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Introduction
Format
All questions are in the A-type multiple-choice format, that is, the single best answer of the five options given.
When visual material has been turned on its side, an arrow on the page indicates the orientation of the visual
material.
Questions do not necessarily appear in the order in which they were first printed.
Answers
Scoring
A correct answer will score one mark and an incorrect answer zero. There is no negative marking in the
FRACP Written Examination.
Queries
Contact the Executive Officer, Examinations’ Section, Department of Training and Assessment via e-mail:
exams@racp.edu.au.
Please note that with changes in medical knowledge, some of the information may no longer be current.
All Written Examination papers are copyright. They may not be reproduced in whole or part without written
permission from The Royal Australasian College of Physicians, 145 Macquarie Street, Sydney, Australia.
2 P200
Question 1
Which one of the following interventions has most consistently been shown to decrease the duration of
hospital stay with acute asthma?
B. Inhaled salbutamol.
C. Intravenous salbutamol.
D. Oral prednisolone.
E. Oral theophylline.
Question 2
A 15-year-old boy has been on an anticonvulsant for three years. The dosage has been stable. He recently
noticed difficulties in seeing at night. A formal ophthalmological assessment demonstrated visual field
constriction.
Which one of the following anticonvulsants is most likely to be the cause of his symptoms?
A. Carbamazepine.
B. Gabapentin.
C. Lamotrigine.
D. Sodium valproate.
E. Vigabatrin.
Question 3
A term neonate presents with ‘jitteriness’ at three hours of age. The following recordings are made:
B. 5 alpha-reductase deficiency.
C. hyperinsulinism.
D. hypopituitarism.
E. 45XO/46XY mosaicism.
The following results are obtained from a 14-year-old boy, prior to elective hernia surgery, who gives a history of
excessive bleeding after dental extraction.
Mixing the patient's plasma with an equal volume of normal plasma normalises the APTT.
C. Haemophilia.
Question 5
The section of the renal biopsy shown was taken from an eight-year-old girl. She had presented with polyuria,
anaemia and growth failure.
A. Lead nephropathy.
D. Post-infectious glomerulonephritis.
A six-year-old presents with the eruption shown on the right ear. It is itchy but not sore.
A. Group A Streptococcus.
C. Pseudomonas aeruginosa.
D. Staphylococcus aureus.
Question 7
Second generation H1 receptor antagonists effectively relieve most of the symptoms of allergic
rhinoconjunctivitis.
A. Nasal congestion.
B. Nasal itch.
C. Ocular tearing.
D. Rhinorrhoea.
E. Sneezing.
A six-month-old girl develops a chylothorax post-cardiac surgery. After two days her chest drain continues to
drain chylous fluid.
The most appropriate feed for the management of chylothorax in this infant is:
A. breast milk.
Question 9
In the pedigree shown above, III:3 is a woman of normal intelligence. She has a family history of mental
retardation. Her nephew IV:1 and her cousin III:1 have recently been diagnosed with Fragile X mental
retardation.
A. 100%.
B. 50%.
C. 25%.
D. 1%.
E. nil.
A 12-hour-old term male infant is transferred from a rural town to a level three neonatal unit with mild
respiratory distress and an oxygen requirement. The provisional diagnosis was transient tachypnoea of the
newborn. The chest radiograph shown below was taken on arrival. His oxygen saturation, measured from the
left foot, is 95%. The FiO2 is 0.45.
B. Organise a thoracotomy.
Question 11
Which one of the following vaccines is contraindicated in a child with anaphylactic egg allergy?
B. Influenza.
C. Measles-mumps-rubella (MMR).
D. Oral polio.
An 18-month-old boy has recurrent blue breath-holding episodes, followed on one occasion by a 15-second
generalised seizure.
A. electrocardiogram (ECG).
B. electroencephalogram (EEG).
C. iron studies.
D. plasma calcium.
E. plasma glucose.
Question 13
A three-year-old boy presents with a six-month history of polyarticular arthritis. He had been well until age 12
months when he required hospitalisation for left lower lobe pneumonia. Recurrent otitis media, intermittent
fevers and persistent diarrhoea developed in the second year of life. There was no history of oral thrush or
other fungal infections and no history of opportunistic infections. Developmental milestones and physical
growth were normal and immunisations were appropriate for age.
Physical examination shows a febrile boy who refuses to weight bear. He has purulent nasal discharge. The
lung fields are clear. Both knees are swollen, tender and warm with effusions and decreased range of
movement. Both ankles are tender with synovial swelling and there is a reduced range of movement.
Examination of the heart is normal. Skin examination is normal.
A. Chronic meningococcaemia.
D. Rheumatic fever.
E. Yersinia arthritis.
Which one of the following chemotherapy drugs, on extravasation, is most likely to have caused the
appearance as shown above?
A. Cyclophosphamide.
B. Cytosine arabinoside.
C. Ifosfamide.
D. Methotrexate.
E. Vincristine.
A three-year-old boy was brought to your office for evaluation of multiple skin lesions, some of which are
shown in the photograph below. A presumptive diagnosis of neurofibromatosis 1 (NF-1) is made but he does
not yet fulfil diagnostic criteria for diagnosis.
Which one of the following is not one of the diagnostic criteria for NF-1?
