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2003 FRACP Written Examination

Paediatrics & Child Health

Paper 2 – Clinical Applications

Introduction
Format

Paper 1 – Medical Sciences: 70 questions; time allowed: 2 hours


Paper 2 – Clinical Applications: 100 questions; time allowed: 3 hours

All questions are in the A-type multiple-choice format, that is, the single best answer of the five options given.

In the questions, values appearing within [ ] refer to normal ranges.

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

A table of answers is located at the end of each paper.

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.

Copyright © 2004 by The Royal Australasian College of Physicians

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 P203

QUESTION 1

Which of the following is more characteristic of streptococcal toxic shock syndrome than of staphylococcal
toxic shock syndrome?

A. Conjunctivitis.

B. Encephalopathy.

C. Generalised erythema.

D. Intractable hypotension.

E. Septicaemia.

QUESTION 2

A nine-year-old boy presents with recurrent episodes of obstructive dysphagia. Over the past year he has
required endoscopic removal of impacted food in the upper oesophagus on several occasions. A barium
meal is normal.

Which of the following is the most likely diagnosis?

A. Achalasia.

B. Barrett’s oesophagus.

C. Eosinophilic oesophagitis.

D. Globus hystericus.

E. Mediastinal tumour.

QUESTION 3

A five-year-old presents with a three-week history of polyuria and polydipsia and 24 hours of vomiting.
Investigations are as follows:

plasma glucose 26.2 mmol/L [4.1-6.2]


plasma bicarbonate 3.8 mmol/L [21.0-28.0]
plasma pH 6.9

During the first 36 hours of therapy, which of the following presents the greatest risk for mortality?

A. Cerebral oedema.

B. Circulatory collapse.

C. Hyperkalaemia.

D. Hypokalaemia.

E. Sepsis.

Copyright © 2004 by The Royal Australasian College of Physicians


3 P203

QUESTION 4

The full term infant, shown above at age 36 hours, was born to a primigravida. The pregnancy was
complicated by polyhydramnios and poor foetal movements. The infant required intubation and ventilation
from birth for poor respiratory effort. He remained floppy and had few spontaneous movements.

Which one of the following is most likely to provide diagnostic information?

A. Creatine kinase levels.

B. Electromyography (EMG).

C. Magnetic resonance imaging (MRI) scan of the brain.

D. Muscle biopsy.

E. Triplet repeat studies.

QUESTION 5

When assessing an adolescent, whose history is likely to have the greatest sensitivity for the detection of
depressive symptoms?

A. Friends.

B. Siblings.

C. The adolescent.

D. The classroom teacher.

E. The mother.

Copyright © 2004 by The Royal Australasian College of Physicians


4 P203

QUESTION 6

Which of the following is least characteristic of sleepwalking?

A. Amnesia.

B. Episodes in the last third of the night.

C. Occurrence during non-REM sleep.

D. Peak incidence in primary school age.

E. Positive family history.

QUESTION 7

A 34-week infant with hyaline membrane disease was ventilated from birth. At 48 hours of age the infant
‘collapses’. His pulses are all depressed and the liver is palpable 4 cm below the right costal margin. He
has an arterial pH of 6.95. His blood pressure, as measured on his umbilical arterial line located at the
diaphragm, is 105/55 mmHg.

Which of the following is the most likely cause of his presentation?

A. Adrenal insufficiency.

B. Coarctation of the aorta.

C. Hypoplastic left heart syndrome.

D. Sepsis.

E. Systemic hypertension.

QUESTION 8

The carrier frequency for cystic fibrosis in the Caucasian population in Australia is approximately 4%. The
∆F508 mutation accounts for 75% of all mutations among carriers in this population.

A girl is diagnosed with cystic fibrosis. DNA studies identify one ∆F508 mutation but fail to identify a
mutation in the other allele. DNA studies of her unaffected brother are normal.

What is the risk of the brother being a carrier?

A. <1%.

B. 4%.

C. 25%.

D. 50%.

E. 66%.

Copyright © 2004 by The Royal Australasian College of Physicians


5 P203

QUESTION 9

A nine-year-old boy presents with a two-week history of cough, tachypnoea, recession and increasing
cyanosis. The chest X-ray and a lung biopsy (stained with methenamine silver nitrate) are shown above.

