GUU PAEDIATRICS MOCK EXAMINATION APRIL 2023

1. Which one of the following is not among the six regions of a primary heart tube?
a. Aortic roots (Arterial poles)
b. Truncus arteriosus
c. Bulbus cordis
d. Sinus venosus (Venous poles)
e. None of the above

2. Which of the following is the normal flow of blood in the heart chambers?
a. From SVC and IVC →Left atrium→ Lungs→ Pulmonary artery→ Right ventricle→ Left
ventricle→ Right atrium→ Aorta→ Systemic circulation.
b. From SVC and IVC → Right atrium →Right ventricle →Pulmonary artery →Lungs
→left atrium →left ventricle →Aorta →Systemic circulation.
c. From SVC and IVC → Left ventricle →Left atrium →Pulmonary artery→ Lungs→
Right atrium →Right ventricle→ Aorta →Systemic circulation.
d. From SVC and IVC → Right ventricle→ Pulmonary artery →Left atrium →Right
atrium→ Lungs →Right ventricle→Aorta →Systemic circulation.
e. From SVC and IVC → Right atrium →Left atrium→ Pulmonary artery →Right
atrium→Lungs →Right ventricle→Aorta →Systemic circulation.

3. The best site for auscultation of the heart sound includes the fol,lowing except;
a. Aortic region; the 2nd right intercostal space
b. Pulmonic region: the 2nd left intercostal space
c. Tricuspid region: the 5th left intercostal space
d. Mitral region: the 5th left intercostal space mid-clavicular region
e. Tricuspid region: 5th right intercostals space

4. Concerning the embryology of the respiratory system, which of the following is not
true?
a. Before birth, surfactant is produced by alveolar epithelial cells type I
b. Growth of the lungs after birth is mainly due to an increase in the number of respiratory
bronchioli and alveoli and not to an increase in size of the alveoli.
c. The esophagotracheal septum divides the foregut into the respiratory diverticulum
anteriorly and the oesophagus posteriorly.
d. The left lung bud develops into two main bronchi and two lobes.
e. The right bud forms three main bronchi and three lobes.

5. Concerning the anatomy of the respiratory system, which of the following is not
true?
a. The lower respiratory tract involves the trachea, bronchi, bronchioles and alveoli.
b. The trachea is lined by a ciliated columnar epithelium with goblet cells within.
c. The right main bronchus is wider, shorter and more vertical than the left.
d. There is a greater tendency for foreign bodies and aspirated material to pass into the left
than the right bronchus.
e. The left lung has only an oblique fissure and hence only two lobes.

6. Which one of the following factors does not lead to increased risk of developing
asthma?
a. Obesity
b. Eczema
c. Rural environment
d. Prematurity
e. Low birth weight

7. The functions of the skin include all of the following except?

a. The skin acts as a protective membrane over the entire body.
b. Nerve fibers located under the skin act as receptors for sensations such as pain,
temperature, pressure and touch.
c. Several different tissues in the skin aid in maintaining the body temperature.
d. Sweat glands produce a watery secretion called sweat that helps to helps to lubricate the
surface of the skin
e. The Sebaceous glands produce an oily secretion called sebum.

8. Identify the acyanotic congenital heart disease that is associated with reduced
pulmonary blood flow and right ventricular hypertrophy.
a. Aortic Stenosis,
b. Aortic Regurgitation
c. Coarctation of the aorta
d. Mitral regurgitation.
e. Pulmonary stenosis

9. Concerning Atrial septal defect, which of the following statements is not correct?
a. The majority of cases of ASD are sporadic.
b. Heart failure is usually common.
c. Ostium secundum type located at the fossa ovalis.
d. In Uncomplicated ASD, there is always a left-to-right shunt as the pressure in the left
atrium is higher than that on the right.
e. Wide fixed splitting of second heart sound.
10. Which of the following cyanotic congenital heart diseases is not associated with ↑
pulmonary blood flow?
a. Transposition of the great vessels
b. Tricuspid atresia
c. Single ventricle
d. Truncus arteriosus
e. Total anomalous pulmonary venous return without obstruction.

11. Concerning Tricuspid atresia, which one of the following is not correct?
a. Polycythemia may occur
b. An increased left ventricular impulse may be noted.
c. Holosystolic murmurs audible along the left sternal border.
d. Cyanosis is usually rare.
e. The 2nd heart sound is usually single.

12. Concerning Truncus arteriosus which of the following statement is not true?
a. Both ventricles are at systemic pressure and both eject blood into the truncus.
b. It is a total mixing lesion with total admixture of pulmonary and systemic venous return.
c. It may be associated with DiGeorge syndrome,
d. A membraneous VSD is always present.
e. First and second heart sounds are normal.

13. Concerning pneumonia, which of the following is not true?

a. Vitamin A deficiency is a risk factor.
b. In 20-60% of pneumonias, no pathogen may be identified.
c. Streptococcus pneumoniae ,Streptococcus pyogenes and Staphylococcus aureus are the
commonest causative pathogens in newborn.
d. Pneumonia is an inflammation of the parenchyma of the lung caused by
microorganismns.
e. More common in families with poor socioeconomic status.

