please select 1 option)

Factitious thyrotoxicosis
Familial hyperthyroglobulinaemia
Hashitoxicosis
Graves' disease

Incorrect answer selected

This is the correct answer

Riedel's thyroiditis

Although the lead-in might make you think that this patient could gain
access to thyroxine and so a diagnosis of factitious hyperthyroidism is
possible, in practice this is extremely unlikely.
A strong family history of thyrotoxicosis is typical for Graves' disease and
the absence of a goitre with the absence of TPO antibodies (found in 80%
of Graves' cases) again is compatible with a diagnosis of Graves'.