Kod:
WELCOME
to a written examination in Reproduction and Development
Wednesday April 29, 2009
9 a.m until 1 p.m. (incl going through the exam)
Name:……………………………………................
Total: 122,5 points
Pass: 82 points
Result : .................. points
Good luckl!!
Written exam in Reprod and Developm spring 2009
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Kod:
Question 1
A woman visits you at Antenatal care(ANC) in pregnancy week 20. She is healthy and gave birth
to a child three years ago, partus normalis (PN). The baby weighed 2.3 kg. Blood pressure today
125/75 mm Hg, urine test shows 0/trace for proteinuria. She has just been on a routine ultrasound
and everything was good there. She feels good and is working as usual and it goes well.
a)
Name three important reasons for routine ultrasound? (1,5p)
b)
Are there any reasons in accordance with the above to take any more action during
pregnancy? (1p)
Question 2
Sometimes a distinction is made between symmetrical and asymmetrical SGA. In the first case is
both the head and abdomen involved in a similar extent, in the latter case, the abdominal diameter
is particularly reduced.
a)
What is the abbreviation for SGA? (1p)
b)
What other measurement in addition to the head and abdomen diameters underlies the
weight estimate by ultrasound. (1p)
c)
What is the reason for the lower perinatal morbidity / mortality in symmetric when
compared to asymmetric SGA? (1p)
Question 3
A woman consults you at the ANC in pregnancy week 37. She has gained 14 kg during pregnancy
and her legs feel tense. She states that she is otherwise healthy. Blood pressure is 125/75 mm Hg,
urine test shows 0/trace for proteinuria. When you examine her you find substantial edema in the
lower parts of the legs but no facial swelling.
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Kod:
a)
Do you want to take some tests and if so, which? (1p)
b)
What is your advice to her? (2p)
Question 4
You work as junior doctor at the obstetric ward. The midwife in charge of the phone counselling
is asking you for help with a phone call. She speaks to a man whose wife is 8 months pregnant,
and who suddenly got pain in the abdomen and vaginal bleeding.
a)
You must now tell them what they should do. What is the most important? (1p)
b)
Your hospital is the nearest one. The ambulance is on its way. You are waiting for the
patient to arrive. She enters on a stretcher. Ambulance staff have already placed an iv
catheter an initiated an infusion of Ringer acetate. Blood pressure is 110/60. Pulse 110.
Ambulance staff reported substantial blood on the floor when they arrived at the patients
home. In the ambulance the patient lost approximately 500ml blood as estimated by
ambulance paramedics.
They inform you that the abdomen is tense and painful and a clot of at least 2 dl from the
vagina is noted when the patient is placed into the bed.
You have called the senior consultant who is now on her way to the hospital.
You are being informed that the patient is pregnant v 35 +6. The fetal heart can be
registered with a rate of 90 using CTG. You examine the abdomen and find it tense and
painful.
What diagnosis do you suspect? (1p)
c)
What action would you recommend? (1p)
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Kod:
d)
What complication may encounter because of the major bleeding, and what analysis should
you order? (3p)
Question 5
Annika, a 32-year-old 2-g 0-para, phones the obstetric ward. She is now in 39 +6 weeks of
pregnancy. She is worried and reports she has contractions every three minutes. Annika wonder if
it is time to come in to the hospital. She suspects that a rupture of the membranes has occurred.
a)
What is the correct answer from the midwife? (1p)
b)
Mention four examinations, always performed when a woman comes in to the delivery ward
with contractions? (2p)
c)
Annika has a quick delivery and it is assessed as a partus normalis (PN). Describe at least
four criteria that must be fulfilled for a PN. (2p)
Question 6
a)
Give two (2) symptoms of chorionamnionitis during delivery. (1p)
b)
Give 2 obstetric diagnoses that are associated with this complication. (1p)
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Kod:
Question 7
Malena has had insulin-treated diabetes since she was 14 years. She is now 24 years and has
regular partner since one year and they want to have children.