14. With regards to the pathophysiological basis of the clinical manifestation of cardiac
failure, which of the following is not true?
a. Pulmonary venous congestion: gives rise to tachypnea, dyspnea, crepitations and rhonchi.
b. Systemic venous congestion result to raised JVP and hepatomegaly.
c. Increased sympathetic adrenergic activity triggered by reduced cardiac output causes
pallor.
d. Pulmonary venous congestion results in cold extremities.
e. Systemic venous congestion gives rise to edema.

15. The principle of management of heart failure is aimed at all of the following except?
a. Reducing the work load on the heart.
b. Improving myocardial perfomance.
c. Correcting the underlying causes.
d. All of the above.
e. None of the above.

16. With regards to shock, it can result from all of the above except?
a. Inadequate blood volume or oxygen carrying capacity.
b. Inappropriate distribution of blood volume and flow.
c. Impaired cardiac contractility.
d. Obstructed blood flow.
e. None of the above.

17. Concerning the pathophysiology of hypovolemic shock which of the following

statements is not true?
a. Results from deficiency of both intravascular and extravascular fluid volume.
b. It is characterized by decreased preload leading.
c. There is to increased stroke volume and high cardiac output.
d. Tachycardia and increased SVR are compensatory mechanisns.
e. Increased cardiac contractility is also a compensatory mechanismns.

18. Croup is associated with all of the following except?

a. Expiratory stridor
b. Hoarse voice or cry
c. Inspiratory stridor
d. Loud brassy (metallic) cough
e. Varying degrees of inflammatory obstruction of the larynx, trachea and bronchi occurs.

19. Which of the following is not a differential diagnosis of viral croup?

a. Acute epiglottitis
b. Gastritis
c. Bacterial tracheitis
d. Spasmodic croup
e. Foreign body aspiration.

20. The following are common causes of pleural effusion except?

a. Pneumonia
b. Epiglotitis
c. Heart failure
d. Tuberculosis
e. Lupus erythematosus
ANSWERS TO BOF QUESTIONS

1) E
2) B
3) E
4) A
5) D
6) C
7) D
8) E
9) A
10) B
11) D
12) E
13) C
14) D
15) D
16) E
17) C
18) A
19) B
20) B

ESSAY QUESTIONS
 QUESTION 1. A 6months old male was brought to children emergency in severe
respiratory distress with a history of clear catarrh, cough and fever of 3 days duration.
Examination findings revealed an irritable infant with temperature of 38.7 degrees
centigrade, fine inspiratory crepitations and rhonchi.

a. What is the diagnosis? (2 marks)

b. Discuss the condition above under the following headings

i. Epidemiology (2 marks)

ii. Aetiology (2 marks)

iii. Clinical features (2 marks)

iv. Investigation (2 marks)

v. Differential diagnosis (2 marks)

vi. Complications and cormorbidities (2 marks)

vii. Treatment (2 marks)

QUESTION 2: Briefly discuss Atrial Septal Defect(ASD) under the following headings;

i. Introduction (2 marks)

ii. Types (2 marks)

iii. Pathophysiology (6 marks)

iv. Clinical features (2 marks)

v. Investigations (2 marks)

vi. Treatment (2 marks)

ANSWERS TO ESSAY QUESTION

QUESTION 1a. Bronchiolitis

b. i. Epidemiology (0.2 marks for each answer, total 2 marks)

• Peak incidence occurs during the rainy season in tropical countries and winter in
temperate countries.

• Incidence in developing countries is not known but is believed to be similar to developed

countries.

• Prevalence is higher in urban areas.

• It occurs during the first 2 years of life.

• Peak age incidence is 2-8 months (average at 6 months).

• It is commoner in males with M:F of 2:1.

• Most cases are mild lasting for 7-10 days.

• Low socio-economic status increases the risk of hospitalization.

• The mortality of bronchiolitis in hospitalized cases is about 1-2% and occurs most in
children < 6 months.

• Mortality of severe cases is higher in developing countries because of poor nutrition and
healthcare services.

• PREDISPOSING FACTORS

• Rainy season, Cold but dry and dusty harmattan season, Babies that are not breastfed,

Overcrowding, Day-care centers, Babies exposed to cigarette smoke, Low birth weight,

Chronic lung diseases, Congenital heart lesions, Older family members are a common
source of infection.

ii. AETIOLOGY (0.2 marks for any answer, total 2 marks)

• Viruses; Respiratory syncitial virus, Adenovirus, Parainfluenza 1,2,3, Human

Metapneumovirus, Bocavirus, Rhinovirus, Influenza virus

• Bacteria: Mycoplasma pneumonia, Chlamydia pneumonia, Simikania negevensis,

Staphylococcus aureus, Staphylococcus epidermidis, Klebsiella pneumonia

iii. CLINICAL FEATURES (0.2 marks for any answer, total 2 marks)
 SYMPTOMS: Sneezing and clear rhinorrhea, Diminished appetite, Fever of 38.5–39°C
(101–102°F), Subnormal temperature, Respiratory distress, Paroxysmal wheezy cough,
Dyspnea ,Irritability, Tachypneic, Apnea.

