THG22-001
A 17-year-old adolescent girl presents to the pediatrician with weight gain and irregular periods. An ultrasound abdomen done reveals polycystic ovaries. The girl raises a concern of unwanted facial hair for the past 1 year.
a. Identify the purpose of the scoring system depicted in the image in this clinical context.
b. Name two criteria that can be used to identify polycystic ovary syndrome (PCOS) in adolescent girls.
c. Define the specification for polycystic ovary on the ultrasound.
d. Mention two differential diagnoses one should consider in this girl.
e. Mention two conditions to rule out in this girl before making a diagnosis of PCOS.
Answer
| a. | Hirsutism quantified by modified Ferriman–Gallwey score to assess extent and location of excessive male pattern hair growth |
| b. | Rotterdam criteria, Androgen Excess Society, National Institute of Health criteria |
| c. | 12 or more follicles in a single ovary or ovarian volume of >10 mm3 in one ovary |
| d. | Congenital adrenal hyperplasia and Cushing’s syndrome |
| e. | Hypothyroidism and hyperprolactinemia |
THG22-002
A 5-year-old girl presents with features of early sexual maturation. The child has height at the 97th percentile and weight at the 25th percentile. Tanner stage: Breast stage 3 and pubic hair stage 2. A gonadotropin-releasing hormone (GnRH) analog stimulation is done with leuprolide as a stimulant. The results of the test are as below:
a. Mention the interpretation of the GnRH analog stimulation test.
b. Mention any two reasons to support your interpretation.
c. What would be the findings in ultrasound abdomen?
d. What is the bone age expected?
e. Mention the next investigation that should be performed for the child.
f. Mention the drug, dose (4 weekly) and route of medication that can be administered for this condition.
Answer
| a. | Central precocious puberty |
| b. | Stimulated estradiol level >50 pg/mL; stimulated LH >5 IU/L, stimulated LH:FSH >1 |
| c. | Enlarged pelvic organs (uterine size and ovarian volume) |
| d. | Advanced bone age (by 2–3 SD) |
| e. | MRI brain |
| f. | Leuprolide acetate, 0.2–0.3 mg/kg, intramuscularly every 4 weeks |
THG22-003
Master “R” is a child with type 1 diabetes mellitus (DM) for the past 2 years. Please administer 7 units regular and 14 units isophane (NPH) insulin to this child with type 1 DM for breakfast using a syringe. Recite all steps as you say.
Answer
Steps:
| ■ | Introduce and rapport. |
| ■ | Hand hygiene. |
| ■ | Make sure that syringe and vials are of the same strength, i.e., U-40 syringe with U-40 insulin; and U-100 syringe with U-100 insulin. |
| ■ | Ensure cold chain; ensure that the regular insulin is clear. |
| ■ | Check expiry dates. Clean the top of the vials with spirit. |
| ■ | Gently roll the insulin suspension NPH 10–20 times to mix—do not shake. |
| ■ | Draw air equivalent to the 18U of NPH required into the syringe, and inject into the vial containing NPH and remove the syringe without taking insulin or air. |
| ■ | Then draw air equivalent to the 10U of human insulin R (HIR) insulin required into the syringe and insert in the HIR vial. |
| ■ | Draw HIR insulin, draw into the syringe. |
| ■ | Now draw NPH into the syringe. |
| ■ | Remember the sites to choose in the mock doll (thigh, arms, abdomen, and buttocks). |
| ■ | Inject subcutaneously. |
| ■ | Count for 6–10 after injection, do not rub. |
| ■ | Tell the child to take adequate exchanges of carbohydrates after injection as advised to avoid sugar fluctuations. |
| ■ | Dispose the sharps in appropriate bin. |
| ■ | Place the insulin back in the refrigerator. |
THG22-004
A 2-month-old “male” infant (weight 5 kg) presented with weight loss, lethargy, and refusal of feeds. Examination revealed that the child was lethargic, obtunded, hypotonic, and weak cry to a painful stimulus. Sugar checked in the emergency room (ER) was 23 mg/dL and genital examination revealed the following finding.
a. Name the likely medical emergency.
b. Name the likely underlying cause.
c. Name the life saving drug, dose, and route for this child.
d. Name two electrolyte abnormalities you would encounter in this child.
e. Identify the clinical finding in the given image.
f. Name two investigations to be taken as an emergency before medications.
g. How should the blood glucose of 23 mg/dL be corrected?
h. What is the ideal dose of fludrocortisone in the ER?