A. Acoustic neuroma.
C. Inguinal freckling.
D. Lisch nodules.
E. Optic glioma.
Question 16
A four-year-old child has a pneumonia with an effusion that is unresponsive to antibiotic therapy given
intravenously in appropriate doses (ceftriaxone, tobramycin and flucloxacillin) and formal surgical drainage of
the effusion/empyema. Five days after the surgery the child still has temperatures greater than 39°C and
looks unwell. Bacteroides fragilis is grown from the effusion.
A change to which one of the following antibiotics is likely to improve the child?
A. Ceftazidime.
B. Clindamycin.
C. Erythromycin.
D. Penicillin G.
E. Vancomycin.
Question 18
You are asked for a second opinion regarding a 10-year-old boy who has a long history of hyperactive,
impulsive, attention-seeking and destructive behaviour, both at home and at school. A paediatrician and a
child psychiatrist have previously diagnosed him as having attention deficit hyperactivity disorder (ADHD). He
responded poorly to dexamphetamine but concentration and attention have improved on methylphenidate. He
is currently on 30 mg/day. His weight is 35 kg.
Further assessment demonstrated average intelligence but with a significant language-based learning
disorder. He is at the 3rd percentile for receptive language and the 14th percentile for expressive language.
He is making progress at school with the provision of remedial help and an integration aide.
He also receives on-going counselling and cognitive behavioural management from his psychiatrist.
His parents are divorced and are unable to manage him consistently. His father is strict, distant and loses his
temper with his son. His mother is caring, finds it hard to set limits and is overwhelmed by his demands. The
boy dominates and intrudes on all aspects of family life. His father denigrates his ex-wife in front of the boy.
B. Family therapy.
C. Foster care.
A 10-year-old boy presents with a six-month history of progressive dyspnoea and palpitations. On
examination his respiratory rate is 35/minute with no overt distress. The liver is palpable 3 cm below the right
costal margin. Occasional crackles are audible in both bases. His chest X-ray demonstrated moderate
cardiomegaly. His electrocardiogram is shown below.
A. Anomalous origin of the left coronary artery from the pulmonary artery.
E. Viral myocarditis.
Two sisters developed a febrile illness with coryza and sore throat. They were both started on amoxycillin.
One week later this rash (shown below) appeared on their arms, and the older girl aged 10, complained of stiff
joints.
A. Drug reaction.
B. Enterovirus infection.
E. Scarlatina.
Question 21
A 14-month-old infant has been dependent on parenteral nutrition since birth due to surgical resection secondary
to volvulus of the small bowel. He currently receives 30% of his caloric requirement by the parenteral route and
the remainder as Pregestimil® via a nasogastric tube. On examination he is icteric. He has 3 cm of
splenomegaly, the liver is not palpable and there is no ascites.
Abdominal ultrasound shows a small liver with normal intra and extra hepatic ducts and an enlarged spleen. A
Doppler study of his portal vessels shows blood flowing from the liver to the spleen.
The most effective intervention to arrest the progression of his liver disease would be to:
B. administer phenobarbitone.
C. administer rifampicin.
Question 22
Which one of the following would be the most appropriate reason for testing a nine-year-old child?
Question 23
A four-year-old boy presents with the sole symptom of a generally dry cough of four months duration, which
has been affecting his sleep. He is well grown and there are no localising or generalised signs. He has not
responded to nebulised salbutamol prescribed by his general practitioner. His blood count and chest X-ray
are normal.
A. Bedroom humidification.
B. Erythromycin.
C. Inhaled corticosteroids.
D. No therapy.
E. Oral steroids.
A four-month-old boy is investigated following a urinary tract infection. The micturating cystourethrogram is
shown below.
B. neuropathic bladder.
A 14-year-old obese boy presents with a velvety, pigmented rash on his axillae and neck (shown below).
Which one of the following investigations is the most relevant for his future management?
C. Plasma leptin.
A four-year-old child presents to the emergency department with a two-day history of multiple bruises and a
bleeding nose, two weeks after an upper respiratory tract infection. His past medical history is unremarkable. On
examination, in addition to the features described in the history, there is a widespread petechial rash noted mainly
over the trunk but there are no other abnormal features. Full blood count shows the following results:
Which one of the following treatments will result in the most rapid rise in the platelet count?
A. Anti-D immunoglobulin.
B. Danazol.
C. Dexamethasone.
D. Intravenous immunoglobulin.
E. Prednisolone.
Question 27
Which one of the following factors is most likely to be associated with the occurrence of late-onset
haemorrhagic disease (vitamin K deficiency bleeding)?
A. Breastfeeding.
B. Formula feeding.
C. Maternal anticonvulsants.
E. Prematurity.
Question 28
A previously well two and a half-year-old girl, whose parents are divorced, returns from weekend access with
her father. On return home the child is a little more demanding than usual but is otherwise behaviourally
normal. At bed-time the mother notices that her daughter has a significantly reddened vulva.
A. Candidiasis.
C. Lichen sclerosis.
D. Non-specific vulvovaginitis.
E. Straddle injury.
An eight-year-old boy presents with behavioural problems and a noted deterioration in his performance at school.
Examination reveals mild unsteadiness of gait and a slight brown discolouration of the gums. A computed
tomography (CT) scan of his head is shown below.