The underlying immune deficiency is most likely to be primarily affecting his:

A. B lymphocytes.

B. macrophages.

C. natural killer cells.

D. neutrophils.

E. T lymphocytes.

Copyright © 2004 by The Royal Australasian College of Physicians


6 P203

QUESTION 10

A one-year-old child arrives in the emergency department intubated and ventilated with high flow oxygen,
following a motor vehicle accident. Observation reveals a child who is unconscious, cyanosed, pale and with
limited chest expansion. Neck veins are slightly distended.

Further examination demonstrates poor peripheral perfusion, a weak pulse and tachycardia at 160/minute.
The child’s trachea is deviated to the right. Air entry is decreased bilaterally but with air entry on the left
reduced compared with the right-hand side. There is hyperresonance over the left chest.

The most appropriate next step is:

A. chest drain insertion to the left chest.

B. needle thoracocentesis of the left chest.

C. repositioning of the endotracheal tube.

D. suction of the endotracheal tube.

E. urgent chest X-ray.

QUESTION 11

A 12-year-old boy with acute myeloid leukaemia undergoes allogeneic stem cell transplantation from a
human leucocyte antigen (HLA)-matched sibling. He is progressing well for the first 10 days, but then
complains of abdominal pain and leg swelling.

He is noted to have marked ascites, moderate peripheral oedema and jaundice.

Liver function test results are as follows:

bilirubin 123 µmol/L [3-23]


alkaline phosphatase (ALP) 510 U/L [200-495]
gamma glutamyltransferase (GGT) 680 U/L [<65]
aspartate aminotransferase (AST) 1254 U/L [5-45]
alanine aminotransferase (ALT) 1356 U/L [5-45]
albumin 30 g/L [40-52]

An abdominal ultrasound confirms large volume ascites with an enlarged liver (span 18 cm). The spleen is
normal in size.

The most likely explanation for his condition is:

A. cytomegalovirus hepatitis.

B. graft-versus-host disease.

C. hepatosplenic candidiasis.

D. portal vein thrombosis.

E. veno-occlusive disease.

Copyright © 2004 by The Royal Australasian College of Physicians


7 P203

QUESTION 12

A mother develops chickenpox two days after delivery of a normal healthy baby boy. She caught the
chickenpox from her five-year-old daughter. The baby is breastfed.

Which of the following would be the most appropriate action with respect to the baby?

A. Do his varicella-zoster virus (VZV) serology and give zoster immunoglobulin (ZIG) if negative.

B. Give him aciclovir.

C. Give him ZIG.

D. Isolate him from his mother and sibling until their lesions have crusted.

E. Stop breastfeeding.

QUESTION 13

A four-year-old girl is noted by her parents to have a ‘funny looking’ eye (pictured). She has not complained
of anything herself but seems to be bumping into things more often recently.

On examination, the only other finding is a swollen right knee. There is a history of back problems on her
father’s side of the family. Her maternal grandmother has rheumatoid arthritis.

Which of the following tests is most likely to be diagnostically useful?

A. Anti-double stranded DNA antibody (anti-dsDNA).

B. Antinuclear antibody (ANA).

C. Antineutrophil cytoplasmic antibody (ANCA).

D. HLA-B27.

E. Rheumatoid factor.

Copyright © 2004 by The Royal Australasian College of Physicians


8 P203

QUESTION 14

A 10-year-old boy, with steroid sensitive nephrotic syndrome, presents to the emergency department with a
one-day history of recurrent vomiting and headaches. He is on 60 mg prednisolone daily because of a
recent relapse. He is well perfused, with a blood pressure of 99/60 mmHg and a pulse rate of 130/minute.
He has a dry mouth and coated tongue. He has mild to moderate peripheral oedema and his abdomen is
soft and non-tender.

Laboratory investigations show:

haemoglobin 202 g/L [120-160]


serum creatinine 0.08 mmol/L [0.05-0.10]
urea 9.1 mmol/L [3.2-7.7]
sodium 132 mmol/L [135-146]
potassium 5.0 mmol/L [3.5-5.0]
albumin 14 g/L [35-46]

The most appropriate intravenous treatment is:

A. cyclophosphamide.

B. frusemide.

C. hydrocortisone.

D. normal saline.

E. 20% albumin.

QUESTION 15

A 14-year-old girl presents with a three-month history of diarrhoea with significant weight loss. Stool
investigations reveal no bacterial or viral pathogens. Colonoscopy is macroscopically normal. Colonic
biopsies show melanosis coli. Stool electrolytes are as follows:

sodium 22 mmol/L
potassium 15 mmol/L
chloride 32 mmol/L

stool pH 6.0
stool osmolality 300 mosm/kg

Which of the following is the most likely cause of the persistent diarrhoea?

