December 2022

Question 1

1
You are a general practitioner. A healthy woman in the 8th week of pregnancy is being tested for rubella
virus serology. She is a kindergarten teacher and there have been non-vaccinated children with rubella
in the kindergarten. Her blood sample is positive for rubella-IgG, but not for rubella-IgM antibodies.
What is the most appropriate advice and guidance you can give her?

A If she is exposed to rubella infection, she will not get sick herself, but there is a danger that the
fetus may get rubella.

B She should be revaccinated against rubella before returning to work in kindergarten

C She can go to work safely - neither the fetus nor herself is in danger of getting rubella

D If she is exposed to rubella infection, she and the fetus can get rubella

Answer 1

C. As she has IgG (but not IgM) antibodies, she has longstanding immunity to rubella, probably because of previous vaccination. Recent infection would give both IgG and IgM antibodies.

Question 2

2
A mother comes with her 15-month-old daughter to the emergency service (“Legevakten”) where you
work as a junior doctor. The mother explains that this afternoon the girl had generalized convulsions in
both arms and legs lasting around 8 minutes. You interpret this description as tonic-clonic convulsions.
During the episode the girl was unconscious, and the parents got very scared.
Earlier today the girl had a runny nose, and a rectal temperature of 39.9 OC shortly before onset of
seizures.
The girl has never had convulsions/seizures before. However, her father has epilepsy.
On examination at the emergency service the child is awake, and in a good condition. There are
normal findings on the neurological examination.
What is the best classification of this episode?

A New onset childhood epilepsy – hereditary origin
B First time simple febrile seizures
C Meningitis-related seizures
D First time complex febrile seizures

Answer 2

B
The description of this seizure attack is in line with the definition of simple febrile seizures (duration shorter than 15 minutes, generalised seizure attack)
Simple febrile seizures
– Generalised seizure
– Duration < 15 min
– Occur once in a 24-h period
Complex febrile seizures
Defined by one of the following:
* Focal seizures
* Prolonged seizure attack (> 15 min)
* Multiple; occur more than once in a 24-h period
This is a provoked seizure attack with fever, and cannot at this stage be classified as epilepsy.
She has recovered and is in good condition on examination, so it was probably not meningitis.
Learning outcome: K4

Question 3

3
You are a general practitioner. A father brings his 3-year-old son with history of a limp for two days with
quite sudden onset. No trauma. The boy’s general condition is reduced and he is not running around.
On examination you find reduced flexion and internal rotation in his right hip. He seems in obvious pain
when you examine the hip.
Rectal temperature 39.7 C OC.
C-reactive protein (CRP) 107 mg/L (Ref <5 mg/L).
Leukocytes 27,5 (Ref 4,4-12,5 x 10^9/L)
What is the most likely diagnosis?
A Calvé-Legg-Perthes disease
B Bacterial arthritis
C Juvenile idiopathic arthritis
D Coxitis simplex

Answer 3

B
Bacterial arthritis is most likely as he has general symptoms, pain and local symptoms (not weight-bearing) and raised leukocytes and CRP.
Coxitis simplex is less likely with high fever and high CRP. Juvenile idiopathic arthritis and Calvé -Legg-Perthes disease may start like this but usually don’t have this sudden onset.
Learning outcome: K4

Question 4

4
Some children with epilepsy are treated with a diet. This diet has a well-documented effect and may
reduce seizure frequency in many patients.
What are the characteristics and effects of this diet?
A It is rich in aminoacids and suppresses seizures
B It is rich in carbohydrates and contributes with enough glucose
C It is rich in proteins and helps brain repair
D It is rich in fat and maintains ketosis

Answer 4

D
The ketogenic diet may be helpful for some patients with epilepsy. It is a diet predominantly rich in
fat and maintains long-term ketosis. High concentrations of ketone bodies have been correlated
with better seizure control. The mechanism of action is not entirely known, but ketone bodies
increase degradation of glutamate and increase the conversion of glutamine to inhibitory GABA
Learning outcome: K5

Question 5

5
You are a junior doctor in the Department of Pediatrics. You are asked to see a baby in the Maternity
ward who was born 23 hours ago. It was an uncomplicated vaginal delivery at term. Birth weight 2890
g. Mother has started breastfeeding. The baby looks healthy, but is clearly jaundiced.
You check blood tests that show
* Baby: Total serum bilirubin 188 μmol/L. Direct anti-globuline (Coombs) test: positive. Blood type A
and Rh-D positive
* Mother: Blood type is O, Rh-D positive.
What is the most likely cause of jaundice (icterus) in this case?

A Breast milk induced jaundice
B Physiological jaundice
C Bile duct obstruction
D Immunization

Answer 5

D
Physiological jaundice is not correct when jaundice appaears that early, more common after 36-48 hours. Hemolytic disease is most likely due to blood group incompatibilities and immunization; in this case the mother has blood group O and the baby blood group A, and the
DAT test is positive indicating antibodies in the baby’s red blood cells.
Bile duct atresia uncommon, typically prolonged jaundice (high conj. bilirubin).
Breast milk induced in 15% of all healthy newborns, typically a diagnosis of exclusion if jaundice persists after 10-14 days of age.
Learning outcome: K3

Question 6

6
A 5-year-old boy receives furosemide due to a severe cardiomyopathy and congestive heart failure.
What is the pharmacodynamic action of furosemide?
A Blocks the Na+ channels in the distal tubuli, and thereby inhibiting Na+ reabsorption
B Acts as an aldosterone antagonist with diuretic and antihypertensive effect
C Inhibits the Na+/Cl- co-transporter in the proximal part of the distal tubules
D Inhibits the Na+/K+/2Cl- co-transporter in the ascending part of Henle’s loop

Answer 6

D
Correct is that furosemide inhibits the Na+/K+/2Cl- co-transporter in the ascending part of Henle’s
loop; a loop diuretic
Learning outcome: K8

Question 7

7
A 15-month-old boy comes to the community health center with his dad to have the measles-mumps-
rubella (MMR)-vaccine. The dad wants to know why the boy has to take all these three vaccines now,
since he received diphtheria, pertussis and tetanus vaccine only three months ago.
Why is childhood vaccination recommended for mumps, morbilli, diphtheria, measles?

A Mumps carries a risk for male infertility and hearing impairment
Morbilli carries a high risk for pregnant women of adverse pregnancy outcomes
Measles is a dangerous disease in childhood with risk of encephalitis and death
Diphtheria carries the risk for severe breathing problems

B Mumps carry the risk for severe breathing problems
Morbilli carry a high risk for pregnant women of adverse pregnancy outcomes
Measles is a dangerous disease in childhood with risk of encephalitis and death
Diphtheria carry the risk for male infertility and hearing impairment

C Mumps carry the risk for severe breathing problems
Morbilli is a dangerous disease in childhood with risk of encephalitis and death
Diphtheria carries a high risk for pregnant women of adverse pregnancy outcomes
Measles carries a risk for male infertility and hearing impairment

D Mumps is a dangerous disease in childhood with risk of encephalitis and death
Morbilli carries the risk for male infertility and hearing impairment
Diphtheria carries the risk for severe breathing problems
Measles carries a high risk for pregnant women of adverse pregnancy outcomes

Answer 7

A

Question 8

8
MRI examination shows a closed midline deficiency, including the lipoma, and open spinal arch of the
L5 vertebra and a thickened filum terminale. The child is at risk for developing progressive neurological
deficits, affecting lower limbs- and bladder-function.
At which age are such symptoms most likely to occur?
An otherwhise healthy newborn child has a midline lumbosacral subcutaneous lipoma (see picture in exam document canvas)

A In late adult age, when ageing causes degenerative disease.
B At around one-year age, when the child starts to walk.
C At around seven months age, when the child starts to crawl.
D In the time of puberty, when the child is in its growth spurt

Answer 8

Children with a closed midline deficit and a thickened filum terminale are at risk for developing a tethered cord, because the conus is not free to move upwards from the sacrum to the normal position at L1/2 in adult life. Tethering causes stretching of the spinal cord and myelopathy. During
the accelerated length growth at the time of puberty, the conus retracts to its’ adult position at L1/2, but this is counteracted by the tethering, causing stretching of the cord, and the symptoms therefore typically develop at this stage.
At 7- and 12-months age, the conus of the spinal cord is still located distally in the spinal canal, and stretching does not occur. In adulthood, additional degenerative disease can cause
worsening of pre-existing symptoms, but onset at this stage is rare.
Learning outcome: K1

Question 9

9
A 12-year-old boy with seasonal rhinoconjunctivitis during springtime (birch pollen) is brought to you in general practice due to intense itching in the oral cavity and the throat after ingestion of apples and carrots. Sometimes he even feels that it seems difficult to swallow.
What is the most appropriate advice and information in this situation?

A Inform the patient and his parents that apples and carrots are histamine rich foods that may cause such symptoms, which never will escalate to serious symptoms.

B Inform the patient and parents that the reactions are because of cross-reactivity due to his birch pollen allergy and that such reactions are without potential for serious reactions. He may tolerate
the foods if they are cooked.

C Due to his difficulties with swallowing consider this a serious allergy to apples and carrots and
advise strict avoidance and prescribe an adrenalin auto-injector.

D Inform the patient and parents that the reactions are because of cross-reactivity due to his birch
pollen allergy. Due to possible serious reactions you refer the patient to an allergy clinic to
perform controlled oral challenges with apples and carrots and advise strict avoidance in the
meantime.