Answer
| a. | Acute adrenal insufficiency/acute adrenal crisis |
| b. | Salt wasting type of congenital adrenal hyperplasia due to 21 alpha-hydroxylase deficiency |
| c. | Hydrocortisone, 25 mg, parenteral (intravenous or intramuscular) |
| d. | Hyponatremia and hyperkalemia |
| e. | Clitoromegaly |
| f. | 17-hydroxyprogesterone and serum cortisol |
| g. | Intravenous dextrose bolus 10% as 4 mL/kg |
| h. | No fludrocortisone needed in acute situation, can be considered after stabilization |
THG22-005
A healthy term neonate is screened for congenital adrenal hyperplasia (CAH) by heel prick method. The screening report comes as 108 nmol/L for heel prick 17-hydroxyprogesterone.
a. What is your interpretation of the screening report?
b. What are the next steps that can be planned based on screening report?
c. What is the disease that is aimed to be identified based on the screening test?
d. Mention two causes for false-positive screening result.
e. Mention one cause for false-negative screening result.
f. Mention two advantages of screening.
Answer
| a. | This is a screen positive baby (as the screening 17-OH progesterone is >37.5 nmol/L) |
| b. | A repeat heel prick screen for 17-hydroxyprogesterone or a direct venous measurement of 17-hydroxyprogesterone and electrolytes should be planned |
| c. | Salt wasting type of CAH due to 21 alpha-hydroxylase deficiency |
| d. | False positive: Preterm baby, sick baby, low birth weight baby |
| e. | Maternal corticosteroid therapy |
| f. | Advantages: Prevention of salt wasting crisis, avoidance of incorrect sex assignment |
THG22-006
A healthy term baby is screened for congenital hypothyroidism by heel prick method. The screening report comes as thyroid-stimulating hormone (TSH) of 66 mIU/L. A venous test is ordered which shows: TSH of 76 mIU/L, free T4 of 0.5 ng/dL, and total T4 of 4 µg/dL.
a. What is your interpretation of screening report?
b. What is your interpretation of the venous TSH?
c. What is your interpretation of venous T4?
d. What is your interpretation of free T4?
e. Name the drug and dose for this baby.
f. Mention two risk factors responsible for false-negative screening report.
g. Mention one cause for congenital hypothyroidism that cannot be identified by this screening test.
h. Name an alternative method to screen for primary congenital hypothyroidism.
Answer
| a. | Screening TSH ≥20 mIU/L is considered as screen positive as per the Indian Society of Pediatric and Adolescent Endocrinology (ISPAE) recommendations |
| b. | Elevated TSH (venous TSH ≥20 mIU/L in first 2 weeks and ≥10 mIU/L beyond 2 weeks is considered as elevated TSH as per ISPAE guidelines) |
| c. | Low total T4 (total T4 <10 µg/dL is low as per ISPAE guidelines) |
| d. | Low free T4 (free T4 <1.17 ng/dL is low as per ISPAE guidelines) |
| e. | Oral levothyroxine 15 μg/kg once a day |
| f. | Preterm baby, neonatal sickness, trisomy 21, and twins |
| g. | Central hypothyroidism |
| h. | Cord TSH screening method |
THG22-007
Two children with congenital hypothyroidism underwent evaluation:
a. Name the scan that has been performed.
b. What is the purpose of this scan?
c. Identify findings in image A.
d. Identify the findings in image B.
e. What is the half-life of dye used in this scan?
f. Name an alternative to this scan.
Answer
| a. | Technetium thyroid scintigraphy |
| b. | To elucidate the cause of congenital hypothyroidism |
| c. | Increased uptake of dye in the thyroid tissue with increased size—probable dyshormonogenesis |
| d. | Absence of uptake of dye in the thyroid tissue, abnormal uptake of dye in the posterior aspect of tongue—probably ectopic lingual thyroid tissue |
| e. | 6 hours |
| f. | Iodine 123 scan |
THG22-008
A 13-year-old adolescent boy presents with neck swelling, tremor, panic attacks, weight loss, irritability, and heat intolerance.
a. Identify one clinical finding in the given image.
b. What is the probable diagnosis?
c. Name the likely underlying etiology.
d. Mention the most important biochemical investigation to confirm the underlying etiology.
e. What is the first line of therapy for this boy?
f. What is the medical emergency to be considered in case the boy presents with fever and delirium?
g. What definitive therapy can be suggested that might be cost effective, but might worsen eye manifestations?
h. What definitive therapy can be offered in case of large goiter?
i. Name one pubertal abnormality encountered in girls with this condition.