SIGNS: Work of breathing may be markedly increased, Nasal flaring and retractions,

Fine inspiratory crepitations, Rhonchi, Prolongation of the expiratory phase of breathing,

Reduced breath sounds, Hepatomegaly and splenomegaly due to lung hyperinflation.

iv. INVESTIGATIONS (0.4 marks each for any answer, total 2marks)

a. Chest X-ray, b. Full blood count, c. Viral testing, d. pulse oximetry,

e. Blood gas / acid base analysis

v. DIFFERENTIAL DIAGNOSIS (0.2 for each answer, Total 2 marks)

Bronchial asthma, Wheeze associated respiratory infection(WARI), pertussis, croup,

Congestive cardiac failure, Aspirated foreign body, Gastro-oesophageal reflux diseases,

retropharyngeal abscess, Acute epiglotittis, Impacted foreign body in the upper airways

COMPLICATIONS AND CO-MORBIDITIES (0.2marks each for any answer, total 2 marks)

Features of dehydration, apnoe and bradycardia especially in infants <2months,

Acute otitis media, Hypoxaemia with or without hypercarbia, Viral pneumonia

Secondary bacterial pneumonia,Recurrent wheezing or asthma, Urinary tract infection

TREATMENT (0.2 marks for each answer, total 2 marks)

Oxygen therapy, Increase fluids and feeds, Trial of bronchodilators, Antiviral ribavirin,

Corticosteriod therapy and other antinflamatory agents such as leukotriene, antipyretics, nasal
decongestion, cough mixtures, antibiotics, antipyretics, chest physiotherapy.

QUESTION 2
INTRODUCTION (0.4 marks each for any 5, total 2 marks)

• Accounts for 5-10% of all congenital cardiac defects in live births.

• Male: Female is 1:3

• The majority of cases of ASD are sporadic.

• autosomal dominant inheritance does occur in;

-(i) the Holt-Oram syndrome (hypoplastic or absent radii, 1st-degree heart block, ASD).

-(ii)families with secundum ASD and heart block.

TYPES (total 2 marks)

(i) Ostium secundum type located at the fossa Ovalis. It is the most common accounting for up to
80% of all ASDs.

(ii) Ostium primum type located at the lower part of the septum. It is also known as partial
endocardial cushion defect.

(iii) Sinus venosus type located in the superior part of the septum. Usually associated with
anomalous drainage of the right pulm. Veins.

PATHOPHYSIOLOGY (0.5mark for each answer, total of 6 marks)

• In Uncomplicated ASD, there is always a left-to-right shunt as the pressure in the left
atrium is higher than that on the right.
• The degree of left-to-right shunting is dependent on the size of the defect, the relative
compliance of the right and left ventricles, and the relative vascular resistance in the
pulmonary and systemic circulations.
• In large defects, a considerable shunt of oxygenated blood flows from the left to the right
atrium.
• This blood is added to the usual venous return to the right atrium and is pumped by the
right ventricle to the lungs.
• With large defects, the ratio of pulmonary to systemic blood flow (Qp : Qs) is usually
between 2 : 1 and 4 : 1.
• The large blood flow through the right side of the heart results in enlargement of the right
atrium and ventricle and dilatation of the pulmonary artery.
 • Despite the large pulmonary blood flow, pulmonary arterial pressure is usually normal
because of the absence of a high-pressure communication between the pulmonary and
systemic circulations.
• The paucity of symptoms in infants with ASDs is related to the structure of the right
ventricle in early life when its muscular wall is thick and less compliant, thus limiting the
left-to-right shunt.
• -As the infant becomes older and pulmonary vascular resistance drops, the right
ventricular wall becomes thinner and the left-to-right shunt across the ASD increases.

CLINICAL FEATURES (0.2 marks each for any answer, total 2 marks)
 Asymptomatic in most cases.
 Subtle failure to thrive in younger children.
 Easy fatigability or exercise intolerance as older children or adults.
 Mild left precordial bulge.
 Wide fixed splitting of second heart sound.
 P2 is normal.
 Medium pitched ejection systolic murmur best heard at the left middle and upper sternal
border (produced by the increased flow across the pulmonary artery and not by low-
pressure flow across the ASD).
 Short, rumbling mid-diastolic murmur produced by the increased volume of blood flow
across the tricuspid valve audible at LLSB
 left parasternal heave of RVH
 Pigeon chest deformity.
 Rarely heart failure.

INVESTIGATIONS (total 2 marks)

i. Chest X-ray, ii. Electrocardiography, iii. Echocardiography

TREATMENT (total 2 marks)

• Surgical or transcatheter device closure is advised for all symptomatic patients and also
for asymptomatic patients with a Qp : Qs ratio of at least 2 : 1.
• The timing for elective closure is usually after the 1st yr and before entry into school.
• Atrial septal occlusion devices are implanted transvenously in the cardiac catheterization
laboratory.