Answer 9

B
Correct is that you inform the patient that the reactions are because of cross-reactivity due to his
birch pollen allergy and that such reactions are mild without potential for serious reactions. He
may tolerate the foods if they are cooked.
There are no specific allergies towards apples and carrots, only cross-reactivities (mainly birch).
These allergens are unstable and destroyed by cooking/heating. There is no need for further
testing and no need for adrenaline.
Learning outcome: K4

Question 10

10
A 7-year-old boy with a history of anaphylaxis in relation to ingestion of cow’s milk at one year of age is
referred to you at the paediatric outpatient clinic. The parents want to know if he has outgrown his allergy to cow’s milk. He has not been exposed to cow’s milk and the specific IgE-value against cow’s
milk has decreased from 62 kU/L to 3.5 kU/L. He has not experienced allergic reactions since the episode at one year of age.
How is it best to proceed to find out if he has outgrown his allergy to cow’s milk?

A No need for further testing. The decrease in IgE to cow’s milk is diagnostic for tolerance. They can introduce small amounts of cow’s milk at home.

B No need for further testing. Most children with cow’s milk allergy become tolerant to cow’s milk by 2-3 years of age. They can introduce small amounts of cow’s milk at home.

C Perform an oral provocation test with cow’s milk. This cannot be done at home since he had experienced anaphylaxis and since he has not been exposed to cow’s milk later.

D Further testing with introduction and elimination of cow’s milk with intervals of 3 weeks.

Answer 10

C
A provocation is recommended, despite falling sIgE levels, and this should not be done at home
since he had experienced anaphylaxis and since he has not been exposed to cow’s milk later.
Learning outcome: K4

Question 11

11
The parents bring this previously healthy 6-month-old boy to you at your general practitioner office.
He has been coughing for 3-4 days. From this morning his cough and general condition has worsened.
Clinical examination: Respiratory rate 65/min (normal <45/min). Pulse 180/min (normal < 160/min).
SpO2 94%. Capillary re-fill time 2 sec. Temperature 39.5 OC.
Respiration: Sub- and intercostal retractions. Grunting. On auscultation there are reduced respiratory
sounds on lower left side.
CRP 150
What is the most likely diagnosis?

A Asthma exacerbation

B Acute bronchiolitis

C Bacterial pneumonia

D Foreign body aspiration

Answer 11

C
Bacterial pneumonia is most likely. High fever, reduced respiratory sounds lower left lung, grunting and high CRP make you suspect bacterial pneumonia.
In bronchiolitis you would expect to find wheezing and prolonged expiration, and not unilateral reduced breathing sounds. Usually also lower CRP.
No previous history of asthma.
Foreign body aspiration does not typically cause a high fever.

Question 12

12
A 16-year-old boy is admitted to the paediatric emergency ward where you work as a junior doctor.
He complains about dry cough for around 3 weeks. He tells you that his general condition has
deteriorated, and he has developed breathing problems, first on exertion but now also at rest. He has
also lost 4 kg in weight, has reduced appetite, sweats at night (but did not have fever) and has noticed
enlarged lumps on the neck. On examination, you palpate 3 cm large, firm, untender lymph nodes on
both side of the neck and notice jugular vein distention. His respiratory rate is 26/min (Ref < 20), pulse
105/min, SpO2 95%, temperature 36.6OC. He has normal CRP and normal hematological blood
samples. You take an X-ray of his chest (see picture in canvas):
What is the most likely diagnosis?

A Congestive heart failure with pleural effusion
B Superior vena cava syndrome due to lymphoma
C Pulmonary tuberculosis
D Atypical pneumonia due to a mycoplasma infection

Answer 12

B
Most likely superior vena cava syndrome due to lymphoma. Large mediastinal tumor, enlarged
cervical lymph nodes and B-symptoms. Dyspnea and jugular vein distention indicate a superior
vena cava syndrome.
Normal CRP, no lung parenchyma pathology, no signs of infection; not very suspect for
tuberculois or atypical pneumonia.
Not enlarged heart and young age - no suspected cardiac failure.
Learning outcome: K4

Question 13

13
A 6-month-old girl comes with her father to the community health care center for a routine check-up.
On examination you find normal findings except that the right leg is approximately 1.5 cm shorter than
the left leg.
What is the best way to manage this finding and why?

A Reassure the father that a minor leg length discrepancy is common and is usually a normal finding

B Order an X-ray of the pelvis/hips to exclude hip dislocation on the right side

C Order an X-ray of the lower extremities to exclude a “green-stick” fracture

D Refer to physiotherapist to correct muscle tone and asymmetry in lower extremities

Answer 13

B
Hip dysplasia/dislocation is the most important underlying condition that can cause leg length
discrepancy and must be rapidly ruled out.
Learning outcome: K1

Question 14

14
You are a general practitioner. A 3-year-old girl is brought to you by her mom because she has fever
and severe throat pain. She has refused to eat and has increasing difficulties drinking even water.
On examination you find the following clinical picture (white, circular spots on tounge and in throat).
What is the most likely cause of this clinical picture?
A Measles with oral Koplic spots
B Hand, foot and mouth disease
C Herpes simplex virus, primary infection
D Human herpes virus 6 or 7

Answer 14

C
Herpes simplex virus, primary infection may cause a severe stomatitis, as described.

Question 15

15
As a general practitioner you examine a 6-month-old son, who over the past months has developed a rather large, red lesion on his skull. The lesion first became visible a few weeks after birth like a small
red nodule, but has grown steadily ever since. The child otherwise appears perfectly healthy.
What is the best and most reasonable management of this child?

A Refer the patient to a plastic surgeon to have the lesion removed surgically

B Do nothing for the moment, reassure the parents that this lesion will stop growing and slowly involute

C Have the child examined by computer tomography (CT scan) to rule out a malignant disease

D Tie a string around the lump so that it is strangulated and eventually drops off

Answer 15

B

Infantile vascular haemangiomas usually enlarge during the first months of a child’s life but will then gradually decrease in size and extent during the coming years. Normally one should do nothing and wait for the end result until possible definite surgical correction is performed. Bleeding
haemangiomas might have to be removed earlier. If the location is difficult or if very large, treatment with beta blockers is the best option.
Learning outcome: K1

Question 16

16
Syndactyly is the most frequent congenital malformation of the upper extremity, whereby fingers fail to separate in utero. In a complex syndactyly the digital bones are also fused (see illustration).
What is the most important reason for surgery of a complex syndactyly?

A The fused fingers might be further deformed as the hand develops

B The deformity might spread to other fingers

C The deformity carries a risk of malignant development

D The child will be bullied by others at school

Answer 16

A
As the hand develops/grows a complex syndactyly will result in further bending of the fingers and
worsened hand function. The function of the rest of the hand might be affected by a severe
distortion from syndactyly.

Question 17

17
You are a general practitioner, and many children are seen in your practice. Your next patient today is
a 6-year old boy coming with his mother because of bed wetting at night.
What is most likely the best communicative approach for this consultation?

A In order to create a child friendly and good atmosphere, prioritise to let the boy take full control of
the structure of the clinical consultation.

B Focus predominantly on the boy – and not the mother – and try to get most information about the
medical history directly from the boy.

C Talk mainly to the boy because at this age children are capable to distinguish between real
experiences and imagination. The general practitioner can trust what he is telling you.

D Start by talking to the boy and giving him room to settle in order to create a good atmosphere in
the consultation. Then get the medical history mainly from the mother.

Answer 17

D
Giving the child time and room to settle is important and increases the likeliness of a successful
clinical examination later. Medical history at this age will primarily be from the mother. At this age
childen have a lively fantasy and are often not able to to distinguish between real experiences
and imagination. The ability to distinguish between real experiences and imagination develops
later (8-12 years age)
Learning outcome: K4

Question 18

18
A young woman from Eritrea comes to the labour ward with contractions. She has lived in Norway for 1
year. In the health card for pregnant women, it appears that she is giving birth for the first time, and
that the hepatitis B serology indicates that she is HBsAg and HBeAg positive.
What preventive guidelines concerning Hepatitis B apply to her newborn child?

A No specific guidelines apply in this situation. Hepatitis B vaccine is not included in the Norwegian
child vaccination program

B Give hepatitis B immune globulin (HBIG) and vaccination at birth. Then give vaccine after 1, 3, 5
and 12 months

C Give an accelerated vaccination program due to increased risk of infection: At birth, after 4 weeks
and 3 months

D Follow the usual vaccination program with vaccinations that are given after 3, 5 and 12 months

Answer 18

B
The woman is a chronic carrier and since she is both HBsAg and HBeAg positive there is a high
risk of transmission if no preventative measures. The child must be protected from infection
during/after birth by giving hepatitis B immune globulin (HBIG) and vaccination at birth, and then
give vaccine after 1, 3, 5 and 12 months.
Hepatitis B has been in the in the Norwegian child vaccination program since 2017.
Learning outcome: K3

Question 19

19
A 6-year-old boy is referred to the pediatric outpatient clinic. His weight has dropped from the 50th percentile to the 2.5th percentile between 4 to 6 years of age. Weight in relation to height is on the
2.5th percentile. His general condition is acceptable. However, the mother thinks he looks pale and tells you that he often has loose stools. The primary laboratory investigation showed:
Hb 9.8 g/dL (ref.: 11.5-14.5 g/dL)
Ferritin 3 μmol/L (ref.: 15-100 μmol/L)
Calprotectin test in stool is negative (low value)
Which test is most likely to reveal the cause of his anemia/his condition?

A Specific IgE against cow’s milk protein

B Anti-tissue transglutaminase

C A Hemofec to detect blood in faeces

D Skin test with food allergens

Answer 19

B
Celiac disease often causes relatively few symptoms, but affects growth and often results in iron deficiency anaemia due to malabsorption.
Occult blood will most often not reveal the cause of iron deficiency anemia in children, where the cause is most often low intake or malabsorption
Food allergy, including Cow’s milk protein allergy, will most often cause more pronounced skin
and gastrointestinal symptoms and rarely growth abnormalities
Learning outcome: K4

Question 20

20
You are a general practitioner. A mother brings her 18-month old son who has fever, cough and a runny nose. He is in good general condition and previously healthy with normal development.
On examination you hear a mid-systolic cardiac murmur grade II that has not been noted at previous examinations. He has normal peripheral circulation, and the liver is not enlarged. He has a normal
oxygen saturation. Which approach to the patient’s cardiac murmur is most appropriate?