B. Ophthalmological examination.
Question 30
A four-year-old girl has had a sore, swollen left knee for one month. She is noted to have the abnormality
shown in the photograph below, on examination of her eyes.
Question 31
A 15-year-old girl presents with a three-year history of school avoidance, attending approximately one week
per month. She held a scholarship in secondary school but this was withdrawn due to poor attendance.
At home, she spends her day watching television, drinking alcohol or smoking marijuana. She has a few
friends but is reluctant to leave the house. She is preoccupied with her body and feels herself to be a freak
because she perceives asymmetry in her facial appearance. She panics in social situations, believing that
other people see this appearance. She is volatile and flies into a rage if she is thwarted. She hates herself,
has grazed her wrists and there are scars from cigarette burns on her arms. She denies suicidal ideation.
At night, she finds it difficult to fall asleep, worries about being attacked and often checks the door and window
locks. She has frequent nightmares and on waking, she thinks she hears strangers in her room.
Her parents divorced eight years ago and do not get on well. She lives with her mother and brother, the latter
having similar but less severe difficulties. He is now at university. Her mother is anxious and ineffectual and it
is clear that the children control the family.
C. Obsessive-compulsive disorder.
D. Panic disorder.
E. Schizophrenia.
Question 32
Which one of the following would not be consistent with a diagnosis of night terrors?
A. Associated somnambulism.
A 13-year-old boy is brought to the emergency room following an intentional ingestion of battery acid 15
minutes previously. He complains of abdominal pain. On examination he is pale with a pulse rate of
100/minute, respiratory rate of 30/minute and a systolic blood pressure of 120 mmHg. He has upper
abdominal tenderness with no obvious rebound tenderness. Bowel sounds are present and normal in
character.
A. Administer antacid.
B. Administer corticosteroids.
C. Administer ipecac.
E. Perform a gastroscopy.
Question 34
A nine-month-old boy, who has been fully immunised, presents with a pneumonia and has the following results:
Lymphocyte markers:
His pneumonia is most likely to be due to which one of the following organisms?
A. Escherichia coli.
C. Mycoplasma pneumoniae.
D. Pneumocystis carinii.
E. Staphylococcus aureus.
Question 35
An eight-month-old breast-fed baby girl is brought to the emergency department with a 10-day history of
vomiting, irritability and weight loss. The baby developed normally until six months of age but since then her
development has regressed and she is no longer able to sit unsupported.
She is afebrile, pale and listless. Her weight is 6.5 kg (3-10th percentile), length 68 cm (50th percentile) and
head circumference is 43 cm (10-50th percentile). She is generally hypotonic and has brisk reflexes with
positive Babinski responses. Abdominal examination is normal.
Investigations show:
A. Cobalamin C deficiency.
C. Homocystinuria.
D. Methylmalonic acidaemia.
Question 36
An 11-year-old girl is referred because of recurrent severe asthma and very high doses of inhaled steroids and
repeated courses of oral steroids (eight months on oral steroids in the last 12 months). She complains of severe
shortness of breath with minimal exercise. She has gained 7 kg in the past 12 months. She has missed four
months of school in the past year because of respiratory illness. Her lung function tests are normal. During an
exercise test which she terminated at six minutes of bicycling, she was noted to have ‘severe distress’ associated
with stridor and inspiratory and expiratory wheezes. Her flow volume loops (tidal volumes) during exercise are
shown (see previous page) and exhibit a saw-tooth appearance.
B. obliterative bronchiolitis.
C. psychogenic asthma.
E. unstable asthma.
Question 37
A neonate with Down syndrome is found to have hepatosplenomegaly. A photograph of the cord blood film is
shown below.
A. acute erythroleukaemia.
D. congenital infection.
Question 38
The most significant hurdle to the eradication of measles in Australia and New Zealand is the:
Question 39
Which anti-arrhythmic drug is inappropriate in the treatment of the arrhythmia with which it is paired?
Question 40
Which one of the following has been most clearly demonstrated to be effective in the treatment of depression
in young people?
B. Desipramine.
C. Exercise.
D. Fluoxetine.
A 30-year-old mother and her five-year-old son are both HIV (human immunodeficiency virus)-positive. She is
well and takes all her own medication reliably. She is pregnant and would like to know what are the chances of
her baby developing HIV infection. She understands that both baby and she will be treated with the best available
current treatments.
A. 90%.
B. 70%.
C. 50%.
D. 30%.
E. 10%.
Question 42
An eight-year-old boy is being investigated for short stature and headache. A magnetic resonance imaging
(MRI) scan is obtained and is shown below.
A. Aneurysm.
B. Craniopharyngioma.
C. Metastatic tumour.
D. Optic glioma.
E. Pituitary adenoma.
A two-year-old boy presents with a three-month history of frequent, loose stools and failure to thrive. His diet
consists of three bottles of cows’ milk per day and two small meals, usually a Vegemite® sandwich for lunch,
and chicken nuggets and chips or plain pasta for dinner.
A. coeliac disease.
C. pancreatic insufficiency.
D. post-gastroenteritis enteropathy.
Question 44
Which one of the following sets of urinary electrolytes is most likely to be found in established pyloric
stenosis?