A. Crohn disease.

B. Cryptosporidium infection.

C. Giardia infection.

D. Hyperthyroidism.

E. Laxative abuse.

Copyright © 2004 by The Royal Australasian College of Physicians


9 P203

QUESTION 16

A nine-year-old girl presents to the emergency department following an episode of confusion. Her parents
say that the episode began with a brief outburst of laughter while sitting at the dinner table, after which she
was unable to respond, but picked at her food, chewing without food in her mouth as well as rocking
backwards and forwards in her chair. She was taken to the couch where she lay down and slept for half an
hour. After she woke she behaved normally, but was unable to describe what had happened. In the last
year or so there have been several other episodes of laughter that have seemed ‘forced’ and ‘out of place’.

She has a past history of precocious puberty diagnosed at six years of age and treated with monthly
injections of the luteinising hormone-releasing hormone (LHRH) agonist leuprolide.

Physical examination is normal. An electroencephalogram (EEG) is reported as showing some paroxysmal


sharp-slow activity over the left temporal region. A magnetic resonance imaging (MRI) scan of the brain is
performed and is shown below.

Which one of the following is the most likely diagnosis?

A. Colloid cyst of the third ventricle.

B. Hypothalamic hamartoma.

C. Mesial temporal sclerosis.

D. Pituitary adenoma.

E. Tuberous sclerosis.

Copyright © 2004 by The Royal Australasian College of Physicians


10 P203

QUESTION 17

An infant of 15 months presents with bruising to the forehead, right ear lobe, right malar eminence, ulnar
border of the left arm, back of the second metacarpal, buttocks, lateral thigh and shins. The infant has been
walking for four months and has been climbing for two months. The mother says that the infant fell from the
kitchen table onto a linoleum floor.

Which site of bruising is most suggestive of non-accidental injury?

A. Buttocks.

B. Forearm.

C. Forehead.

D. Shins.

E. Zygoma.

QUESTION 18

A teenaged patient, previously untreated, is commenced on phenytoin therapy with an intravenous loading
dose of 1000 mg, followed immediately by oral administration of 300 mg/day as a single daily dose.

Assuming phenytoin has an elimination half-life of 30 hours, what is the best estimate of the length of time
after the initial loading dose that the patient will achieve steady state conditions with respect to phenytoin?

A. Immediately.

B. One day.

C. Three days.

D. Six days.

E. Twelve days.

QUESTION 19

A 13-year-old girl presents with excessive bleeding following a tooth extraction. She has a history of heavy
menstrual loss. The following coagulation tests are obtained:

activated partial thromboplastin time (APTT) 40 seconds [27.5-34.5]


50:50 mix with normal plasma 32 seconds
prothrombin time (PT) 14 seconds [14-18]
thrombin clotting time (TCT) 16 seconds [14-18]

Which one of the following is the most likely diagnosis?

A. Dysfibrinogenaemia.

B. Factor XII deficiency.

C. Haemophilia A.

D. Lupus anticoagulant.

E. von Willebrand disease.

Copyright © 2004 by The Royal Australasian College of Physicians


11 P203

QUESTION 20

The electrocardiogram (ECG) of an asymptomatic four-year-old girl who presented with a systolic murmur is
illustrated above. She was acyanotic. Precordial examination revealed a single loud second heart sound
and a soft systolic ejection murmur at the left sternal edge.

Which one of the following is the most likely diagnosis?

A. Eisenmenger syndrome.

B. l-Transposition of the great arteries (corrected transposition).

C. Primary pulmonary hypertension.

D. Pulmonary stenosis (valvular).

E. Tetralogy of Fallot (acyanotic).

QUESTION 21

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:

diphtheria-tetanus-pertussis vaccine (DTP) at two and four months


oral polio vaccine (OPV) at two and four months
measles-mumps-rubella vaccine (MMR) at 12 months

Which one of the following should the child now be given?

A. Childhood diphtheria and tetanus toxoids (CDT), tetanus immunoglobulin and OPV.

B. DTP.

C. DTP and OPV.

D. DTP, tetanus immunoglobulin and OPV.

E. Tetanus toxoid and tetanus immunoglobulin.

Copyright © 2004 by The Royal Australasian College of Physicians


12 P203

QUESTION 22

A 13-year-old girl presents to the emergency department after ingesting an unknown quantity of a medication
found in the bathroom cupboard. On arrival she is agitated and confused, flushed and has dry mucous
membranes. Her temperature is 38.5°C and her heart rate is 140/minute with a respiratory rate of 35/minute.
She has dilated pupils which react poorly to light.