A All cardiac murmurs in children should immediately be examined by echocardiography.

B You reassure the mother that the murmur you heard is innocent and that it does not need to be followed up.

C You assume that the murmur is physiological and book a new appointment in order to control it when the patient no longer has fever.

D The patient should be referred to a pediatric cardiologist since the murmur most likely is caused by a previously not diagnosed congenital heart defect.

Answer 20

C
Most appropriate is that you assume that the murmur is physiological due to the influence of the
fever on the circulation, but you book a new appointment in order to control it when the patient no
longer has fever. Children with murmur during fever do not need immediate referral to pediatric
cardiologist.
Learning outcome: K4

Question 21

21
You are a general practitioner. A mother comes to you with her 4-year old daugther
She has for 3-4 months had small amounts of soft stool in her underpants (soiling) almost every day.
The girl is otherwise healthy, but often complains about abdominal pain. The parents are frustrated and
concerned.
What is the most likely cause for this problem?
A A progressive neurological deficit
B Celiac disease
C Constipation
D Attention deficit hyperactivity disorder

Answer 21

C
Functional constipation is very common and by far the most common cause of fecal incontinence
in otherwise healthy children.
Learning outcome: K4

Question 22

22
You work as a general practitioner. A mother brings her 8-year-old son. He has had three attacks of
severe headache over the last 15 months, starting first time when he was seven years old. He vomits during these attacks and wants to sleep in a dark room. After 2-3 hours of sleep, he usually recovers
well. His mother and grandmother both have migraine. What would be the best advice in this situation?

A If severe pain during migraine attacks, morphine tablets are first choice in children

B Always prescribe triptan tablets as first-line acute therapy of migraine attacks in this age group

C Recommend ibuprofen, paracetamol and maybe an antiemetic if there are new migraine attacks

D Start prophylactic therapy with a beta-blocker due to the frequent migraine attacks

Answer 22

C
Not very frequent attacks, no indication for prophylactic therapy.
Ibuprofen and paracetamol first choice, sometimes combined with an antiemetic
Triptan nasal spray indicated from 12 years of age, but used as second choice if no effect of
NSAIDs, paracetamol down to 10 years of age (or even younger)
Opioids not used for migraine attacks
Learning outcome: K5

Question 23

23
The Hippocratic Oath is one of the most widely known Greek medical texts.
What are the four major principles of medical ethics – partly based on The Hippocratic Oath?
A Beneficience, non-maleficence, fidelity and accountability
B Beneficence, non-maleficence, justice and respect for autonomy
C Respect, transparancy, sustainability and justice.
D Solidarity, dignity, justice and autonomy

Answer 23

B
Correct is: Beneficence, non-maleficence, justice and respect for autonomy
Learning outcome: K4

Question 24

24
A woman gives birth rather quickly in the ambulance on her way to hospital. You are the doctor on call in the ambulance.
The child comes out blueish-purple with pale limbs, and is rather floppy. Palpating the cord you can feel a pulse of 120 beats/minute, and the baby gasps a little. You start drying and stimulating the baby.
Very quickly, within a minute, the baby is crying loud, spitting when you insert a suction catether, moving his arms and legs vigorously and is starting to achieve a bright, pink colour on his face and trunk. Arms and legs are still purple.
What Apgar score at 1 minute will you give this baby?
A 3
B 5
C 7
D 9

Answer 24

Respiration: 2 (crying loud)
Circulation: 2 (heartbeat > 100/min)
Tone: 2 (moving arms and legs2
Reflexes: 2 (reaction to suctioning)
Skin colour: 1 (pink central, cyanotic extremities)
Total Apgar-1 min score 9
Learning outcome: K3

Question 25

25
Different antibiotic classes have different modes of action (difference in pharmacodynamics).
Which is the correct statement regarding these antbiotic classes?
A Macrolides target the bacterial cell membrane
B Sulfonamides inhibit synthesis of folate
C Beta lactams inhibit bacterial protein synthesis
D Glycopetides inhibit beta lactamases

Answer 25

B
Learning outcome: K8

Question 26

26
You work as a junior doctor in a large paediatric department. A mother who has not been to antenatal
ultrasound screening has just delivered a baby. You are called to the labour ward to see this baby
which is born with a congenital malformation, see picture (Pic of intestines outside abdomen not covered by peritoneum). What is the diagnosis/name of this
condition?
A Omphalocele
B Gastroschisis
C Bladder extrophy
D Pyloric stenosis

Answer 26

B
Correct is gastroschisis
Learning outcome: K1

Question 27

27
You work as a junior doctor in a neonatal unit. Today you are in charge of a little girl born prematurely
by caserean delivery at 29 weeks gestation. You have started treatment with non-invasive respiratory
support, but the baby is having increasing breathing difficulties and she needs 50% oxygen to maintain
SpO2 > 90%.
What is the most likely reason for her breathing difficulty?

A Respiratory distress syndrome because of lack of surfactant

B Persistent pulmonary hypertension and constricted pulmonary vasculature

C Respiratory distress syndrome because of too much surfactant

D Wet lungs with too much amniotic fluid in the lungs

Answer 27

A
She was born 11 weeks prematurely. The most likely reason in this situation is Respiratory
distress syndrome because of lack of surfactant
Learning outcome: K3

Question 28

28
You work as a junior doctor in a neonatal unit and collaborate closely with the midwives. It is
recommended to delay the clamping of the cord after a baby is born.
What is the physiology behind the beneficial effects of delayed cord clamping?

A The baby may provide fetal blood via the umbilical artery to the placenta and thereby preventing postnatal lung fluid overload which improve breathing

B The baby will receive a “transfusion” of extra blood from the placenta and the umbilical vessels, but mainly before the child has started breathing.

C The baby will receive a “transfusion” of extra blood from the placenta and the umbilical vessels, and even more if waiting to after the child has started breathing

D The baby will not receive a “transfusion” of extra blood, but the contact with the mother is important for temperature control and bonding

Answer 28

C
Most correct is that the baby will receive a “transfusion” of extra blood from the placenta and the
umbilical vessels, and even more if waiting until the child has started breathing. There is usually
not more flow going from the baby to placenta
Learning outcome: K3

Question 29

29
You are a junior doctor in the pediatric department. Today you see a 5-year old girl who recently was
diagnosed with juvenile idiopathic arthritis (JIA). The parents have heard that their daughter is at risk of
developing extra-articular manifestations, and want advice on this.
What is the most common extra-articular feature of JIA?
A Dermatitis
B Sinusitis
C Nephritis
D Uveitis

Answer 29

D
Uveitis is found in 10-25% of children with JIA, while the other are rare or not relevant.

Question 30

30
You are a general practitioner. Today you see a 15-year old girl who is a refugee from Congo arriving in Norway around 5 months ago. She came to you 2 months ago and complained about a troublesome cough. You gave her a course of antibiotics due to a suspected lower respiratory tract infection. At that
time her sedimentation rate (SR) was 65 mm (ref. <10 mm). Her cough has not become better and now she comes back and tells you, via an interpreter, that she has lost around 5 kg of weight over last
2 months. She has also been sweating at night and the coughing is even worse.
Which diagnostic procedure should you prioritize in this situation?

A C-reactive protein (CRP) test in serum

B Nasopharyngeal swab for influenzae and respiratory viruses

C Serology for Mycoplasma pneumonia and Chlamydophila pneumoniae

D Interferon-gamma-release-assay (IGRA) blood test

Answer 30

D
The clinical history (land of origin, chronic cough, elevated SR, sweating at night and weight loss)
makes TB highly suspicious. IGRA test would be positive if it is TB (high sensitivity of the IGRA
test in this age group). CRP is unspecific. M. or C. pneumoniae/respiratory viruses rarely have
many months of symptoms.
Learning outcome: K4

Question 31

31
Your are a junior doctor in the pediatric outpatient clinic. A 16-month-old boy is referred because he
has been coughing more or less every day over the last 3-4 months. The parents can often hear
wheezing sounds from the chest. It started with a respiratory tract infection (RTI) shortly after starting
in kindergarten. Later he has had four episodes with acute exacerbations related to viral RTIs, but
also milder symptoms in between infections. During the night, he often coughs until he is vomiting
mucus.
There are family members with atopic disease on both sides of his family.
What would be the most appropriate first therapy for this child?

A Inhaled corticosteroid given as inhalation aerosol on a chamber with a face mask twice daily and
short acting beta-2-agonist given the same way when needed.

B Short acting beta-2-agonist given as inhalation aerosol on a chamber with a face mask when
needed or 4 times daily every day.

C Corticosteroid inhalations given via a nebuliser twice daily and short acting beta-2-agonist
inhalations given the same way as needed.

D Combined inhaled corticosteroid and long acting beta-2 agonist given as powder inhalator and
leukotrien receptor antagonist mixture. Short acting beta-2 agonist given as powder inhalations
when needed.

Answer 31

A
Best is to start with inhaled corticosteroid (ICS) given as inhalation aerosol on a chamber with a
face mask twice daily and short acting beta-2- agonist given the same way as needed. The child
will most likely benefit most from ICS, and he has asthma.
He should have prophylactic therapy (ICS), not only short acting beta-2 agonist.
Nebuliser therapy twice daily is not the first choice as it is cumbersome.
He is too young for powder inhalator
Learning outcome: K4 and K8

Question 32

32
A 7-year-old boy is admitted to the paediatric department with a new-onset diabetes. You are the junior
doctor on call. On examination he is breathing fast and deep and looks dehydrated.
He responds slowly to your questions. SpO2 is 98% (> 94%). Blood pressure is normal.
Laboratory parameters including a blood gas show:
Plasma glucose 26 mmol/L (Ref < 7 mmol)
pH 7.05 (Ref 7.35-7.45)
pCO2 2.7 kPa (Ref 4.5-6.5)
Bicarbonate 5 mmol/L (Ref 22-26)
What are the main principles and correct order of medical treatment for this child?