B. 5 5 30 6
C. 40 40 80 8
D. 110 5 60 8
E. 35 45 5 6
Stevens-Johnson syndrome is most likely to occur with which one of the following anticonvulsant drugs?
A. Carbamazepine.
B. Lamotrigine.
C. Phenytoin.
D. Sodium valproate.
E. Vigabatrin.
Question 46
A 10-year-old girl presents with a recurrent persistent distressing cough of four months duration. The cough
does not occur during sleep, but starts on awakening and fluctuates in intensity and frequency throughout the
day. Her mother describes the cough as very loud. The cough has been present daily and it started with an
upper respiratory tract infection. There was a similar episode 12 months ago at the same time of the year.
The cough was not associated with wheeze, dyspnoea or any sputum production. Her chest X-ray is normal.
B. Episodic asthma.
C. Pertussis.
E. Psychogenic cough.
An eight-year-old previously well girl presents with a four-week history of increasing pallor, shortness of breath
and easy bruising. Her parents are vegetarians. Physical examination confirms marked pallor, extensive
petechial rash over lower limbs with bruising of various ages on trunk and limbs. There was no
lymphadenopathy present and the rest of her examination was unremarkable. Full blood count showed:
B. Myelodysplastic syndrome.
D. Parvovirus infection.
A 12-year-old girl presents with a six-month history of pain and colour change in her fingers when exposed to
cold. The fingers go white in the cold, then blue and become red and painful when they are warmed up.
Examination on a warm day reveals a well, appropriately grown 12-year-old girl with normal peripheral pulses
and puffy fingers but no trophic changes in the skin. Nail-fold capillaroscopy is performed (shown below).
The photograph on the left shows a normal control (A) and the photograph on the right is of the patient’s nail
fold capillaroscopy (B).
A B
Which one of the following is the most likely cause of this clinical picture?
C. Rheumatoid arthritis.
D. Scleroderma.
You have been asked to review the biochemical profile of a 13-year-old girl who is undergoing nasogastric feeding
for severe anorexia nervosa, which was initiated three days earlier. You calculate that she is receiving 100
calories per hour. She had normal biochemistry on admission.
A. Addisonian crisis.
B. Diuretic abuse.
C. Laxative abuse.
Question 50
Which one of the following cardiac lesions would be an unexpected finding in a baby with a 22q11 deletion?
D. Tetralogy of Fallot.
E. Truncus arteriosus.
Question 51
Which one of the following measures is most effective in preventing neonatal early onset group B
streptococcal infection?
A. Antibiotics (single intramuscular dose) given after delivery to babies of colonised mothers.
C. Antibiotics given during pregnancy to colonised mothers with group B streptococcal antigenuria.
E. Vaginal antiseptic douches before and during delivery to intrapartum colonised mothers.
A five-year-old boy presents with a one-week history of fever and malaise. He has a mild cough, but no
dyspnoea or tachypnoea and no chest signs. His chest X-ray is shown below.
A. Cryptococcoma.
B. Hydatid cyst.
C. Lung abscess.
D. Pneumatocele.
E. Round pneumonia.
A 15-year-old boy presents following a syncopal episode outside the headmaster’s office prior to being
reprimanded. The above rhythm strip (A) was obtained by the ambulance officers upon their arrival and the
attached 12 lead electrocardiogram (B) was obtained the following day.
C. Hyperparathyroidism.
D. Hypoparathyroidism.
E. Long QT syndrome.
The tympanogram shown below was obtained from the right ear of a six-year-old child.
Examine the five air-conduction audiograms shown below. Which one of these audiograms is most likely to
have been obtained from the same ear as the tympanogram?
Which one of the following has most consistently been shown to be associated with an increased risk of
sudden infant death syndrome?
A. Bottle feeding.
C. Non-immunisation.
Question 56
A 13-year-old boy with severe spastic quadriplegia is referred for consideration of placement of a gastrostomy
tube to aid with feeding. He has scoliosis and chronic lung disease.
Which one of the following factors would be a contraindication to percutaneous endoscopic gastrostomy tube
placement in this patient?
A. Oropharyngeal incoordination.
C. Recurrent constipation.
Question 57
A five-year-old girl is referred with day and night wetting. Her neuro-developmental history is otherwise
normal and bowel training was established prior to three years.
The history reveals that her pants are constantly wet and her teacher has already expressed concern
regarding comments from other children.
A renal ultrasound is suggestive of a duplex right kidney and a normal left kidney, but is otherwise
unremarkable.
A. Intravenous pyelogram.
B. Micturating cystourethrogram.
E. Urodynamic studies.
The cytokine likely to be responsible for proliferation of the cells indicated in the photograph above is:
C. interleukin 1 (IL-1).
D. interleukin 2 (IL-2).
E. interleukin 5 (IL-5).
Question 59
A six-year-old boy, previously well, has a one-week history of rhinitis followed by cough and fever. His chest X-
ray is shown below.
The abnormality shown is most likely to be due to which one of the following?
A. Hamartoma.
B. Metastatic lesion.
C. Neuroblastoma.
D. Pneumonia.
E. Tuberculosis.
Question 60
Prophylactic surfactant (given within 15 minutes of birth) has been compared to rescue surfactant (given
immediately after intubation for established hyaline membrane disease), in several controlled trials.