a)
What is the most important information she should get if she will try get pregnant with
regard to her diabetes? (1p)
b)
She wonders how her pregnancy will affect her diabetes and lifestyle? (1,5p)
c)
She asks if there are any risks for the baby? Mention at least two. (1p)
Question 8
a)
Define urgency incontinence . (1p)
b)
Name two (2) conditions that may cause urgency incontinence (1p)
c)
How would you treat idiopathic urgency incontinence? (1p)
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Kod:
Question 9
A woman consults you, in pregnancy week 5+6 days (since LMP), because of a minor vaginal
bleeding. Her menstrual cycle is normally 28 days.
a)
How many days ago did her ovulation take place most probably? (1p)
b)
Describe what you see in the picture? (1p)
c)
You can not verify any heart movements during examination. What is your plan for the
patient? (1p)
d)
Mention four (4) risk factors for miscarriage? (2 p)
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Kod:
Question 10
38-year-old woman consults at the gynecology clinic due to bleeding. She is I-g, 0-p, with a
history of a surgical abortion 15 years ago. Previously healthy. Since 6 months heavy bleeding
forcing her to refrain from work. She feels weak and is dizzy. She visited her general practitioner
three months ago and was prescribed Cyklokapron (tranexam acid) tablets 500 mg 2 tabl x 4 in 5
days, no appointments scheduled after that.
a)
What information do you miss in her history? Mention three (3) important things you would
like to know (1,5p)
The patient is pale, heart rate 88 bpm. Blood pressure 110/70. No fever
Abdomen: Soft, no defense.
Vaginal examination: on-going bleeding from uterus. Bimanual examination reveals an enlarged
uterus corresponding to the size of a 10-11 weeks pregnancy. No palpable mass in the pelvis
b)
What tests would you like to perform? (1,5p)
c)
What treatment do you suggest for her menorrhagia? (2p)
Question 11
a)
Give two (2) genetic explanations to male infertility (1p)
b)
How to treat a 37-year-old woman with a previously known severe endometriosis and
infertility, 2 years after she stopped using the pill if she wants to get pregnant? (1p)
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Kod:
Question 12
Annabelle, 32 years, has been on gynecological health check where a PAP smear was taken. She
has now been informed that there were some abnormalities found in the test "precursor to cancer"
corresponding to CIN II.
a)
She asks you if the answer may be right since she has no symptoms at all. What do you tell
her? (1p)
b)
What is the cause of abnormal cervical cytology? (1p)
c)
How should you handle this abnormal cytology? (1p)
d)
The patient has heard about conization- how and why is this procedure performed? (2p)
Question 13
Johanna, 28 years of age, visited the midwife at the familiy planning clinic for contraceptive
counselling.
She has 2 children, during both pregnancies she had preeclampsia.
She would now have an IUD. Lately, she experienced a certain sense of discomfort to the left in
the lower abdomen. Menstruation varies between 25-40 days since the last 4 months. LMP 4
weeks ago. Pregnancy test is negative. In the attempt to insert the IUD the midwife palpates
something "slightly to the left, maybe a cyst." Johanna is very worried.
a)
What should the midwife do? (1p)
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Kod:
b)
What is the most likely explanation to the mass palpated by the midwife? 1p)
c)
An ultrasound examination is performed and a 5 cm echo-free, single cyst without any solid
parts is found. How do you handle this finding? (1p)
Question 14
Lena discovers that she forgot to take two oral contraceptives. She had intercourse yesterday. She
does not want to become pregnant and comes to you for help. What two treatment methods can
you recommend? (1p)
Question 15
a)
Mention three (3) possible symptoms indicating ovarian cancer. (1,5p)
b)
Mention three (3) possible clinical findings in ovarian cancer (1,5p)
c)
Give three (3) risk factors for ovarian cancer. (1,5p)
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Kod:
Question 16
You work temporarily as a general practitioner on the VC Vingåker ( a small community) when a
22-year-old, 0-para, consult you with a daily history of abdominal pain localized to the lower part
of the abdomen.