A
* Intravenous fluid resuscitation
* Intravenous insulin infusion to reverse ketosis and reduce plasma glucose
* Intravenous potassium to restore losses

B
* Intravenous insulin infusion to reverse ketosis and reduce plasma glucose
* Intravenous sodium to restore losses
* Intravenous fluid resuscitation

C
* Subcutaneous insulin to slowly reverse ketosis and reduce plasma glucose
* Intravenous fluid resuscitation
* Intravenous sodium to restore losses

D
* Intravenous bicarbonate to correct acidosis
* Intravenous insulin infusion to reverse ketosis and reduce plasma glucose
* Intravenous potassium to restore losses

Answer 32

This child has a severe diabetic ketoacidosis.
Main principles for therapy and order of these therapies are: IV fluid, IV insulin and potassium
correction
Learning outcome: K4

Question 33

33
You are a general practitioner. A 17-year-old girl has booked an appointment to talk about use of contraceptives. She is previously healthy, in a steady relationship and is currently using an oral
combined contraceptive. She is having trouble remembering taking her pill and want to discuss other options available.
What is the most correct advice about long acting reversible contraceptives (LARC)?

A Hormonal IUD, copper IUD, contraceptive implant, and contraceptive injection are equal first
choices for LARC in young women.

B Hormonal IUD, copper IUD and contraceptive implant are equal first choices for LARC in young
women.

C Long acting reversible contraceptives are expensive and she is therefore advised to continue on the pill.

D A contraceptive implant or contraceptive injection is the best options for her since she has not given birth.

Answer 33

B
The most correct answer is that hormonal IUD, copper IUD and contraceptive implant are equal
first choices for LARC in young women.
Contraceptive injection is not a recommended first choice for girls <18 years old because of risk
of osteoporosis.
There is no difference in recommending IUDs in nulliparous/multiparous women.
LARC has the same financial support as oral contraceptives in women 16-22 years old. In
addition; the price divided by duration is lower than for the contraceptive pill, even if the price for
IUD is higher at start up.
Learning outcome: K6

Question 34

34
You are a general practitioner. A 19 year old previously healthy girl has booked an appointment due to increased vaginal discharge. She started dating her boyfriend six weeks ago. She is in good general condition. Her boyfriend has no symptoms of sexually transmitted infections.
What is the best way to examine and treat this patient?

A Perform a gynecological examination and take relevant samples. If the test comes back positive
for chlamydia you write a prescription for doxycycline on §4. Inform her that it is mandatory to inform her latest sexual partners about the infection.

B Send her to the bathroom to take a urine sample for Chlamydia trachomatis. If the test is positive
you write a prescription for doxycycline on §4. Inform her that it is mandatory to inform her latest
sexual partners about the infection.

C Perform a gynecological examination and take relevant samples. If the test comes back positive
for chlamydia you write a prescription for doxycycline on §4. Inform her that it is a good idea to
inform her latest sexual partners about the infection.

D Send her to the bathroom to take a vaginal sample for Chlamydia trachomatis. If the test is
positive you write a prescription for doxycycline. Inform her that it is mandatory to inform her latest
sexual partners about the infection.

Answer 34

A
Increased vaginal discharge can have many explanations other than sexually transmitted diseases (STDs), you should therefore perform a gynecological examination.
Chlamydia is regarded a «allmennfarlig smittsom sykdom». Treatment is therefore free and it is
mandatory to perform contact tracing (smittevernloven).
Learning outcome: K2

Question 35

35
You are a general practitioner. A 25-year-old woman has booked an appointment for a Pap smear as a
routine test in the Norwegian Cervical Cancer Screening Programme. She has received three doses of
HPV-vaccine (HPV 16/18) in school when she was 12 years old. She asks if you can take an HPV-test
in addition to Pap smear (co-testing).
Is there an indication for co-testing; both Pap smear cytology and a HPV test?

A Yes. Two independent screening tests are better than one. Women with both a normal Pap smear
and a negative HPV-test (negative co-test) have very low risk of cervical cancer for the next five
years.

B No. The prevalence of HPV in women 25-33 years of age with normal cytology is high, even in women who have received the HPV-vaccine. Young women with normal cytology and a positive
HPV-test have low risk of cervical cancer.

C No. In Norway HPV-screening is only recommended for women 34-69 years of age. Women 25-33 years with normal cytology should not be HPV-tested.

D Yes. It is important to document that the HPV-vaccine has protected her for any HPV-infection.

Answer 35

B
Women 25-33 years of age are recommended for screening with cytology only because the prevalence of HPV-infection is high, even in women with normal cytology. HPV-testing of young
women will result in overmanagement and risk of overtreatment. About 30% of unvaccinated
women younger than 30 years of age will have a positive HPV-test. In vaccinated women the
HPV prevalence is 20%.
Learning outcome: K2

Question 36

36
A 32-year-old woman returns to the general practitioner ́s office a week after having had an intrauterine device (IUD = spiral) inserted. The procedure was somewhat complicated, and the patient
subsequently had minor bleedings over the next two days. She now presents with lower abdominal pain and a fever of 38.2°C. You suspect that she may have acquired a bacterial endometritis after
insertion of the IUD and you want to determine the microbiological agent causing this condition. Which clinical material and analysis is best suited to determine the causative agent in this condition?

A Culture of cervical discharge taken during gynaecological examination.

B Specific PCRs for sexually transmitted agents including N. gonorrhoeae, C. trachomatis and M. genitalum in urine or cervical swab.

C Culture of endometrial material extracted during gynaecological examination.

D Broad-range PCR of the vaginal flora in self-taken sample.

Answer 36

C
Culture of endometrial material extracted during gynaecological examination is the best answer.
Broad-range PCR is not appropriate from a location with abundant normal flora, and culture of
cervical discharge will most likely only reflect mixed flora without clear identification of the
causative agent.
Bacterial post-surgical endometritis is rarely associated with specific sexually transmitted
organisms.
Learning outcome: K2

Question 37

37
You are a general practitioner. One of your colleagues had taken a vaginal sample from a 22-year-old woman which was submitted for routine culture even though the patient had no specific complaints from her lower genitals. The report comes back to you, and it states the sample contained mixed normal flora and moderate growth of yeast (Candida albicans).
What is the interpretation of the finding of Candida albicans, and how is it best to further manage the patient?

A Candida albicans is a useful marker for bacterial vaginosis, and antibiotic treatment should be directed at this underlying condition.

B Candida albicans is considered a component of the normal vaginal flora. As the patient is asymptomatic, no further action is warranted.

C Yeast infection is a marker of local or systemic immune deficiency. The patient should be referred
to further clinical examination to exclude underlying disease.

D Candida albicans is the most common cause of fungal vaginitis, and the patient should be treated
with local antifungal medication

Answer 37

B
Candida albicans is present in the vaginal flora of most women of fertile age and does not have
any clinical implications in asymptomatic women.

Question 38

38
You are a general practitioner and a 69-year-old woman has an appointment. She tells you that she
has had a couple of episodes with vaginal bleeding. The bleedings were unprovoked. She has had
some itching in the introitus area and a few urinary tract infections. Upon examination you find thin
atrophic skin on the vulva as well as atrophy in the vagina. The cervix is small and the orificium looks
stenosed. There are no pathologic pelvic masses.
What is the best further course of action?

A Refer the patient to a gynecologist to exclude a malignant cause of the bleedings.

B Check sex hormones and gonadotropins to assess whether the bleeding can be due to atrophic
vaginitis.

C Start the patient with estrogen + progestin combination to treat atrophy on the basis of clinical findings and age.

D Try to open the cervical canal to be able to take a biopsy from the endometrium.

Answer 38

A
Best is to refer the patient to a gynecologist to exclude a malignant cause of the bleedings.
The patient probably has atrophy due to low estrogen levels, but endometrial cancer still should
be excluded. If the uterine cavity is accessible, the general practitioner can take an endometrial
biopsy, but as the orificium is stenosed, there is a risk of perforation.
Learning outcome: K7

Question 39

39
Menopause is defined as the time of the last menstruation and is a sign of ovarian failure. Which of the following statements is the most appropriate?

A There is redused estrogen which with time will respond to combined LH and FSH treatment.

B Menopause should be diagnosed by blood samples with low sex hormone values and high FSH-
and LH-values.

C At menopause the failure of ovarian function results in high FSH levels due to a fall in negative feedback.

D Due to decreased negative feedback to the hypothalamus and pituitary gland from the ovaries,
increased values of GnRH can be measured as a sign of menopause.

Answer 39

C
The best answer is that at menopause the failure of ovarian function results in high FSH levels
due to a fall in negative feedback.
Depletion of follicles in the perimenopause leads to a fall in inhibin and thus less negative
feedback. This gives rise to increased pulsatility of GnRH which in turn leads to increased FSH-
levels. GnRH is released in pulses and serum levels will vary. Values are accordingly unreliable.
Although the general trend is lower sex hormones and rising gonadotropins, values will vary and
are unpredictable. The need for estrogen (hormone replacement therapy-HRT) is based on
symptoms rather than the biochemical low estrogen levels. LH and FSH are not given as therapy.
Learning outcome: K7

Question 40

40
An 18-year-old woman presents with pelvic pain at your general practitioner’s office.
The pain is present more or less all the time, but it gets worse a few days before and during
menstruation. The dysmenorrhea has been present since menarche at 11 years. She has been using
NSAIDs on the first days of menstruation, but this is no longer enough. She is not on any permanent
medication. Her menstruation lasts for 3 days with sparse dark bleeding. She has never had sexual
intercourse.
What is the most probable diagnosis, and how should it best be treated?