The use of prophylactic surfactant as opposed to rescue surfactant in very low birthweight infants has been shown
to decrease the incidence of which one of the following?
A. Air-leak syndrome.
B. Bronchopulmonary dysplasia.
E. Periventricular leukomalacia.
Question 61
In an asymptomatic person with human immunodeficiency virus (HIV) infection, which one of the following is the
best predictor of the future rate of decline of immune function?
C. p24 antigenaemia.
Question 62
You are asked to review a 15-year-old boy regarding his short stature. He was treated for medulloblastoma at
age six with cranio-spinal irradiation. His height was on the 50th percentile at diagnosis. At age 11, when puberty
was first noticed, his height was 140 cm (25th percentile). He is now 156 cm tall and his arm span is 167 cm. His
father's height is 172 cm and his mother's height is 158 cm. Preliminary investigations include:
E. hypothyroidism.
Question 63
A two-month-old girl had a murmur identified at birth. To your assessment now, she is pink and thriving. She
shows no signs of respiratory distress or other signs of heart failure. The S2 is single and there is a long
systolic murmur heard loudest at the left sternal edge. Her chest X-ray is normal and her ECG is shown
above.
A. Aortic stenosis.
E. Tetralogy of Fallot.
A 16-year-old intellectually disabled boy, living in a community residential home, is brought to you for re-
evaluation of longstanding epilepsy and autistic features. His seizures have been well controlled over the last
two years. He had early-onset epilepsy and has been given a diagnosis of autism. You notice unusual
fingernails, which are shown below.
A. Fabry disease.
B. Lesch-Nyhan syndrome.
C. Neurofibromatosis.
D. Tuberous sclerosis.
Question 65
A 14-year-old boy in the second year of secondary schooling has always been anxious, insecure and isolated but
has had no previous panic or phobic symptoms. He has a few friends, but at times he behaves in an
inappropriate manner. At school, he is an average student. His teachers believe he is immature but otherwise
normal.
For the last two years, he has been masturbating, preoccupied with sexual matters and has interfered with his
parents' conversations with other adults. He worries that whenever his parents go out, they are having affairs with
other people. Over the last four months he has become irritable, moody and angrily reacts to even mild criticism
from his older brothers. He has developed a fear of germs and of being contaminated. After he has emptied his
bowels he has to have a shower and he worries about stepping on dirty band-aids. He also worries about being
attacked when he rides his bike and has to repeatedly check his windows at night, to ensure that they are locked
but even so, he finds it difficult to sleep. He spends large amounts of time with his mother but worries that if she
touches his clothes, she may become pregnant. He mostly believes that these fears are "silly" but cannot stop
worrying.
A. Anxiety disorder.
B. Depression.
C. Obsessive-compulsive disorder.
D. Phobic disorder.
E. Schizophrenia.
In Kawasaki disease, which one of the following laboratory findings would be the least likely?
A. Aseptic meningitis.
C. Sterile pyuria.
D. Thrombocytopenia.
Question 67
A four-month-old infant presents with biphasic stridor since day one of life and an unusual cry, which has been
described as ‘quiet’. The infant sucks and swallows normally. Growth and development are also normal.
B. lingual cyst.
C. subglottic haemangioma.
D. vascular ring.
Question 68
An orthopaedic surgeon was asked to see this teenager because of her foot deformities. The surgeon is
concerned about her lack of facial animation and refers her to you. Her photograph is shown below. You note
that her mother has the same expression and that the maternal grandfather recently had bilateral cataract
surgery.
A. Anticipation.
B. Genomic imprinting.
C. Germinal mosaicism.
D. Lyonisation.
E. Uniparental disomy.
Question 69
A three-year-old boy presents with a three-day history of complaining of a ‘sore bottom’, which is intensely
itchy. He complains particularly of pain on defaecation and has a mucopurulent anal discharge. His anal
appearance is shown below.
A. Candidiasis.
D. Pruritus ani.
E. Threadworm infestation.
A general practitioner requests your advice about a six-year-old boy who has sustained a laceration which has
been heavily soiled with manure after a fall in a horse stable. His immunisation status, confirmed by his child
health records, is as follows:
A. Childhood diphtheria and tetanus toxoids (CDT), tetanus immunoglobulin and OPV.
B. DTP.
Question 71
An eight-year-old girl presents with recurrent urinary infection causing symptoms of dysuria and frequency.
She ceased wearing nappies during the day at two and a half years and at night at three years. Her
underpants are often damp in the afternoon and evening. Her mother states that she only passes urine two or
three times per day and she does not void at school. Urgency and posturing occur infrequently. She was
constipated as an infant and the only abnormal physical finding is the presence of palpable faecal masses on
abdominal examination.
C. normal bladder.
Question 72
Which one of the following blood products is likely to have the highest risk of bacterial contamination?
A. Cryoprecipitate.
D. Platelet concentrate.
A 15-year-old boy is brought to see his paediatrician because of longstanding difficulty climbing stairs.
Examination reveals symmetric proximal muscle weakness. A photograph of his legs is shown below.
B. Charcot-Marie-Tooth disease.
D. Myotonic dystrophy.
Question 74
The child whose photograph and electrocardiogram are shown (see following page), has a loud systolic
ejection murmur at the upper left sternal edge, radiating to the back and axillae.