Ingestion of which of the following best explains the clinical presentation?

A. Codeine phosphate.

B. Eucalyptus oil.

C. Imipramine.

D. Theophylline.

E. Verapamil.

QUESTION 23

The parents of a 15-year-old boy telephone about his changing behaviour over the previous two weeks. His
teachers have described poor concentration and disruptive behaviour at school and he has been truant for
most of the past week. He has been very difficult to live with, arguing with his older brother, watching
television all night and going out during the day. The parents of his girlfriend are also concerned as they
believe the boy and their daughter have started having unprotected sex and he has encouraged her to leave
school. The boy refuses to see you.

Which one of the following diagnoses best explains these symptoms?

A. Attention deficit/hyperactivity disorder.

B. Bipolar affective disorder.

C. Conduct disorder.

D. Marijuana abuse.

E. Schizophreniform disorder.

Copyright © 2004 by The Royal Australasian College of Physicians


13 P203

QUESTION 24

A boy aged three years and three months, with behavioural problems, had a language assessment showing
that his expressive language is equivalent to a three-year level. He presents for further developmental
assessment. His drawing of a person is shown.

What is the most appropriate interpretation of this boy’s language and drawing abilities?

A. Global developmental delay.

B. Language average; drawing above average.

C. Language average; drawing average.

D. Language delay; drawing above average.

E. Language delay; drawing average.

QUESTION 25

A four-year-old boy with a known diagnosis of congenital adrenal hyperplasia presents to the emergency
department with a six-hour history of vomiting and diarrhoea. He is assessed to be adequately hydrated.
Blood is sent for urea and electrolytes.

Which of the following is the most important next step in management?

A. Intravenous antibiotics.

B. Intravenous glucose.

C. Parenteral fludrocortisone.

D. Parenteral hydrocortisone.

E. Saline bolus.

Copyright © 2004 by The Royal Australasian College of Physicians


14 P203

QUESTION 26

A three-month-old girl presents with a facial lesion (shown above). She is commenced on oral prednisolone
at a dose of 2 mg/kg/day. At review, two weeks after starting treatment, the lesion has grown and is now
impinging significantly on her visual axis.

The most appropriate next step in her management is to:

A. administer interferon alfa subcutaneously.

B. cease the oral corticosteroids.

C. excise the lesion.

D. increase the dose of oral corticosteroids.

E. inject corticosteroids into the lesion.

QUESTION 27

A three-year-old boy with beta thalassaemia presents with three days of fever to 39.5°C, and 24 hours of
watery diarrhoea, colicky abdominal pain, poor oral intake and decreased urine output. He has blood
transfusions every four weeks and receives a desferrioxamine transfusion six nights a week.

On examination he is febrile (39.4°C) and alert but looks ill. He is not clinically dehydrated. His pulse rate is
165/minute, with a capillary refill time of 3 seconds. His respiratory rate is 32/minute. His abdomen is
distended and generally slightly tender. Bowel sounds are present. His liver and spleen are both palpable
2-3 cm below the costal margin.

Infection with which of the following is the most likely cause of his illness?

A. Escherichia coli.

B. Rotavirus.

C. Salmonella enteritidis.

D. Streptococcus pneumoniae.

E. Yersinia enterocolitica.

Copyright © 2004 by The Royal Australasian College of Physicians


15 P203

QUESTION 28

A previously well four-year-old girl presents with acute painless rectal bleeding. Her stools have the
appearance of red currant jelly. Her haemoglobin is 98 g/L [110-150] and she is haemodynamically stable.
Examination of her abdomen reveals no organomegaly or tenderness.

Which of the following investigations is most likely to reveal the source of bleeding?

A. Abdominal ultrasound.

B. Colonoscopy.

C. Gas enema of the colon.

D. Oesophago-gastro-duodenoscopy.
99m
E. Technetium pertechnetate scan.

QUESTION 29

A 37-year-old woman has neurofibromatosis type 1 (NF1). She is concerned that her 10-year-old son may
also be affected by the disorder.

The best way to establish whether he is affected by NF1 is:

A. biopsy of a neurofibroma.

B. clinical examination.

C. karyotype.

D. magnetic resonance imaging of his brain.

E. NF1 mutation analysis.

Copyright © 2004 by The Royal Australasian College of Physicians


16 P203

QUESTION 30

A seven-year-old boy has trodden on a bee and presents to the emergency department with swelling and
redness of the foot spreading to mid-calf. He has been stung on one previous occasion with only minor
redness and swelling. He has a history of mild intermittent asthma. There are no other symptoms. His
mother is concerned about the size of the present reaction, its treatment and about consequences of future
bee stings.