Temp 37.3 °C. Mild nausea, episodes of diarrhea, urination without problem
a)
What anamnestic information are you missing? (2p)
During examination of the abdomen you find a tenderness in the lower abdomen, no defense.
Vaginal examination reveals a minor sanguineous discharge.
Uterus anteverted, normal-sized, tender at dislocation, firm,mobile. Bimanual examination reveals
bilateral pain.
b)
Give four (4) differential diagnosis (2p)
c)
Which tests do you order? (2p)
You perform a wet smear, see figure
d)
What is the possible diagnosis? (1p)
Later you will find the Chlamydia test
positive.
e)
How will you now manage the case?
(2p)
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Kod:
Question 17
Glomerulonephritis and Nephrotic Syndrome (especially “minimal change disease” which is the
most common form) are next to urinary tract infections two of the most common renal diseases
that you may come across. Below follows a list of symptoms and complications for each disease
of which one is not correct. Please underline which symptom/complication is wrong.
a)
Nephritis: (1p)
1. Headache
2. Decreased urine output
3. Macroscopic hematuria
4. Elevated kreatinin.
5. Hypervolemia
6. Elevated Hb/HCT
b)
Motivate your answer in question a). (2p)
c)
Nephrotic syndrome: (1p)
1. Massive oedema
2. Proteinuria
3. Elevated creatinine
4. Risk of thrombosis
5. Elevated Hb/HCT
6. Hypovolemia
d)
Motivate your answer in question c). (2p)
Question 18
A refugee family who recently (about 1 week ago) came to Sweden comes to the emergency ward
because of coughing and running noses in their two children, Ali 2 months and Latifa 18 months.
The children have been ill in their airways for about 2 weeks and Latifa is the most ill. She has a
tiresome cough both night and day. Ali had about one week ago something that the interpreter
describes as an apneoa about 1 minute long. No high fever. Respiration without remarks, the
children are not obstructive.
a)
You suspect that this is not a normal cold. Suggest a relevant differential diagnosis. (1p)
Written exam in Reprod and Developm spring 2009
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Kod:
b)
Suggest a simple capillary test that may strengthen your thought. (1p)
c)
You were right! Can you treat this condition and in that case how? (1p)
Question 19
Jaundice in neonates is one of the most common conditions to assess not only for pediatricians but
also for general practitioners and others.
a)
Suggest at least three things that contribute to the sometimes very high bilirubin levels seen
in neonates (the first 1-2 weeks of life). (2p)
b)
Which two ways to treat are there when the bilirubin exceeds the critical upper limit (which
varies with age, if the child is otherwise healthy etc). (2p)
c)
A 4 weeks old baby girl has icterus and the following lab parameters:
Hemoglobine 160, thrombocytes 290, white bloodcell count 4,9, differential count normal.
Bil 360 (conjugated 300 – unconjugated 60), ASAT 1.0, PK 1.0
The girl seems well. Diagnostic suggestions? (2p)
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Kod:
Question 20
Seizures.
a)
Focal seizures are always signs of more serious pathology Which is the treatable disease
that should always be suspected when a newborn child (1-2 weeks) develops a focal
seizure? (1p)
b)
A 4 year old boy comes because of a general seizure that lasted a few minutes. EEG showed
“Rolandic spikes”. What is your primary diagnosis? (1p)
c)
A 1–year old child with high fever comes to emergency ward after having had a seizure at
home (about 1 hour before arriving to the emergency ward). The seizures have passed but
the fever is still high and the general condition is still affected with a clearly reduced
consciousness. What is the first thing that you must do as a diagnostic action? (1p)
d)
A boy, 4 months old, comes acutely because he is grumpy, his development has stagnated
and he has strange twitches. The right diagnosis is made with an EEG and the typical
clinical picture (BNS-seizure). What is the characteristic picture on the EEG called? (1p)
Question 21
Pyelonephritis affects 2-3% of all children during childhood. All investigations and follow ups
aim at preventing renal damage.