E. Secundum ASD.
An 18-month-old child is referred by his general practitioner for paediatric assessment because of concern
about his language development. According to his mother, he seems to understand about 60 words but the
only clear words he says are "mama", "up", "shoe" and "duck".
He smiled socially at seven weeks, sat at six and a half months, crawled at nine months and walked at 14
months. He has had two known episodes of acute otitis media, at age 10 months and 13 months. He is not
yet toilet trained.
He is very active during the assessment, which his mother confirms is usual for him. He is observed to point,
to tug his mother by the hand to show her some toys, and to pretend to drink from a toy cup. Physical
examination is normal.
Which one of the following is most likely to explain this pattern of language development?
A. Asperger disorder.
B. Normal variant.
Question 76
Testicular relapse within the first two years following initial diagnosis is more likely to occur in patients who
have which one of the following?
Question 77
A 15-year-old boy presents with a long history of obsessive-compulsive disorder and episodes of depression.
He has previously consulted psychiatrists and psychologists and now, mistrustful of conventional medicine,
sees a naturopath, but without significant alleviation of his symptoms. Although previously an excellent
student, he has lost interest in his studies and sees no point in continuing at school. He denies feeling unduly
sad but admits to some difficulties getting to sleep. Upon further questioning he describes smoking marijuana
three or four times each night to assist his insomnia.
B. Prescribe sertraline.
A 12-year-old boy with spastic quadriplegia presents with a 24-hour history of vomiting. A gastrostomy tube
was inserted 12 months ago for supplementary enteral feeding. Currently he has a balloon gastrostomy tube
in situ. Over the past 24 hours the patient has become uncomfortable with oral drinks and solids, but has
tolerated gastrostomy tube feeds. This discomfort appears to be relieved by vomiting. A barium study is
performed (shown below).
E. oesophageal stricture.
Question 79
A three-week-old boy presents with a one-week history of cough. The cough is not present all the time but
comes in bouts lasting up to a minute. For two days the baby has been breathing faster and has been having
difficulty feeding. He has had no fever.
He was born by vaginal delivery at term to an 18-year-old primigravida mother. The pregnancy was normal.
He is bottle-fed. At one week of age he developed bilateral conjunctivitis which responded to chloramphenicol
eye drops.
On examination the baby is afebrile. He is in mild respiratory distress, with a respiratory rate of 52/minute,
heart rate of 140/minute and moderate intercostal recession. He is not cyanosed. He has some fine crackles
audible at both lung bases. His chest is not clinically hyperexpanded. His heart is not enlarged and heart
sounds are normal. His oxygen saturation by pulse oximetry is 94%. His chest X-ray is shown (see following
page).
A. Bordetella pertussis.
B. Chlamydia trachomatis.
C. Group B Streptococcus.
D. Pneumocystis carinii.
Question 80
A 28-week gestation infant collapsed on day 12 with necrotising enterocolitis. At laparotomy, the distal 30 cm
of ileum was found to be necrotic and was resected. An ileostomy was performed. The ileo-caecal valve was
preserved. An additional 20 cm of the remaining ileum had extensive intramural gas but was thought to be
viable, and was not resected. Enteral feeds were withheld for 14 days and parenteral nutrition (100
kcal/kg/day) was administered. The infant recovered uneventfully after surgery, and oral feeds (Pregestimil
20 kcal/30 mL) were recommenced on day 26. There had been a weight gain of 200 g since the laparotomy.
By day 40 enteral feeds had been increased to 90 mL/kg/day (60 kcal/kg/day). The infant was also receiving
parenteral nutrition via a central venous line in a volume of 80 mL/kg/day, providing a further 60 kcal/kg/day.
Sodium, 3 mmol/kg/day, and potassium, 3 mmol/kg/day, were administered with the parenteral nutrition
throughout. Ileostomy fluid losses were 60-80 mL/kg/day after enteral feeds were resumed. No weight gain
occurred between day 26 and day 40. There were no clinical signs of dehydration.
blood:
sodium 138 mmol/L [135-145]
potassium 3.1 mmol/L [3.4-5.5]
chloride 101 mmol/L [98-110]
pH 7.25
PaCO2 44 mmHg
base excess -9 mmol/L [-4-+3]
bilirubin conjugated 220 µmol/L [<15]
bilirubin unconjugated 110 µmol/L [<15]
alanine aminotransferase (ALT) 320 U/L [0-105]
gamma glutamyltransferase (GGT) 1100 U/L [9-76]
urinary:
sodium <5 mmol/L
potassium 25 mmol/L
osmolality 120 mosmol/kg
ileostomy fluid:
sodium 70 mmol/L
potassium 12 mmol/L
chloride 52 mmol/L
The most important next step in achieving adequate weight gain is to:
Question 81
A three-year-old girl presents with an abnormal gait but no other symptoms. Her photograph is shown below.
Apart from the abnormality shown, her examination is otherwise normal.
Which one of the following is most commonly associated with her abnormality?
A. Craniopharyngioma.
B. Ewing sarcoma.
C. Osteosarcoma.
D. Retinoblastoma.
E. Wilms tumour.
A six-year-old girl has a three-month history of pubic hair development, body odour and acne. On
examination, she has Tanner stage 1 breasts, stage 3 pubic hair and axillary hair. Her height and weight are
on the 75th percentile.