Which of the following is the most appropriate advice about the management of the current reaction and
prognosis for future stings?

A. There is a moderate risk that this particular reaction will progress because of the background of
asthma and immediate administration of adrenaline is required with provision of adrenaline for future
emergency use.

B. This is a large local reaction and requires treatment with oral corticosteroids as would any future
similar reactions.

C. This reaction is a large local reaction and requires no immediate treatment but there is a high risk that
any future stings will result in a systemic reaction and adrenaline should be provided for emergency
use.

D. This reaction requires treatment with oral antihistamines and any future stings should be treated by
the immediate administration of a fast-acting oral antihistamine.

E. This reaction should be treated with intravenous corticosteroids and antihistamines and a referral
made for commencement of venom immunotherapy.

QUESTION 31

A seven-year-old boy has been awakening at 2 a.m. confused and crying with headache almost every night
for the last two weeks. He has vomited on several of these occasions. He is well during the day. His
mother has a history of migraine.

Clinical examination reveals a normally grown child with a normal gait and no evidence of papilloedema,
nystagmus or localising neurological signs.

The most appropriate next step in management is to:

A. commence prophylactic propranolol.

B. counsel regarding night terrors.

C. image with computerised axial tomography.

D. perform an electroencephalogram (EEG).

E. reassure and invite to return if things get worse.

Copyright © 2004 by The Royal Australasian College of Physicians


17 P203

QUESTION 32

An 18-month-old girl presents with severe pallor associated with irritability and anorexia. A full blood count is
performed and is as follows:

haemoglobin (Hb) 28 g/L [105-140]


mean corpuscular volume (MCV) 90 fL [70-86]
white cell count (WCC) 3.9 x 109/L [6.0-17.5]
platelet count 135 x 109/L [150-400]
reticulocytes 0.4% [<2.0]

A bone marrow aspirate (A) and blood film (B) are shown below.

A B

Which of the following is the most likely diagnosis?

A. Acute lymphoblastic leukaemia.

B. Autoimmune haemolytic anaemia.

C. Diamond-Blackfan anaemia.

D. Human parvovirus B19 infection.

E. Transient erythroblastopenia of childhood.

Copyright © 2004 by The Royal Australasian College of Physicians


18 P203

QUESTION 33

A female infant of Caucasian parents born at term with a birth weight of 3500 g is discharged from hospital at
48 hours of age fully breastfed. At three weeks of age she is referred by her general practitioner because of
jaundice. Her serum bilirubin is: direct 2 µmol/L and indirect 320 µmol/L. The mother reports that her baby
has been very well and is exclusively breastfed every three to four hours. She wakes for feeds and has
generally been a very settled baby with no change in behaviour. The mother has noted that her baby has
always been yellow. There has been no vomiting and she has passed six to eight normal bowel actions per
day.

Examination reveals an alert but jaundiced baby who fixes and follows. Her temperature is 37°C and her
weight is 4100 g. There are no abnormalities found on examination. The neonatal thyroid function screen is
normal.

Which of the following is the most appropriate management?

A. Cease breastfeeding for 24 hours and recheck the bilirubin.

B. Commence phototherapy.

C. Measure liver function tests.

D. Reassure the mother and advise continuation of breastfeeding.

E. Septic workup and commence antibiotics.

QUESTION 34

Graft-versus-host disease is a major complication of allogeneic stem cell transplantation for haematological
malignancy.

Which one of the following has the least influence on the risk of developing graft-versus-host disease?

A. Age of recipient.

B. Donor-recipient ABO blood group incompatibility.

C. Donor-recipient HLA mismatch.

D. In vitro T cell depletion of the graft.

E. Type of HLA-matched donor (sibling versus unrelated).

QUESTION 35

Which of the following pathogens is most commonly associated with bronchiolitis obliterans?

A. Adenovirus.

B. Influenza virus.

C. Measles.

D. Mycoplasma pneumoniae.

E. Respiratory syncytial virus.

Copyright © 2004 by The Royal Australasian College of Physicians


19 P203

QUESTION 36

A five-year-old girl of Indian origin presents with three months of increasing lethargy and fatigue, with
occasional fevers. Previously active, she is increasingly reluctant to get up in the morning or walk, and cries
and complains that she hurts all over. A lump has appeared in her armpit and discharges white material
intermittently (see photograph shown above). The family moved from India two years ago. She is fully
immunised. There is no history of tuberculosis (TB) in the family or of TB contact.