Answer
| a. | Stage 2 goiter (WHO grading of goiter) |
| b. | Hyperthyroidism |
| c. | Graves’ disease |
| d. | Anti-TSH receptor antibody |
| e. | Antithyroid drugs like methimazole or carbimazole |
| f. | Thyroid storm |
| g. | Radioactive iodine therapy with I-131 |
| h. | Total thyroidectomy |
| i. | Secondary amenorrhea |
THG22-009
A 3-month-old baby presented in the pediatric Out Patient Department (OPD) with severe constipation, lethargy, and refusal of feeds.
a. What is the likely diagnosis?
b. State whether the following statements are True or False about this child:
i. Head size may be slightly small in this baby
v. Temperature is usually elevated in this baby
Answer
| a. | Congenital hypothyroidism |
b. i. False (usually larger due to myxedema)
| ii. | False (length is usually normal at birth) |
| iii. | True |
| iv. | True |
| v. | False (temperature is <35°C) |
| vi. | False (macrocytic anemia is encountered) |
THG22-010
Complete the following statements with normal, high, or low as applicable.
a. The intravascular volume status in cerebral salt wasting is _________
b. In syndrome of inappropriate antidiuretic hormone secretion (SIADH), the urine sodium is _________
c. Serum vasopressin level in central diabetes insipidus is _________
d. Urine sodium in pseudohyponatremia due to hypertriglyceridemia is ________
e. Serum sodium in cerebral salt wasting is ____________
f. Urine sodium in hypoaldosteronism is ___________
g. Serum sodium in SIADH is _____
h. Urine sodium in primary polydipsia is _____________
Answer
| a. | Low |
| b. | High |
| c. | Low |
| d. | Normal |
| e. | Low |
| f. | High |
| g. | Low |
| h. | Normal |
THG22-011
Fill in the blanks:
a. Anti-müllerian hormone (AMH), inhibin and activin belong to ______family of growth factors.
b. AMH is secreted by ______ cells of the testes.
c. AMH causes regression of ______________ ducts (mesonephric ducts/paramesonephric ducts).
d. Inhibin is secreted by ___ cells of the ovary.
e. In males, hypogonadism in delayed puberty is identified by measuring ____.
f. _______ stimulates FSH secretion by the pituitary gland.
g. ________ binds activins and inhibits FSH secretion.
Answer
| a. | Transforming growth factor beta (TGF-beta) |
| b. | Sertoli cells |
| c. | Paramesonephric duct |
| d. | Theca cells |
| e. | Inhibin B |
| f. | Activin |
| g. | Follistatin |
THG22-012
A 7-year-old boy weighing 27 kg with polydipsia underwent water deprivation test.
a. What is the diagnosis arrived at 1 PM?
b. Mention two reasons to support your answer.
c. What is your diagnosis at 3 PM?
d. Mention two reasons to support your answer.
e. Name the drug to treat this boy and its oral dose.
f. Mention two precautions before starting the procedure.
Answer
| a. | Diabetes insipidus |
| b. | Serum osmolality >300 and urine osmolality <300 (accompanied by weight loss and tachycardia) |
| c. | Central diabetes insipidus |
| d. | Reduction in urine volume and rise in urine osmolality with parenteral vasopressin |
| e. | Oral desmopressin (DDAVP), 25–300 µg/day |
| f. | Ensure that the cortisol and thyroid hormone levels are normal |
THG22-013
Use the following diagnosis to fill up the table below.