a)
State at least 3 principally different risk factors for renal damage after urinary tract infection
(pyelonephritis). (2p)
Written exam in Reprod and Developm spring 2009
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Kod:
b)
Ultrasound is compulsory during ongoing infection especially in small children below 2
years of age. State 3 pathological findings that are possible to notice on an ultrasound and
are of significance for the assessment. (2p)
c)
Especially in older children it is common that children have a negative dip-stick but growth
of bacteria in the culture. How do you explain this discrepancy between the dip-stick and
the urinary culture? (2p)
Question 22
Many children who tolerate cow´s milk have a positive skin prick against cow´s milk protein
and/or cow´s milk specific IgE-antibodies in RAST. On the other hand a negative RAST does not
exclude cow´s milk allergy if the disease history clearly points in this direction. This is also true
for other common allergens. Why is it then that you may still have use of skin prick and RAST in
the investigation of an allergic child?
Explain shortly! (3p)
Question 23
State shortly the background to why general vaccination against Hemophilus Influenzae is desired
in Sweden! (2p)
Question 24
Why do proteins from vegetables need to be combined in the food of a child who is fed up mainly
on a vegetarian diet while combining different protein sources are not so important when it comes
to food from animals? (2p)
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Kod:
Question 25
The fetus has a ductus arteriousus that is normally closed a few days after delivery. Sometimes
this connection remains for months, sometimes even for years and is then called persistent ductus
arteriosus (PDA).
Motivate your answer by shortly describing the conditions in pressure and resistance that are
present in the fetus and after birth.
a)
In which direction does the blood flow across the ductus before birth? (2p)
b)
Which is the direction of the flow in an older child? (2p)
Question 26
What symptoms can be seen in children who are deficient in:
a)
vitamin A (1p)
b)
vitamin D (1p)
c)
iodine (1p)
d)
iron (1p)
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Kod:
Question 27
Hugo, 1 year and 8 months, comes acutely to a primary health care center somewhere in the
middle of Sweden. His mother tells that he has had a cold for a week but he has also had a cough
and a running nose. The last two days he has developed increasing breathing difficulties. He has
been given Bricanyl (B2-stimulator) in oral suspension at home, which he has previously been
prescribed for a cough, but it has hardly helped. When you see him he is pale and in a cold sweat
but he is not cyanotic. He sits on his mother´s lap with risen shoulders, he has retractions. Upon
auscultation you find weak breathing sounds, rhonki and a prolonged expirium. Breathing
frequence 55-60, temperature 38,6°.
a)
State at least 3 actions that need to be taken to get a grip of this affected boy. (2p)
b)
What medicines do you treat with? State at least 2 different medicines. (2p)
Question 28
State 4 clinical findings in children with leucemia and relate/explain each symptom to the
hematological background. (4p)
Question 29
To the emergency ward comes a 2 months old girl with her mother. According to the mother she
has rolled down from the bed. She screamed directly and they never went to see a doctor. Now 2
days later she has started to vomit which has made the mother worried. Upon examination of the
girl you find a bruise on her temple that seems fresh. She further has bruises on both sides of her
thorax, which seem to be of the same date. The girl seems alert and laughs against the examiner.
Apart from this you do not note anything special. How should this be handled? (3p)
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Kod:
Question 30
Stina 5 years has a rash since three days on her legs that is localized to the back of her thighs, on
her buttocks and on her lower legs. The rash consists of small read-blue papulae of different size
from mm – cm. They cannot be pressed away. She also has a swollen ankle and limps because of
this. The last 2 hours she has further been complaining about stomach pains. What diagnosis do
you suspect? Which simple tests do you take and why? How can you treat her stomach pains? (4p)
Question 31
Sture 7 years old has since two months started to be grumpy and unhappy. On a few occasions he
has woken up and complained about headache. On several occasions the last couple of weeks he
has vomited in the morning. He also tells you that he has started to see double and upon
examination you suspect paresis of the abducens nerve.
a)
What diagnosis do you suspect primarily? (1p)
b)
Which (at least two) examinations would you like to perform to verify or exclude your
suspected diagnosis. (2p)
c)
How do you explain the paresis of the abduscens nerve? (2p)
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