On examination she has difficulty rising from the floor unaided and has generalised weakness most marked
in the hips and shoulders. The lesion in the axilla is firm and non-tender with induration of the underlying
skin.

Which one of the following is the most likely diagnosis?

A. Dermatomyositis.

B. Relapsing panniculitis (Weber-Christian disease).

C. Systemic lupus erythematosus.

D. Tuberculosis.

E. Visceral larva migrans.

QUESTION 37

Which of the following conditions overlaps least with chronic fatigue syndrome?

A. Anxiety.

B. Depression.

C. Fibromyalgia.

D. Hypothyroidism.

E. Irritable bowel syndrome.

Copyright © 2004 by The Royal Australasian College of Physicians


20 P203

QUESTION 38

A 10-year-old boy presents with a six-month history of lethargy and weight gain. History reveals that he has
been on thyroxine in the past, and that his parents are first cousins. On examination he has a firm
moderately sized goitre. His thyroid function tests are as follows:

free thyroxine (free T4) 9 pmol/L [10-20]


thyroid-stimulating hormone (TSH) 37.00 mU/L [0.03-4.00]

Thyroid technetium pertechnetate scan is demonstrated below and shows increased uptake.

Which one of the following is the most likely diagnosis?

A. Autoimmune hypothyroidism.

B. Dyshormonogenesis.

C. Graves disease.

D. Iodine excess.

E. Thyroid dysgenesis.

QUESTION 39

A six-day-old breastfed female infant is taken to the emergency department by her mother because of bright
red rectal bleeding, mild diarrhoea with mucus and persistent crying.

On examination the baby is generally well and haemodynamically stable. The perianal region appears
normal.

Which one of the following is the most likely diagnosis?

A. Allergic colitis.

B. Colonic duplication.

C. Juvenile polyp.

D. Meckel diverticulum.

E. Swallowed blood.

Copyright © 2004 by The Royal Australasian College of Physicians


21 P203

QUESTION 40

A 12-year-old boy was born in Thailand and was fully immunised, including neonatal BCG (bacille Calmette-
Guérin). The family migrated when the boy was four years old. The whole family was well. They had re-
visited Thailand for the first time one year previously, staying in a city with their family. They had bought a
kitten six months earlier which would often scratch the boy when he played with it.

Over a three-month period the boy developed a lump in his neck, which gradually enlarged. It was painless
and not discoloured. He had no fever or other systemic upset and had not lost weight.

On examination the boy is well and afebrile. He has a 5 cm rubbery oval-shaped mass palpable in the right
posterior cervical triangle and no other positive findings on clinical examination.

Which of the following is the most likely diagnosis?

A. Atypical mycobacterial infection.

B. Cat scratch disease.

C. Cytomegalovirus infection.

D. Toxoplasmosis.

E. Tuberculosis.

QUESTION 41

?
A woman (arrowed in the pedigree above) seeks your advice about the risk of her unborn child having
haemophilia A. The two affected males were diagnosed at a year of age and died in their teens. The
woman is married to her first cousin.

What is the risk of her unborn child having haemophilia A?

A. <1%.

B. 6.25%.

C. 12.5%.

D. 25%.

E. 33%.

Copyright © 2004 by The Royal Australasian College of Physicians


22 P203

QUESTION 42

A 24-year-old pregnant woman reports at her first antenatal visit that her sister gave birth to a child with
congenital heart block (CHB). Which one of the following tests would be most useful in assessing the risk of
CHB in this pregnancy?

A. Antibodies to DNA.

B. Antibodies to extractable nuclear antigens (ENA).

C. Anticardiolipin antibodies.

D. Fluorescent antinuclear antibody (ANA) test.

E. Lupus anticoagulant.

QUESTION 43

A 14-year-old boy presents to the emergency department with a painful right eye after being hit in the eye
with a stone. On examination, his right pupil is slightly dilated and reacts sluggishly to light, he has reduced
visual acuity on the right, and his extraocular eye movements are normal with no pain. The appearance of
his right eye on examination is shown below.

Which of the following is the most likely acute complication?