Diagnosis: WT-1 defect, SRY gene defect, HSD3B2 defect, CYP 21 A2 defect, partial androgen insensitivity syndrome, 5α-reductase deficiency, AMH defect, SF-1 defect
| 0 | Diagnosis |
|---|---|
| 46 XX DSD | |
| Renal abnormality | |
| Primary adrenal failure | |
| Dysgenetic testes | |
| Absent Mullerian structure |
Answer
| 0 | Dlaagnois |
|---|---|
| 46 XX DSD | CYP21A2 |
| Renal abnormality | WT1 defect |
| Primary adrenal failure | SF1 defect, HSD3BA2, and CYP21A2 |
| Dysgenetic testes | WT1 defect, SF1 defect, SRY gene defect |
| Absent Mullerian structure | Partial androgen insensitivity syndrome and 5a-reductase deficiency |
THG22-014
Q22.14
a. Name this tool.
b. What is the purpose of this tool?
c. How is this tool used to make a diagnosis of delayed puberty?
d. How is this tool used to make a diagnosis of precocious puberty?
e. How is this tool used to make a diagnosis of arrested puberty?
Answer
| a. | Prader’s orchidometer |
| b. | Assessment of testicular volume and perform Tanner’s staging in boys |
| c. | Testicular volume <4 mL beyond a chronological age of 14 years |
| d. | Testicular volume ≥4 mL before a chronological age of 9 years |
| e. | Serial assessment of testicular volume shows no increase for >2 years |
THG22-015
A 5-year-old girl presented with breast stage 3, pubic hair stage 1, and menarche. The child has the below skin lesion:
a. Identify the skin lesion.
b. Mention the probable diagnosis.
c. Mention the third component of the diagnosis.
d. Measurement of LH, FSH, and estradiol is performed, how are they expected to be?
e. Mention the likely genetic mutation involved.
f. Mention two endocrine disorders that can be associated with the disorder.
Answer
| a. | Café-au-lait spots |
| b. | McCune–Albright syndrome |
| c. | Polyostotic fibrous dysplasia |
| d. | High estradiol level, suppressed LH, and suppressed FSH |
| e. | Activating missense mutation in GNAS-1 |
| f. | Acromegaly, Cushing syndrome, and hyperthyroidism |
THG22-016
A 13.5-year-old adolescent boy presented with the following finding:
a. What is the likely diagnosis?
b. What is the peak age this phenomenon occurs?
c. What is the Tanner stage when this process occurs?
d. What is the testicular volume at which this process usually occurs?
e. Is tenderness associated with this diagnosis?
f. What is the likely course of this problem?
g. What is the cause of this problem?
h. What is the treatment of this condition?
Answer
| a. | Puberty gynecomastia |
| b. | 13–14 years |
| c. | Tanner stage 3–4 |
| d. | Testicular volume 5–10 mL |
| e. | Yes |
| f. | Spontaneous resolution with pubertal progress |
| g. | Imbalance between testosterone and estradiol levels |
| h. | No treatment is required |
THG22-017
Match the following
| 1 | SF-1 | A | Hepatosplenomegaly |
| 2 | Smith-Lemli-Opitz syndrome | B | Retinal degeneration |
| 3 | Triple A syndrome | C | Post axial polydactyly |
| 4 | Wolman syndrome | D | Metaphyseal dysplasia |
| 5 | Kearns-Sayre syndrome | E | Craniofacial malformation |
| 6 | Pallister-Hall syndrome | F | Spasticity |
| 7 | IMAGe syndrome | G | Achalasia |
| 8 | Adrenoleukodystrophy | H | 46 XY sex reversal |
Answer
1—H
2—E
3—G
4—A
5—B
6—C
7—D
8—F
THG22-018
Master “A”, aged 7 years and a known child with type 1 DM (weight = 20 kg) on insulin on basal bolus regimen. The child is currently on injection glargine 8 units subcutaneous at bedtime and injection aspart 4 units subcutaneous three times a day. Child develops enteric fever. The current blood glucose is 300 mg/dL and urine ketones are large as shown in given image.
a. What is your advice on injection glargine?
b. How frequently should parents check blood glucose and administer correction doses?
c. Should the family give sugar free fluids or sugar containing fluids?
d. Mention three red flag signs that warrant the child to go to the ER.
e. Name one acute complication that should be prevented.
Answer
| a. | The usual dose and timing of injection glargine should be maintained |
| b. | One hourly |
| c. | Sugar free fluids |
| d. | No oral intake, altered level of consciousness, emesis, dehydration and CBG <50–60 mg/dL |
| e. | Diabetic ketoacidosis |
THG22-019
An 8-year-old boy presents to the ER (weight 30 kg) with history of weight loss, polydipsia, and polyuria. He was in compensated shock. Capillary blood glucose (CBG) measured in the ER is high (>600 mg/dL), urine ketones are large, blood ketone is 5.6 mmol/L, venous blood gas shows that pH is 7.0, and venous bicarbonate is 5 mEq/L. A diagnosis of severe diabetic ketoacidosis is made. Please give initial orders for the management of this child.