A She probably has endometriosis, but is likely to have vulvodynia as well. Avoid a gynecological
examination and refer her to a gynecologist for further evaluation.

B She probably has endometriosis. Do a gynecological examination and start her on continuous
high dose contraceptive pills.

C She might have an imperforated hymen. Do a gynecological examination and refer her to a
gynecologist.

D She probably has endometriosis. Avoid a gynecological examination as she has not had her
sexual debut and start her on contraceptive pills

Answer 40

A
The best answer is: She probably has endometriosis. You do a gynecological examination and
start her on continuous high dose contraceptive pills.
A gynecological examination is needed to exclude anomalies in the lower genital tract and to
assess the level of the pain. It is reasonable to try to induce amenorrhea and contraceptive pills
are first line treatment. High dose pills (30 mcg estrogen) have proven more reliable as far as
bleeding control comes, and should be used continuously to achieve amenorrhea.
Learning outcome: K2

Question 41

41
A woman who is gravida 3 and para 1 (G3P1) comes to her antenatal appointment with her general
practitioner. Gestation length about 6 weeks
She had a normal pregnancy and delivery two years ago. Her BMI is 24. She has normal varied diet.
Her Hb is 12.8 g/dl (Ref > 10.5) and S-ferritin 72 μg/L (Ref > 25-30).
Which diet-supplements or combinations supplements are recommended?

A
Folic acid 400 μg
Iron 60 mg/day
Vitamin D 10 μg/day
B-12 vitamin 1 mg /day until 12 weeks of pregnancy

B
B-12 vitamin until 12 weeks of pregnancy
Vitamin D 10 μg/day

C
Iron 100 mg every other day
B-12 vitamin 1 mg /day

D
Folic acid 400 ug until 12 weeks of pregnancy
Vitamin D 10 μg/day

Answer 41

D
She has normal Hb, Ferritin >70 μg/L so there is no need for iron substitution
Every pregnant woman is recommended to use folic acid 400 μg/day from the time of attempted
pregnancy and until week 12 of gestation
Vitamin D 10 μg/day is recommended to everyone
B-12 vitamin supplement is not necessary when having normal diet
Learning outcome: K10

Question 42

42
You are working as a general practitioner. It takes about 1 hour by car to the closest hospital.
You get a patient who is a 39-year-old Para 1. Her first baby was delivered 2 years ago by acute
caesarean section because of fetal bradycardia during the first stage of labor in pregnancy week 39.
Now she is in pregnancy week 33+3. She has essential hypertension and treatment with labetalol
100mg x3. The blood pressure has been a little higher in the last 2 weeks but is still under the
recommended limits. She smokes around 8 cigarettes/day. She has attended normal antenatal care
with an extra fetal growth control at the hospital at gestational week 32 because of the essential
hypertension and slight decrease in symphysis fundal height curve. She has suddenly started to bleed
and used around 2 menstrual pads in 15 minutes. She is having contractions and abdominal pain. You
find blood pressure 140/95, pulse 98/min, Temp 37.1 oC.
Fetal heartbeat 152/min. With palpation of the uterus, you can feel contractions. There is still some
bleeding.
What is the most likely condition and best management in this situation?

A She has most likely abruptio placentae and needs to be transported immediately to the closest
obstetric ward by ambulance with iv fluids on the way.

B She has preterm contractions, and she needs hospital treatment and her husband can drive her
to the maternity ward. She might need corticosteroids.

C She is most likely bleeding from placenta previa and needs to be immediately transported to the
closest obstetrics ward by ambulance with iv fluids on the way.

D She has most likely abruptio placentae and needs to be immediately transported to the closest
obstetrics ward by ambulance with iv fluids on the way to the hospital. You give Ibuprofen 600mg
for pain relief

Answer 42

A
The most likely condition/diagnosis is abruptio placentae with pain, bleeding and contractions.
Placenta previa is less likely since she has had several ultrasound examinations, the latest only
10 days ago and no such diagnosis has been mentioned. Bleeding from placenta previa is usually
painless and often there are no contractions.
She needs to be evaluated promptly at the obstetric ward to establish the diagnosis and get
appropriate management. The patient who is initially stable may deteriorate rapidly if placental
separation progresses. Smoking and hypertension are risk factors for abruptio placentae.
Premature labor is a differential diagnosis, but it starts more gradually and usually with less
bleeding. The patient has to be managed as abruptio placentae until it is excluded by further
examinations at an obstetric ward
Learning outcome: K12

Alternative D above was not used in the final exam. The published exam has the following
alternative D:
She has most likely a uterine rupture and needs to be immediately transported to the closest
obstetric ward by ambulance with iv fluids on the way to the hospital.

Question 43

43
You are a general practitioner. A pregnant woman is coming for her first consultation in pregnancy. Her previous pregnancy was complicated with early onset preeclampsia 3 years ago. The baby was
delivered by caesarean section at week 32 because of the fetus being growth restricted. The mother was developing severe preeclampsia. You do clinical examination according to guidelines and fill out the pregnancy form. What is the best plan for this patient regarding follow-up?

A To send a referral for the obstetric outpatient clinic for them to take in the woman for estimation of
gestational age and further plan for follow-up. She will have to have all the follow-ups in the
hospital.

B To inform her that the risk of developing complications in this pregnancy is very high, and give
her a sick leave for the rest of the pregnancy in order for her to be at home and rest, the plan for
close follow-up of her blood pressure in your office.

C To reassure her that the risk of complications in this pregnancy is low and refer her for the normal
routine scan in the obstetric outpatient clinic.

D To send a referral for the obstetric outpatient clinic for them to take in the woman for estimation of
gestational age and further plan for follow-up. You inform her that the follow-up in pregnancy will
be shared between you as the general practitioner and the hospital.

Answer 43

D
The best answer is that you measure her blood pressure, fill out har pregnancy form (helsekort) and send this as a referral to the obstetric outpatient clinic for them to estimate gestational age
and further plan for follow up. You inform her that the follow up in pregnancy will be shared between you as the general practitioner and the hospital.
She is a high-risk patient that should be referred to the hospital. At the same time, it is important for the patient to have follow-up with the general practitioner (blood pressure, urine etc) since she
will need close follow-up and these are things that can be monitored outside the hospital.
Learning outcome: K12

Question 44

44
You are a general practitioner. A 25-year-old woman comes for a consultation. She has problems with acne and wants to try treatment with isotretinoin. What is the most correct information to her before starting treatment with isotretinoin in a 25
year old woman?

A Advise her to try to avoid using this medication because of potential side effects.

B Inform her that if she wants to use this medication, she has to use safe contraception, starting at
least one month before starting the isotretinoin

C Inform her that she can start using isotretinoin, but she has to be aware of the potential problems
of using the medication in pregnancy. If she finds out that she becomes pregnant she should stop
treatment.

D Tell her that you have heard a lot of good things about this medication,and recommend this
therapy.

Answer 44

B
The best answer is that you inform her that if she wants to use isotretinoin she has to use a safe
kind of contraception, starting at least one month before starting using isotretinoin, a teratogenic
drug.
It is too late to stop the medication when she finds out that she is pregnant. You have to inform
her regarding beneficial and harmful effects of this drug.
Learning outcome: K9

Question 45

45
Sex-steroid hormone production during pregnancy is dependent on maternal, placental and fetal
enzymes through the fetoplacental unit.
What is a main characteristic of the sex-steroid hormone production in pregnancy?

A Maternal estrogens are used as a precursor for fetal cortisol production

B Progesterone is produced from cholesterol by the fetal adrenal glands

C Progesterone production by the placenta requires fetal tissue

D Fetal organs provide enzymes that convert pregnenolone to weak androgens

Answer 45

D
Progesterone production in pregnancy is not dependent on fetal tissue, but estrogen production is
since the placenta lacks CYP 17 for androgen production. Estrogens cannot be converted to
cortisol.
Learning outcome: K1

Question 46

46
Hormone replacement therapy is a treatment to relieve symptoms of the menopause.
What is the effect of progesterone in such therapies?

A Progesterone opposes the proliferative actions of estradiol-17β and down regulates the estrogen
receptor

B Progesterone stimulates intestinal Ca++ absorption and is a potent regulator of osteoblast and
osteoclast function

C Progesterone decreases adipose tissue by decreasing lipoprotein lipase activity and increasing
hormone-sensitive lipase

D Progesterone promotes vasodilation through increased production of nitric oxide

Answer 46

A
Correct is that progesterone opposes the proliferative actions of estradiol-17β and down regulates
the estrogen receptor. The other alternatives are estradiol-effects, not progesterone effects
Learning outcome: K1

Question 47

47
You are a general practitioner. A 29-year-old woman comes for a consultation because she is
considering becoming pregnant. She has rheumatoid arthritis and receives therapy with methotrexate
and infliximab (immunosuppressant and biologic medications, respectively).
What is your best advice in this situation?

A You check her blood pressure and check her hematology blood values. All the findings are normal
and you tell her it is safe for her to become pregnant.

B You advise her to start using folic acid and as soon as she gets pregnant she should come back
so that you can refer her to a consultation with the gynecologist.

C You refer her to the rheumatologist to optimize her medication before coming pregnant.