A. Glaucoma.

B. Hypopyon.

C. Retinal artery occlusion.

D. Retinal detachment.

E. Spontaneous re-bleed.

Copyright © 2004 by The Royal Australasian College of Physicians


23 P203

QUESTION 44

A five-year-old girl is brought to her paediatrician because of recurrent headaches. During the physical
examination a number of skin lesions were found. These are demonstrated in the photograph below.

Which of the following is the least likely to be associated with her condition?

A. Acoustic neuroma.

B. Learning difficulties.

C. Macrocephaly.

D. Pseudoarthrosis.

E. Scoliosis.

QUESTION 45

A two-year-old girl is known to have doubly committed (supracristal, conal) ventricular septal defect. Over
the six months prior to review her mother reports a significant deterioration in exercise tolerance.

The most likely aetiology of the progressive fatigue is:

A. aortic regurgitation.

B. bacterial endocarditis.

C. hypocalcaemia

D. increasing left to right shunt.

E. mitral regurgitation.

Copyright © 2004 by The Royal Australasian College of Physicians


24 P203

QUESTION 46

An eight-week-old boy presents with a fever and a history of being unwell with poor feeding for two days. On
enquiry he is noted to have had two similar episodes in the past two months. His urine shows 500 white
cells and has a pure growth of >108/L Escherichia coli. His blood culture is negative and his renal function is
normal. He is treated successfully with intravenous cefuroxime.

A micturating cystourethrogram shows no reflux.

Ultrasound of his left kidney is normal. His right kidney ultrasound is shown below.

The next most appropriate investigation is:

A. a dimercaptosuccinic acid (DMSA) scan.

B. a diuretic diethylene triamine pentaacetic acid (DTPA) scan.

C. an antegrade pyelogram.

D. an intravenous urogram.

E. a retrograde pyelogram.

Copyright © 2004 by The Royal Australasian College of Physicians


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QUESTION 47

A 10-year-old boy presents with a 16-month history of recurrent eye blinking, shoulder shrugging and rapid
movements of his eyes. In addition, he has had periods of recurrent throat clearing, sniffing, barking and
grunting. The events tend to wax and wane but are most prominent at school or when he is under stress.
By report he has had longstanding issues with attention and hyperactivity in the classroom. He is diagnosed
with Tourette syndrome.

He is being teased at school and is now refusing to attend school and a decision is made to institute therapy.

Which of the following therapies is most likely to be beneficial in this child?

A. Behavioural therapy.

B. Clonidine.

C. Family therapy.

D. Haloperidol.

E. Methylphenidate.

QUESTION 48

A term male infant weighing 2900 g at birth was found to have a cleft palate and moderate micrognathia. No
airway obstruction was noted. He established enteral feeds with a cleft palate bottle and was discharged
home at seven days of age. He was seen by a paediatrician at three weeks of age. His mother related that
he was taking over 40 minutes to take each feed and vomited after most feeds. His weight was 2400 g.

The most appropriate initial step in management would be:

A. fundoplication and gastrostomy.

B. increase the caloric density of the feeds.

C. insert a nasopharyngeal airway.

D. nasogastric feeding.

E. thicken the feeds and treat with ranitidine.

QUESTION 49

A 14-year-old boy with methicillin-resistant Staphylococcus aureus (MRSA) osteomyelitis is receiving


ongoing treatment with vancomycin. Shortly after administration of his vancomycin dose, he develops
diffuse erythema and hypotension.

The most likely cause is:

A. bacterial contamination of the vancomycin preparation.

B. endotoxin release.

C. hypersensitivity to vancomycin.

D. impurities in the infused vancomycin preparation.

E. rapid intravenous infusion of vancomycin.

Copyright © 2004 by The Royal Australasian College of Physicians


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QUESTION 50

A mother brings her one-year-old son to see you. For the past three months he has been waking every
night, usually two hours after settling. He falls asleep at the start of the night with a bottle of milk. When he
wakes during the night, he cries, stands up in the cot and drools. When his mother is unable to calm him
with patting she gives him a bottle of 30 mL of formula. He settles back to sleep after drinking the formula.
The mother says he is irritable during the day and this is ‘getting her down’. Physical examination is normal.

Which one of the following is the most likely diagnosis?

A. Hunger.

B. Night terrors.

C. Separation anxiety disorder.

D. Sleep association disorder.

E. Teething.

QUESTION 51

A 10-year-old girl presents with a swollen, red, tender right elbow and left knee and a high swinging fever.
Two weeks previously she had complained of sore throat. She is admitted to hospital and the joints improve,
but her left wrist then becomes swollen. Her erythrocyte sedimentation rate (ESR) is 90 mm/hr, and her anti-
streptolysin titre is 1200 U/mL [<200]. Her heart sounds are normal, and chest X-ray and echocardiogram
are normal. Her fever and arthritis settle following administration of aspirin.