Answer
First hour:
300 mL IV of 0.9% normal saline (NS) (10 mL/kg) over a period of 1 hour (1)
Second and subsequent hours: (2)
Fluid calculation = Deficit + Maintenance – Bolus
Deficit is 8.5%–85 mL/kg
(85 × 30) – 300 = 2,250 mL
Maintenance by Holliday–Segar formula fluid calculation for 48 hours =
1,700 mL × 2 = 3,400 mL
Total fluid 2,250 + 3,400 = 5,650/47 = 120 mL/h
This is administered in the beginning as 0.9% saline (NS) or 0.45% saline (1/2 NS) with 40 mEq/L of potassium chloride or potassium phosphate or acetate. Addition of dextrose and adjustment potassium concentration will be titrated as per the findings during monitoring, next 24–48 hours.
How to counter check whether your calculation is correct? Fluid requirement per hour should be within 1.5 to 2.0 times of physiological maintenance rate of that child. Normal maintenance rate for the 30 kg child is 70 mL/h. The rate of fluid calculation per hour should be between 105–140 mL/h and here it is 120 mL/h, hence correct.
PS: There is lot of variations between guidelines. Some books estimate the fluid calculation for 24 hours instead of 48 hours, deficit is calculated as 5-7-10% depending on the severity. Deficit replacement can be provided with 0.45–0.9% saline or a balanced salt solution (Ringer's lactate, Hartmann's solution or Plasmalyte).
Insulin (50 units regular insulin with 50 mL NS), 25 mL should be flushed out. Start insulin administration at 3 mL per hour to give 3 U/h at 0.1 U/kg/h as an intravenous infusion.
Monitor heart rate, blood pressure, signs of dehydration and sensorium to identify cerebral edema early.
THG22-020
Write the appropriate terminology for the following:
| Scenario | Terminnloog |
|---|---|
| HbA1C 6.9% | |
| Fasting blood sugar 116 mg/dL | |
| 2-hour plasma glucose after oral glucose tolerance test of 168 mg/dL | |
| Fasting plasma glucose 12 mmol/L | |
| HbA1C of 6% |
Answer
| Scenario | Temtinnlogg |
|---|---|
| HbA1C 6.9% | Diabetes mellitus |
| Fasting blood sugar 116 mg/dL | Impaired fasting glucose |
| 2-hour plasma glucose after oral glucose tolerance test of 168 mg/dL | Impaired glucose tolerance |
| Fasting plasma glucose 12 mmol/L | Diabetes mellitus |
| HbA1C of 6% | Prediabetes |
THG22-021
A 5-year-old child (weight 10 kg) with type 1 DM on insulin therapy develops a blunt abdominal trauma following a road traffic accident. The child needs to be taken up for emergency laparotomy. The CBG measured in the ER is 310 mg/dL, blood ketones are measured which is shown in given image.
a. Can this child be taken up for surgery?
b. Name the fluid that you will start for this child.
c. What is the fluid rate of administration for this child in this situation?
d. What is the frequency of monitoring of blood glucose for this child?
e. What is the dose and route of insulin administration for this child in this situation?
f. Name two metabolic complications that should be anticipated and prevented.
Answer
| a. | Yes (as ketones are not significantly elevated) |
| b. | 0.45% NS with dextrose (with 20 mEq/L of potassium acetate added) |
| c. | 60 mL per hour (1.5 times the maintenance fluid rate) |
| d. | 1 hourly |
| e. | Intravenous insulin, 0.03 IU/kg/h |
| f. | Diabetic ketoacidosis and hypoglycemia |
THG22-022
State whether the following statements are True or False about hypoglycemia in a child with type 1 DM.
a. Late night hyperglycemia followed by rebound morning hypoglycemia is called Dawn phenomenon.
b. Aggressive behavior in a child with type 1 DM should warrant consideration for hypoglycemia before referral to a child guidance clinic.
c. Dose of oral glucose for hypoglycemia correction in a child with type 1 DM weighing 30 kg is 15 g.
d. The dose of parenteral glucagon for a child who weighs 25 kg is 0.5 mg.
e. Reduced cognition owing to recurrent severe hypoglycemia is common in school going children.
f. Maximum dose of mini glucagon is 100 µg.
g. Epinephrine deficiency is contributory to hypoglycemia associated autonomic failure in young adults with autonomic neuropathy.
h. Severe exercise without insulin dose adjustment can be a triggering factor for occurrence of hypoglycemia.