D You advise her to stop using her medication because it might be teratogenic and can harm the
fetus

Answer 47

C
Different kinds of rheumatic diseases can cause complications in pregnancy and if the patient is
taking several kinds of medication it is important to refer her to the rheumatologist to optimize the
medication before pregnancy.
Learning outcome: K9

Question 48

48
You are a general practitioner in a small village two hours away from nearest hospital. A 38 weeks
pregnant, (gravida 2, para 1) woman comes to your office. She suspects she is going into labour. The
water broke one hour ago, and she is now having regular contractions with 3 minutes intervals, and
they seem to be increasingly painful. You do a vaginal exam and find her cervix to be 4 cm open,
effaced and soft. The baby ́s head is engaged in her pelvic inlet.
What stage of labour is she in?

A Second stage of labour

B Active part of first stage of labour

C Third stage of labour

D Latent part of first stage of labour

Answer 48

B
She is open 4 cm and has regular and increasing contractions, thus is in the active first stage of
labour.
Learning outcome: K13

Question 49

49
As a clinical resident in obstetrics, you are asked to consult a patient that is 16 weeks pregnant and
RhD negative. This is her 3rd child. When her second child was born, she had a large aton bleeding of
more than 2 liters. She comes to you for making a follow-up plan. The booking tests taken at week 13
shows that she has anti-D antibodies at a low titer at 2.
What is the best management in this situation?

A Since she is already immunized, there is no use in giving anti-D prophylaxis. Repeat the titer
around 18-20 weeks and at the same time check the fetal RhD type inform the woman that it may
be indicated to refer her for extra ultrasound if the antibody level increases significantly.

B Since she is RhD negative it is important that she gets the anti-D prophylaxis, and that it should
be given now in week 16 due to the antibodies.

C Since she is already immunized, it could be dangerous to give her anti-D prophylaxis, and if the
fetus is also RhD negative giving a prophylaxis could even harm the fetus.

D Since the antibodies are at a low titer, there is no risk and need to worry. Advise her to follow the
general follow-up program and receive the anti-D prophylaxis in week 28 after checking in week
24 if the fetus is RhD positive or negative.

Answer 49

A
She has detectable anti-D antibodies, meaning it is no use to give any prophylaxis, but it is not
harmful for mother or fetus to do so. However, it is important that you follow-up and check the
titer during pregnancy because increasing titer may indicate a risk of fetal anemia.
Learning outcome: K12

Question 50

50
A 25-year-old primigravida comes for her 1st trimester ultrasound scan. You are a junior doctor in the obstetric department and on ultrasound you see 2 live fetuses. You can see one placenta mass but
you are not able to see a membrane between the twins. You explain to her that this is probably a monochorionic, monoamniotic (MC-MA) twin pregnancy.
What is the main risk in this specific kind of twin pregnancy?

A The main risk is risk of extreme premature delivery, as it is for all kinds of twin pregnancies

B The main risk is that one or both of the fetuses have a structural heart defect as they share the
placenta and the amniotic fluid sac.

C The main risk is cord entanglement since they are sharing the same sac. There is a significant
risk that one or both twins may die during pregnancy because of this.

D This is a low-risk twin pregnancy because they share the amniotic fluid sac. There will not be any
risk for having too much or too little amniotic fluid.

Answer 50

C
This pregnancy is rare and a very high-risk pregnancy, primarily related to the risk of cord
entanglement that may lead to intrauterine death in one or both twins.
All twin pregnancies have higher risk of premature delivery, but the risk of extreme prematurity is
not so high. Monochorionic monoamniotic twins also have a slightly increased risk of having
structural heart defects, but the risk of cord entanglement is by far the highest risk.
Learning outcome: K12

Question 51

51
A 25-year-old man is just diagnosed with testicular cancer. He has no children yet. You are working as
a junior doctor in the Dept of Urology at a big public hospital in Norway. Your task is to explain the
patient that he will need surgery (remove the affected testicle) and chemotherapy, and general
information about this treatment.
What is the best advice regarding future fertility and why?
A Tell him that sperm banking is usually recommended 1-2 years after surviving therapy for his
cancer.
B Tell him that in most cases there is no need for sperm banking, when orchiectomy of only one
testicle is planned
C Tell him that sperm banking and fertility preservation, by law, is not allowed in public hospitals in
Norway (only offered in private clinics).
D Recommend fertility preservation by spermbanking before starting the cancer treatment, at least
before starting chemotherapy.

Answer 51

D Sperm banking is important to preserve male fertility. The chances of getting a child by assisted
fertilization with frozen sperm cells are very good (of course also depending on female factors)
and the banking has to be done at least before chemotherapy is started.
Learning outcome: K4

Question 52

52
A married couple (man 32 years-old and woman 33 years-old) wants to have a child.
However, they have tried already 3 years without success.
The woman has been to her gynecologist, and everything was normal.
The sperm samples of the man have shown azoospermia
What is the most appropriate advice in this situation?

A The couple should be referred to an IVF clinic, and a testicle biopsy is recommended to check for
sperm cells.

B The woman needs to go to an IVF clinic and it is important to do a hysteroscopy

C The couple should wait and see whether another semen sample is showing larger number of
sperm cells

D The couple cannot have children because the sperm sample has shown azoospermia, you
recommend they go for adoption.

Answer 52

A
The couple should be referred to an IVF clinic for further diagnostic and therapy. In case sperm
cells are found in a testicular biopsy further therapy with assisted fertilization is possible. Of course they can choose adoption, if they don`t want further therapy.
Learning outcome: K4

Question 53

53
A 23-year-old woman reports increasing vaginal bleeding, now also after sexual intercourse.
You are a general practitioner and when you perform a gynecological examination you see some small
nodular changes on the portio that bleed on contact.
Which of the statements is most correct?

A Bleeding disorders are common in her age group, and it is not necessary to do more tests

B Cervical cytology/pap-smear is not indicated for patients under 25 year

C Biopsy is more suitable than cervical cytology/pap-smear in case of clinical suspicion of cancer

D Cervical cytology/pap-smear is more suitable than a biopsy in case of clinical suspicion of cancer

Answer 53

C
Correct is that biopsy is more suitable than cervical cytology/pap smear in case of clinical
suspicion of cancer
Learning outcome: K2

Question 54

54
You are a general practitioner. An 81-year-old woman living in a care facility has had blood in her
underwear on several occasions during the last three months.
What is the best recommendation in this situation?

A Recommend a visit at the emergency service this afternoon for assessment and possibly
hospitalization tonight as this could be endometrial cancer that should be examined and treated
promptly

B Recommend a gynaecological examination within a week, and consider referral to gynecologist
as this could be endometrial cancer that can be treated

C Recommend direct referral to gynaecologist for prioritized ultrasound and biopsy, as this could be
endometrial cancer that should be examined and treated promptly

D Recommend to try vaginal estrogen treatment and come to you for examination in 8 weeks if
bleeding continues. This could be endometrial cancer, but the prognosis is very favourable and
treatment can wait

Answer 54

B
Best answer is to recomend to bring the woman for a gynecological examination rather quickly but
it is not an emergency situation, so within a week is ok. You should consider referral to gyencologist as this could be endometrial cancer that can be treated. The investigation should be
conducted within short time (a couple of weekes) but as long as she does not hav heavy bleedings it is not an emergency. Estrogen is contra indicated if this is endometrial cancer and
might increase her bleedings
Learning outcome: K2

Question 55

55
A woman is pregnant with her second child and comes to her first antenatal check-up at 13 weeks.
She tells you that the first child had severe thrombocytopenia when he was born 2 years ago. He was
born at term and weighed 3.5 kg. He is healthy today according to the mother. She was told two years
ago that the baby suffered from fetal neonatal alloimmune thrombocytopenia (FNAIT).
What recommendations is it appropriate to give her regarding follow-up in pregnancy and why?

A She should be checked to see if she has anti-platelet alloantibodies, and depending on type and
level of such antibodies the risk of severe FNAIT in the current pregnancy can be assessed.

B There is a high risk that the next baby will suffer from severe brain bleeding since the first baby
had FNAIT and it usually becomes worse.

C No extra follow-up is necessary, since FNAIT primarily occurs in the first pregnancy and does not
have any recurrence risk.

D Most important here is to check the mother’s platelet count, since there is a high chance that she
also has a severe thrombocytopenia.

Answer 55

A
Correct is that she should be checked to see if she has anti-platelet alloantibodies, and
depending on type and level of such antibodies the risk of severe FNAIT in the current pregnancy
can be assessed. High level of anti-platelet antibodies during pregnancy is currently used to
stratify risk and decide on antenatal and perinatal management.
FNAIT is caused by alloantibodies targeting fetal platelets. The recurrence risk is high, but the
chance of severe brain bleeding is very low since the first child was healthy. There is never
indication to recommend termination of pregnancy due to previous FNAIT. Maternal platelets are
not affected by FNAIT.
Learning outcome: K12

Question 56

56
A 32-year old woman is expecting her first child and comes to the obstetric outpatient clinics for her
routine antenatal ultrasound. Based on her last period she is 18+0 gestational weeks. One of the
purposes of the ultrasound examination is to determine the due date.
What is the most important reason for determining the due date?

A It is important if the mother delivers prematurely or post-term so that necessary measures are
taken and timed correctly.

B It is important to know if the Naegele due date and the ultrasound due date are similar or not in
order to assess the fetal growth in a correct way.

C It is important for the parents to know approximately when the baby will be born in order to make
the appropriate preparations at home around delivery and the weeks after.

D It is important so that both the mother and father can apply for paternal leave from the social
security at the correct time.

Answer 56

Most correct is that it is important to determine the due date if the mother delivers prematurely or
post-term so that necessary measures are taken and timed correctly.
It is also important to determine if Naegele and ultrasound due dates are similar, in particular if
they differ by 2 weeks or more this should be examined further to assess which due date is more
correct.
Learning outcome: K11

Question 57

57
You are a junior doctor in the obstetric department and attend a delivery where the baby is born with
the umbilical cord one time loosely around the neck.
What is the best way to manage this situation?