Investigations reveal:
age-specific
normal ranges
17-hydroxyprogesterone 1.6 nmol/L [0-6.0]
dehydroepiandrosterone sulphate (DHEAS) 1.5 µmol/L [0.5-1.5]
androstenedione 1.2 nmol/L [0.7-1.7]
testosterone 0.2 nmol/L [<1.0]
oestradiol 32 pmol/L [<50]
bone age six years
pelvic ultrasound normal for age
A. adrenal tumour.
Question 83
These findings are most consistent with which one of the following?
A. IgA deficiency.
B. Kostmann syndrome.
C. Normal results.
E. X-linked agammaglobulinaemia.
A 10-day-old baby with Down syndrome, born after a high forceps delivery, develops poor feeding, hypothermia
and lethargy. A magnetic resonance imaging (MRI) scan with contrast of her brain was performed and is shown
below.
A. a cerebral abscess.
C. an intracerebral haematoma.
D. intracerebral calcification.
E. ring artefact.
Question 85
An 11-year-old girl presents with a 10-month history of episodic abdominal pain, which clusters over a two to
three-day period. The pain is described as constant, lasting for 40 minutes to one hour and localised to the
mid-abdomen. There is no clear relationship of the pain to meals, specific foods, activity or stool pattern. She
has no associated vomiting, weight loss, or joint pain.
On examination she is a well looking pre-pubertal girl, weight 35 kg (50th percentile) and height 140 cm (25th
percentile). Her abdomen is soft with mild diffuse tenderness noted throughout on deep palpation. There is
no rebound tenderness elicited. There is no organomegaly or masses felt. The remainder of the examination
is normal.
Which one of the following would most suggest an organic cause for this girl’s pain?
A seven-year-old boy wakes one morning with severe leg pain, predominantly in the calf muscles after an upper
respiratory tract infection four days previously. He is unable to walk but is otherwise well. The casualty officer
thinks that there is weakness distally and has difficulty obtaining reflexes. The boy experiences a lot of calf pain
on examination. His serum creatine kinase is 2,000 U/L [40-240].
A. Dermatomyositis.
B. Guillain-Barré syndrome.
C. Reactive arthritis.
D. Rhabdomyolysis.
E. Viral myositis.
Question 87
A male infant was born at 35 weeks gestation following premature rupture of membranes. Hypothermia and
unconjugated hyperbilirubinaemia were problems during the newborn period.
He presents at six months with myoclonic seizures and is found to be globally developmentally delayed. He is
not rolling, does not reach for objects (although he is reported to have done so previously) and does not
vocalise normally. There is generalised mild hypotonia but no focal neurological signs. He has hair which
breaks easily, leaving generally short hair with a stubbly feel to his scalp. His photograph is shown below.
His mother is said to have had similar hair as a child. A maternal uncle had seizures and developmental delay
and died at age three years.
The child pictured below is noted to have a grade 4/6 systolic murmur.
B. Hypertrophic cardiomyopathy.
Question 89
You are called to see a four-year-old girl with seal-like barking cough, severe inspiratory stridor, marked wheeze
and agitation. Her oxygen saturation is 89% in room air.
Which one of the following would be the most appropriate immediate therapy in addition to oxygen?
A. Nebulised adrenalin.
B. Nebulised ipratropium.
C. Nebulised salbutamol.
D. Nebulised steroids.
E. Oral steroids.
A five-year-old child presents with fever, vomiting, neck stiffness and a petechial rash. All of the following are
contraindications to immediate lumbar puncture except:
A. hypertension.
B. hypotension.
C. intractable fitting.
Question 91
A four and a half-year-old girl is referred for investigation of short stature. Her birthweight was 2650 g and length
48 cm at term. Her mid parental height is 164 cm (50th percentile). At age two, her length was on the 10th
percentile. Her health is good except for recurrent otitis media.
Physical examination reveals no dysmorphic features but she has thickened tympanic membranes with fluid
behind the drums. Her current height is 95 cm (1st percentile) and weight is 14 kg (10th percentile).
A. Bone age.
B. Endomysial antibody.
D. Karyotype.
E. Thyroid-stimulating hormone.
Question 92
A newborn infant delivered vaginally after a pregnancy complicated by polyhydramnios, presents with
intermittent respiratory distress. The radiograph shown (see previous page) was taken.
Which one of the following is the most likely cause of her respiratory difficulties?
B. Duodenal atresia.
E. Oesophageal atresia.
Question 93
A six-month-old girl presents with a 14-day history of diarrhoea. The illness initially began with fever, vomiting and
diarrhoea. Her vomiting and fever resolved after 36 hours, however, her stools have remained watery and loose.
She has recommenced on her usual cow’s milk based formula and solids including pureed fruit and vegetables.
On examination she is a tired but not unwell looking girl. Her weight is on the 25th percentile for age and height is
on the 50th percentile for age. She is not dehydrated or clinically pale. She has no rashes. Her abdominal
examination reveals a soft non-tender abdomen with no masses or hepatosplenomegaly. The following blood
tests were performed:
A. pH 3.
C. rotavirus antigen.
Question 94
A 15-year-old girl lives in a rural town where you consult once per month. She presents with a 12-month
history of anxiety-based symptoms, which have prevented her from attending school.