Answer
| a. | False (Somogyi phenomenon) |
| b. | True |
| c. | True |
| d. | False (1 mg) |
| e. | False (toddlers) |
| f. | False (150 µg) |
| g. | True |
| h. | True |
THG22-023
A 7-year-old child presented with type 1 DM is on basal bolus regimen with injection glargine 9 units at bedtime and injection lispro at each with an insulin carbohydrate ratio of 1 unit for 15 g of carbohydrate for breakfast, lunch, and dinner.
a. What is the action to be taken in week 1?
b. What is the action to be taken in week 2?
c. What is the action to be taken in week 3?
Answer
| a. | Reduction in the glargine dose |
| b. | Reduction in the insulin carbohydrate ratio (resulting in an increase in insulin dose) for breakfast |
| c. | Increase in the insulin carbohydrate ratio (resulting in a reduction in insulin dose) for dinner |
THG22-024
A child with type 1 DM comes with the following device:
a. Name the monitoring tool
b. Where is the glucose monitored?
c. State True or False: Use of this tool eliminates need for glucometer
d. What is the interpretation of glycemic control?
Answer
| a. | Continuous Glucose Monitoring System (CGMS) |
| b. | Interstitial fluid |
| c. | False (Periodic calibrations are needed) |
| d. | Sub-optimal control (Time in target should be maintained above 70%) |
THG22-025
Important calculations in pediatric endocrinology.
| 0 | Calculation | Interpretatioo |
|---|---|---|
| Glycosylated hemoglobin 10% in a child with type 1 diabetes mellitus | What is the estimated average glucoseƒ | What is the interpretationƒ |
| Child with new-onset diabetes mellitus with measured sodium of 130 mEq/L and blood glucose of 500 mg/dL | What is the corrected sodium levelƒ | What is the interpretationƒ |
| Child with nephrotic syndrome with measured serum calcium 6.5 mg/dL and serum albumin 1 g/dL | What is the corrected calcium levelƒ | What is the interpretationƒ |
| Child with failure to thrive, persistent hyperkalemia and metabolic acidosis (serum potassium 6 mEq/dL, spot urine potassium 3.6 mEq/L, serum osmolality 291 mOsm/kg, and urine osmolality 166 mOsm/kg) | What is the transtubular potassium gradient (TTKG)ƒ | What is the interpretationƒ |
Answer
| 0 | Calculation | Interpretation |
|---|---|---|
| Glycosylated hemoglobin 10% in a child with type 1 diabetes mellitus | 240.3 mg/dL = (28.7 × 10) - 46.7 | Poor glycemic control |
| Child with new onset diabetes mellitus with measured sodium of 130 mEq/L and blood glucose of 500 mg/dL | 136.4 mEq/L = 130 + (1.6 × 4) | Pseudohyponatremia |
| Child with nephrotic syndrome with measured serum calcium 6.5 mg/dL and serum albumin 1 g/dL | 8.9 mg/dL = 6.5 + (4 -1) × 0.8 | Corrected calcium is normal. No need for intervention |
| Child with failure to thrive, persistent hyperkalemia and metabolic acidosis (serum potassium 6 mEq/dL, spot urine potassium 3.6 mEq/L, serum osmolality 291 mOsm/kg and urine osmolality 166 mOsm/kg) |  |
Defective tubular action of aldosterone |
| Formulae used: |
| Estimated average glucose = (28.7 × HbA1C) − 46.7 | |
| Corrected sodium = Measured sodium + 1.6 × [(glucose − 100)/100] | |
| Corrected calcium = Measured calcium + (4 − albumin) × 0.8 |
(Normal: 4–10, low level at the time of hyperkalemia suggests defective mineralocorticoid production or action)
Figure Sources
Figures of Q22.3, Q22.4, Q22.7, Q22.9, Q22.14–Q22.16, Q22.18 and Q 22.21 are from author's personal collection.