A You clamp and cut the cord immediately to free the baby from the cord around the neck

B You clamp and cut the cord after one minute, as in all other deliveries

C You try to slip the cord over the baby’s head right after birth and leave the cord until pulsation has
ceased

D You try at least to cut the cord before the placenta comes out so that the cord is released

Answer 57

C
A nuchal cord is common, and complications caused by the condition are rare.
In a situaton as described, usually the cord is loose and can be slipped over the head, then this
is the best solution. This lets the baby get his full placental transfusion before the cord is cut.
There is no reason to calmp after one minute, and definitely no reason to clamp earlier.
Learning outcome: K13

Question 58

There is no reason to calmp after one minute, and definitely no reason to clamp earlier.
Learning outcome: K13
D You try at least to cut the cord before the placenta comes out so that the cord is released 00003639ee1f965ba0
58
You are a general practitioner and a pregnant woman comes for a routine consultation at 28 weeks
gestation. You measure the symphysis-fundal height and find a measurement that is the same as
when she was there four weeks earlier. Her blood pressure and urine test are normal.
What is the best further management?

A To ask her if she feels normal fetal movements and she confirms that the fetus is active. Then
plan for her to come back in two weeks for follow-up.

B To ask her to come back in one week for follow-up since both blood pressure and urine test are
normal you

C To ask her if she has had any kind of suspicion of an infection recently and send her to take a
blood sample to see if she has had cytomegalovirus or toxoplasmosis.

D To send a referral to the obstetric out patient clinic for an urgent evaluation.

Answer 58

D
Best is to check her bloodpressure and check the urine. You write this information and sends a
referral to the obstetric out patient clinic for an urgent evaluation, even if the blood pressure, urine
and previous history is normal. It is a concern that there has been no growth of the uterus for four
weeks. Preeclampsia and infection are causes of growth restriction

Question 59

59
A 28-year-old woman comes to you as her general practitioner 8 weeks after delivery of her first child.
She complains about leakage of urine. She has some leakage at home but mostly this is a problem
during physical exercise. She has just started exercising after delivery and has quite heavy leakage
during these activities. She has to use a pad while training.
What is the best treatment to recommend for her urine incontinence?

A Surgical treatment of stress incontinence

B No particular treatment, this will improve spontaneously

C Avoid physical training which gives her leakage

D Pelvic floor exercise

Answer 59

D
Pelvic floor exercise is correct.
Surgical treatment is only an option when the woman is sure she doesn’t want further children,
and when conservative treatment has been tried without success. Many improve spontanously,
but pelvic floor excercises are recommended to improve the result. Avoiding physical training is
not a good option as there is help for her problem and we recommend women to do physical
training.
Learning outcome: K5

Question 60

60
A 31-year-old woman comes to the emergency care unit where you are the doctor in charge.
She gave birth 9 days ago. She had a vaginal delivery, induced after prolonged rupture of the membranes. Due to obstructed labour the midwife performed an episiotomy. Now she has fever and
abdominal discomfort. She has smelly puerperal bleeding but normal amount. She is in a slightly reduced condition. Her temperature is 38.8 °C. She has CRP at 58 mg/L (ref < 5). Urine dipstick with
blood 1+, leukocytes 1+ and Nitrite negative. She has tenderness in her lower abdomen at palpation.
Which condition is the most likely diagnosis?

A Endometritis
B Wound infection
C Salpingitis
D Urinary tract infection

Answer 60

A
Post partum endometritis is most likely because of fever, smelly bleeding and abdominal pain.
The other alternatives are less likely.
Learning outcome: K2

Question 61

You are junior doctor at an obstetric ward. A healthy 32-year-old woman is admitted to the hospital in
pregnancy week 42+0. She is para 2 with previous normal pregnancies and vaginal deliveries. You do
a vaginal exploration, and her cervix is 3 cm dilated, position is central, consistency is soft and cervical
length is 1 cm; Bishop score is 7.
What is the most appropriate method for inducing labour in this woman?
A Amniotomy and oxytocine
B Membrane sweaping
C Balloon catheter
D Oral prostaglandines

Answer 61

A
The woman is multipara and with ripe cervix, then induction can be done with amniotomy and
oxytocine
Learning outcome: K13

Question 62

62
A 26-year-old woman had a medical induced abortion 5 weeks ago. She was in pregnancy week 8 and
went through the procedure at home. Now she contacts you as her general practitioner because of
almost daily episodes with heavy bleeding and crampy abdominal pain. She is in a good condition. Her
blood pressure is normal. Hb is 10.8 g/dl (ref. 10.5-13.5). Urine dipstick is slightly positive for hCG.
What is the most likely diagnosis?
A Retained pregnancy products
B Normal situation after abortion
C Menstrual bleeding
D Failed abortion

Answer 62

Continuous bleeding more than 2 weeks after an abortion is suspicious of retained pregnancy
products. It is not normal with that prolonged bleeding after an abortion. It might be a menstrual
bleeding but retained pregnancy products needs to be ruled out first. A pregnancy test can still be
positive even though she is not pregnant.
Learning outcome: K2

Question 63

63
A 27-year-old healthy woman, pregnant for the first time, in week 9 after last menstrual period, makes
an emergency appointment with you in general practice because of sparse vaginal bleeding for the last
three days. She does not complain about pain, examination reveals some low abdominal tenderness,
bright red blood in the vagina, closed cervical os, slightly enlarged uterus.
You measure s-HcG with two days in between and the result is 3500 and 4100 mIE/ml (ref. 25 700-
288 000)
What is the most likely diagnosis?
A Complete spontaneous abortion
B Incomplete spontaneous abortion
C Ectopic pregnancy
D Normal pregnancy

Answer 63

C
She has a pathological low rise in s-Hcg and not very large uterus which indicates ectopic
pregnancy rather than normal pregnancy. She does not have a bleeding that indicates
spontaneous abortion.
Learning outcome: K2

Question 64

64
A 31-year-old healthy woman comes to you in general practice for a routine pregnancy control. She is
expecting her first child and is in pregnancy week 25. She takes an oral glucose tolerance test. Her
fasting blood glucose is normal, but two hours after intake she has a glucose value at 9,8 mmol/L (Ref
< 9.0 mmol/L).
What is the best recommended management in this situation?

A Repeat the oral glucose tolerance test in a week

B Start treatment with insulin to decrease glucose values

C Give her diet counseling and instruct her in self-testing of blood glucose

D Start treatment with metformin to increase the insulin sensitivity

Answer 64

C
She has gestational diabetes and need to manage this first with diet changes and monitoring her
blood glucose levels
Learning outcome: K12

Question 65

65
5α-reductase inhibitors may be used to treat scalp hair loss in males.
What is the underlying physiological mechanism of the effect of 5α-reductase inhibitors in this
situation?
A Reduced conversion of testosterone to estrogens in adipose tissue
B Reduced conversion of androgens to greater biological potency peripherally in tissues
C Increased conversion of testosterone to dihydrotestosterone in Leydig cells
D Increased conversion of androgens to estrogens in peripheral tissue.

Answer 65

B
Reduced conversion of androgens to greater biological potency peripherally in tissues. Many of
the masculinizing effects of testosterone is through the formation of DTH which is facilitated
through 5α-reductase in peripheral tissue
Learning outcome: K1

Question 66

66
What are the main phenotypic effects of estrogens in puberty?
A Increased body temperature and ductal growth in the mammae
B Secretory uterus, pubic hear growth and growth spurt
C Female body appearance, secretory uterus, and breast development
D Growth of genitalia, growth spurt and anabolic action in muscles

Answer 66

D
Progesterone makes the uterus secretoric and increases body temperature.
Estrogen contributes to growth of genitalia, growth spurt and anabolic action in muscles
Learning outcome: K1

Question 67

67
Where in the ovarian follicle is estrogen produced?
A In the stromal cells
B In the granulosa cells
C In the zona pellucida
D In the theca cells

Answer 67

B
Only the granulosa cells have aromatase that can convert androgens to estrogens
Learning outcome: K1

Question 68

68
Luteal phase insufficiency is one of the reasons for implantation failure and has been responsible for
miscarriages and unsuccessful assisted reproduction.
Luteinizing hormone = LH
How is sex steroid hormone production regulated in the luteal phase?

A LH leads to increased aromatase activity and estrogen production in the granulosa cells of the
corpus luteum

B The surge of LH induces a shift towards increased androgen production in the theca cells which is
converted to progesterone

C LH stimulates the LH-receptors of the granulosa cells and increases androgen production which is
converted to estrogen by the theca cell

D LH stimulates the LH-receptors of the granulosa cells and increases progesterone production

Answer 68

D
Following ovulation, granulosa cells acquire mote LH receptors and blood supply which will
stimulate progesterone production be these cells as they lack 17α-Hydroxylase/17,20-Lyase to
produce androgens from progesterone. Theca cells produce androgens. Aromatase converts
androgens to estrogens

Question 69

69
A 21-year-old woman is expecting her first child. Her 10-years older sister and her cousin have been
diagnosed with Huntington’s disease, an autosomal dominant disorder. The woman is worried that her
child will develop the disorder, however she does not want to go through genetic testing herself. She
seeks advice, and is refereed for risk assessment from a genetic councelor
What is the probability that this woman’s child will develop Huntington’s disease later in life?
A 50%
B 6.25%
C 25%
D 12.5%

Answer 69

C
25% is correct.
* The woman’s sister has inherited a disease allele. The probability that the woman herself is
carrying the same allele is 50%, but she has yet no symtoms of Huntington’s disease.
* The probability of transmission to her child is 50%.
* The total probability of her child inheriting the pathogenic allele is 25%.

Question 70

70
The pedigree below is from a family suffering from a rare inherited disease, see Figure (the filled symbols indicate the affected individuals). See picture in canvas.
Which mode of inheritance is most likely and what is the probability of person IV:9 to be sick/ affected?