She describes a sense of dread if she is away from home, associated with palpitations, sweating and a heavy
feeling in her chest. She finds it difficult to fall asleep and has numerous nightmares. She worries about
germs and frequently washes her hands. She also describes magical thoughts in that she dreads something
bad will happen if she tapes over her old videos. She believes that these thoughts are silly.
Prior to the onset of her symptoms, she functioned well at school and had many friends. She was not aware
of any pressures at the time.
She lives with her father and a 20-year-old sister, her mother having died from a cerebral haemorrhage eight
years ago. There is no family history of psychiatric illness. She refuses to see a psychiatrist but is willing to
continue to see you.
In addition to further counselling, which one of the following medications is most appropriate?
A. Amitriptyline.
B. Clomipramine.
C. Oxazepam.
D. Paroxetine.
E. Thioridazine.
Question 95
A 14-year-old boy presents with a history of recurrent chest infections, often with wheeze, since five years of
age. He lives with his family on a sheep farm.
Over the last two years he coughs about half a cup of green or yellow sputum into the sink each morning
when he wakes. He does not complain of breathlessness and copes normally with school sports.
He looks well and has no finger clubbing. He is on the 25th percentile for height and weight. His chest is not
hyperexpanded and respiratory examination reveals only coarse crackles at the left base. The rest of the
physical examination is normal. His chest X-ray is shown below.
A. Bronchiectasis.
B. Cystadenomatoid malformation.
C. Diaphragmatic hernia.
D. Hydatid disease.
E. Staphylococcal pneumatoceles.
Which one of the following conditions is most likely to be responsive to treatment with interferon alpha?
A. Arterio-venous malformation.
B. Hepatoblastoma.
D. Neuroblastoma.
E. Wilms tumour.
Question 97
An 18-month-old boy was referred by his general practitioner to a paediatrician for advice about febrile
seizures.
The child has had three previous episodes of febrile convulsions, the first at 13 months of age. On each
occasion, two seizures have occurred in a 24-hour period. Each seizure was brief (less than five minutes) in
the setting of a high fever (greater than 39°C). The child is developing normally and his neurological
examination is unremarkable. The child’s father has a history of febrile seizures.
A. 0.5%.
B. 2%.
C. 5%.
D. 10%.
E. 15%.
Question 98
A two and a half-year-old girl is referred for developmental assessment. Her parents report that she has 10 to 15
single words in her vocabulary and one recognisable two word phrase. Her pronunciation of words is not always
clear. She seems to understand most things said to her. Audiological testing is normal. She is physically very
active and finds it difficult to settle to task. However, she can sit and watch television for up to five minutes. She
plays with toy cars by pushing them up and down repeatedly and making engine noises. She also enjoys playing
with dolls and will kiss, hug, scold, pretend to feed them, and push them around in a toy pram. However, she
does not play cooperatively or interactively with other children, and is somewhat self-absorbed. She runs, climbs
a playground slide, scribbles with a crayon and can feed herself with a spoon. She can also drink from a cup and
take off some of her clothes. She tantrums if things do not go her way and screams on separation from her
mother. She becomes highly agitated and cries when the vacuum cleaner is turned on. She is also frightened of
the neighbour's dog.
A. Anxiety disorder.
C. Intellectual disability.
E. Normal variation.
The clinical photograph shown above was taken soon after birth. The infant was delivered vaginally at 34
weeks gestation after premature onset of labour. Birth weight was 2800 g (>90th percentile).
The lesion was covered with a polythene film, and intravenous 10% dextrose was commenced shortly after
delivery. At one hour of age the infant’s core temperature was 35.8°C and the plasma glucose was 0.8
mmol/L.
Which one of the following is the most likely cause for the plasma glucose reading?
B. Cold stress.
E. Impaired glycogenesis.
A 14-year-old boy presents with a three-week history of dyspnoea and a dry, hacking cough. On examination
there are diffuse crackles throughout his chest and an enlarged liver. His immunoglobulins are elevated and
he has eosinophilia. He has had recurrent parotid swelling and a transient facial nerve lesion. His chest X-ray
is shown below.
A. Churg-Strauss syndrome.
C. Mycoplasma infection.
D. Sarcoidosis.
E. Sjögren’s syndrome.
Answers
1. D 34. B 67. E
2. E 35. E 68. A
3. D 36. C 69. C
4. C 37. E 70. D
5. B 38. B 71. B
6. E 39. D 72. D
7. A 40. A 73. A
8. D 41. E 74. D
9. A 42. B 75. B
10. C 43. C 76. E
11. B 44. A 77. A
12. C 45. B 78. D
13. B 46. E 79. B
14. E 47. A 80. D
15. A 48. D 81. E
16. E 49. E 82. B
17. B 50. A 83. D
18. D 51. D 84. A
19. C 52. C 85. C
20. C 53. E 86. E
21. D 54. D 87. C
22. A 55. B 88. D
23. D 56. D 89. A
24. E 57. A 90. E
25. B 58. E 91. D
26. D 59. D 92. E
27. A 60. A 93. A
28. D 61. D 94. D
29. C 62. B 95. A
30. A 63. E 96. C
31. B 64. D 97. B
32. D 65. C 98. D
33. A 66. D 99. A
100. D