A X-linked dominant, 100% if female.
B Autosomal recessive, 50%.
C X-linked recessive, 100% if female.
D Mitochondrial inheritance, 50%.

Answer 70

A
X-linked dominant, 100% if female is correct.
* It affects either sex, but more in females than males.
* Usually at least one parent is affected.
* Females are often more mildly and more variably affected than males (because of X-
inactivation).
* The child of and affected female, regardless of its sex, has a 50% chance of being affected.
* For an affected male, all his daughters but none of his sons are affected.

Question 71

71
A pregnant woman is referred to an early ultrasound and for a non-invasive prenatal test (NIPT) of the
fetus in gestational week 10.
What is the origin of the extracted material used in the NIPT-test?
A Cell-free DNA from fetal red blood cells
B Cell-free fetal DNA from trophoblast cells from the placenta
C Endothelial cells from the fetus shedded in the blood stream
D Cell-free fetal DNA from fetal lymphocytes

Answer 71

Cell-free fetal DNA from trophoblast cells from the placenta is correct.
As early as week 5 of gestation the trophoblast cells of the placenta is shedding DNA fragments
into maternal circulation. At week 10 of gestation cell-free fetal DNA comprises approximately
10% of cell free DNA in maternal circulation and is a basis of the non-invasive prenatal test
(NIPT) where the fetal DNA is analysed from a maternal blood sample.

Question 72

72
A baby is diagnosed with Down syndrome or trisomy 21, see Figure of karyogram in canvas.
What is the mechanism behind this chromosomal aberration and when does it occur?

A Mis-segregation of chromosomes in the anaphase of meiosis II

B Chromosome rearrangements in the anaphase of mitosis

C Non-disjunction in meiosis I or meiosis II; and rarely in the anaphase of mitosis

D Mis-segregation of chromosomes in the prophase of mitosis 00003639ee1f965ba0

Answer 72

C
Non-disjunction in meiosis I or meiosis II; and in rare instances in the anaphase of mitosis is
correct.
When homologous chromosomes align during prophase I of meiosis I they are normally
separated to opposite poles by the microtubule in the cell. In cases of trisomy both homologous
chromosomes have not separated but both been pulled together to one pole of the cell. This
process is called non-disjunction. It may also occur in meiosis II where sister chromatids are not
separated. In rare instances non-disjunction may also occur during anaphase of mitosis.

Question 73

73
A 7-year-old boy is brought to you as a junior doctor in the pediatric outpatient clinic for evaluation due
to his difficulties reading. His teacher has reported in parent-teacher conferences that the child is
unable to keep up with the rest of the class. His mother explains that generally he is very well
behaved, but he does have the odd tendency of flapping his hands when he gets nervous. Physical
exam shows a high forehead, prominent supraorbital ridges, protruding ears, and a prominent jaw.
Formal testing shows that the patient has an IQ of 69, which appears consistent with his academic
performance. The analysis of the chromosomes indicated a fragile site on the q-arm of the X-
chromosome.
What is the best description of this condition with respect to genetical abberation?

A It is caused by gene mutations named trinucleotide repeat expansions, characterized by
anticipation.

B It is caused by large X-chromosome duplications with detrimental impact on all genes located on
the X-chromosome.

C It is caused by translocations of the X-chromosome causing an imbalance in the most important
genes.

D It is caused by static genome mutations disrupting the whole genome, characterized by gene
silencing.

Answer 73

A
Abnormal facial features (protruding ears) + low IQ = fragile X syndrome
Fragile X syndrome is characterized by expansions of trinucleotide repeats of CGG on X
chromosome. It is a dynamic mutation that that changes over time. These mutations are often
called trinucleotide repeat diseases. The mechanism is slippage during replication. When the
number of repeats are in the range of instability it has a tendency to be longer in the next
generation and thus disease causing. The longer the repeat the worse is the disease. This
tendency is called anticipation, which is he tendency in certain genetic disorders for individuals in
successive generations to present at an earlier age and/or with more severe manifestations.

Question 74

74
Pesticide poisoning is among the most common means of suicide globally. Some pesticides, more
specifically the organophosphate pesticides, have the same mechanism of action as chemical
warfare nerve gases. They are potent inhibitors of acetylcholinesterase, leading to an accumulation of
acetylcholine in the central and peripheral nervous system.
Name an important antidote used in treatment of intoxication with both organophosphate
pesticides and nerve gases.
A Atropine
B Adrenaline
C Naloxone
D Ethanol

Answer 74

A
Atropine is the correct answer.
Naloxone an antidot for opioids
Ethanol an antidot for methanol
Learning outcome: K9, K5

Question 75

75
Smoking is the most important risk factor for developing lung cancer. However, many different
occupational agents are well known lung carcinogens in humans.
What is another environmental and occupational risk factor for developing lung cancer?
A Lead
B Radon
C Mercury
D Fluoride

Answer 75

B
Exposure to the natural radioactive gas radon is an important risk factor for developing lung
cancer.
Learning outcome: K9

Question 76

76
According to WHO ambient and household air pollution accounts for an estimated 6.7 million deaths
per year, and 99% of the world’s population lives in places where air quality exceeds WHO guideline
limits.
Apart from respiratory diseases which disease group has been shown in several big studies to
be associated with ambient air pollution?
A Rheumatic diseases
B Kidney diseases
C Liver diseases
D Cardiovascular diseases

Answer 76

D
Since 2000, substantial evidence has accumulated on air pollution and the cardiovascular system.
As a result, it is now clear that excess morbidity and mortality related to cardiovascular effects of
air pollution occur, in addition to respiratory effects.
Thurston GD, et al. A joint ERS/ATS policy statement: what constitutes an adverse health effect of
air pollution? An analytical framework. Eur Respir J 2017; 49: 1600419
Learning outcome: K5, 8, 9

Question 77

77
You are a junior doctor on an exchange program responsible for pediatric outpatient screening in a
major teaching hospital near a major slum in Nairobi, Kenya. A 10-month old girl is brought to see you
with a history of two days of watery diarrhea. The mother says that she has recently started limiting her
breastfeeding to twice a day. The little girl is awake but a bit lethargic. Her urine production has been
reduced today. She seems very thirsty. The skin on her abdomen remains tented after you have
pinched it. She has slightly sunken eyes.
What is the most appropriate first step of an appropriate course of treatment?

A Give the child a pediatric gentamicin injection to combat the bacterial infection causing the
diarrhea.

B Start rehydration with an oral rehydration solution (ORS), using a cup and spoon.

C Counsel the mother on the importance of breastfeeding and keep her in the clinic until she has
adequately breast fed her child.

D Immediately start the child on an intravenous electrolyte solution and admit.

Answer 77

B
The global standard of care for a child with moderate dehydration secondary to diarrhea is oral
rehydration solution. Intravenous therapy can usually be avoided, and antibiotics are discouraged
as a routine treatment. Breastfeeding is important, but the child requires urgent care before
education of the mother should be undertaken
Learning outcome: K8

Question 78

78
A 17-year old boy from Ethiopia comes to you in general practice. He came to Norway two years ago,
and you have known him for a year. He tells you that he’s been having intermittent stomach ache for
two months. He just got a refusal of his asylum application, and he’s worried about what will happen
with medical care when he turns 18 next week.
What legal rights to medical care does he have when he turns 18?

A When he turns 18, he has no right to any medical care in Norway.

B When he turns 18, he can continue to come to you as you are his general practitioner.

C When he turns 18, he can come to you as a general practitioner, but he doesn’t have the rights to
medical care in the hospital.

D When he turns 18, he only has the legal rights to emergency care.

Answer 78

D
When he turns 18 he only has the legal rights to emergency care. As his asylum application has
been denied he loses the rights to medical care other than emergency care.
Learning outcome: K6, KII, S

Question 79

79
An important goal of health services is to promote greater health equity by addressing social
determinants of health.
Which of the following sets of influences are categorized as social determinants that can result
in disparities and impact the health and safety of populations?

A Family structure, age, gender, genetic or inherited health conditions

B Early childhood education, discrimination, income level, food security

C Community service programs, access to parks and playgrounds, exposure to social media

D Alcohol, tobacco, or other drug use; diet; sexual activity

Answer 79

B
The correct answer is early childhood education, discrimination, income level, food security
Determinants of health are the broad personal, social, economic, and environmental factors that
influence health status. Social determinants are a specific group of social and economic factors
within the broader determinants of health. They are commonly called the conditions in which
people are born, grow, live, work and age. These include the availability of resources to meet
daily needs, ie, living wages; social norms such as discrimination; socioeconomic conditions,
including family income and level of food security; and quality schools, including early childhood
education programs.
Learning outcome: K3, K7

Question 80

80
The black death (plague; Yersinia pestis) caused estimated 75-200 million deaths in Europe from year
1346 to 1353. Plague outbreaks recently took human lives in Madagaskar, as late as in 2017.
How is the plague spread, and how can climate change influence the spread?

A The plague is spread by ticks (typically Ixodes ricinus), and increased temperatures and shorter
winters will change the geographical distribution of the ticks to further north.

B The plague is spread by fecal-oral route of transmission, and will increase after natural disasters
like flooding.

C The plague is spread by mosquitos (typically female Anopheles), and increased temperatures will
change the geographical distribution of the mosquitos to higher altitudes and further north.

D The plague is spread by fleas feeding on rodents (typically rats), and nature disaters like floodings
and hurricanes may damage houses and shelters and make rodents and the fleas come in closer
contact with humans.

Answer 80

D
The plague is spread by fleas feeding on rodents (typically rats)..
The other alternatives apply to malaria (mosquito), tick-borne encephalitis and borreliosis (ticks),
diarrhoea/gastroenteritis (contaminated water and food)
Learning outcome: K5