Which of the following is the most effective long-term treatment plan?

A. Daily oral phenoxymethylpenicillin.

B. Daily salicylate therapy.

C. Intramuscular benzathine penicillin every three weeks.

D. No therapy, but monitor closely.

E. Oral penicillin once every three weeks with probenecid three times a week.

QUESTION 52

An otherwise asymptomatic 15-year-old boy presents with short stature and concerns about lack of pubertal
development. His height is below the 1st percentile, he has Tanner stage 2 pubic hair and his testes are 6
mL in volume bilaterally. His bone age is delayed three years.

The most likely explanation for his short stature is:

A. androgen insensitivity.

B. coeliac disease.

C. constitutional short stature.

D. hypogonadotropic hypogonadism.

E. Klinefelter syndrome.

Copyright © 2004 by The Royal Australasian College of Physicians


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QUESTION 53

An eight-week-old baby girl presents with a two-day history of episodes of coughing and going blue. In
between episodes she is well and continues to breastfeed without problems. She had a cold one week ago.
Her five-year-old brother has a cough and cold which started a week ago.

She was born at 35 weeks gestation, after a normal pregnancy and spontaneous labour. She weighed 2650
g at birth, needed no resuscitation and had no neonatal problems. She is breastfed, has thrived and been
immunised with one dose of hepatitis B vaccine.

She looks well. Her axillary temperature is 36.9°C. Her respiratory rate is 44/minute, and heart rate is
160/minute. She has no recession or retraction and breath sounds are normal. Her chest X-ray shows
streaky perihilar markings.

Full blood count shows:

haemoglobin (Hb) 148 g/L [110-150]


white cell count (WCC) 32.1 x 109/L [4.0-11.0]
differential:
neutrophils 3.2 x 109/L [1.0-4.0]
lymphocytes 28.9 x 109/L [1.0-7.0]
platelet count 285 x 109/L [150-400]

Which of the following is the most likely diagnosis?

A. Chlamydia pneumonitis.

B. Group B streptococcal pneumonia.

C. Mycoplasma pneumoniae infection.

D. Respiratory syncytial virus (RSV) bronchiolitis.

E. Whooping cough.

QUESTION 54

A four-year-old boy is referred to you for investigation of persistent diarrhoea and poor weight gain. The
following results are obtained:

haemoglobin (Hb) 100 g/L [110-150]


mean corpuscular volume (MCV) 70 fL [75-90]
total serum IgA 0.07 g/L [1.23-2.32]
antigliadin-IgG 88 U/L [<50]
antigliadin-IgA 0 U/L [<25]
anti-endomysial antibody negative

Which of the following is the most appropriate next step in management?

A. Commence gluten-free diet.

B. Commence iron supplement.

C. Continue unrestricted diet.

D. Measure tissue transglutaminase antibody.

E. Small bowel biopsy.

Copyright © 2004 by The Royal Australasian College of Physicians


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QUESTION 55

A couple come to see you for advice about the appropriate course of action to be taken after the birth of their
baby, which is due in one month. They have had one other child, a boy, who died at three months of age of
Pneumocystis carinii pneumonia secondary to severe combined immunodeficiency (SCID). Prenatal
amniocentesis has revealed the sex of the expected baby to be male but no other genetic testing has been
performed.

The most appropriate investigation to be performed on a cord blood sample to be taken from the expected
baby in the immediate neonatal period is:

A. genetic analysis for X-SCID.

B. IgG level.

C. IgM level.

D. total haemolytic complement activity.

E. total lymphocyte count.

QUESTION 56

A six-year-old boy presents with a 24-hour history of profuse non-bilious vomiting and watery diarrhoea. He
has tolerated some water orally, but has not passed urine for 12 hours.

On examination he is quiet but awake, pale, with cool peripheries and a capillary refill time of 4 seconds. His
heart rate is 160/minute, respiratory rate is 35/minute with no recession and his blood pressure is 100/65
mmHg. He is afebrile and his oxygen saturation is 98% in room air. His initial electrolytes are:

sodium 133 mmol/L [135-145]


potassium 3.7 mmol/L [3.5-5.5]
chloride 103 mmol/L [95-110]
bicarbonate 16 mmol/L [22-26]
total protein 77 g/L [55-80]
urea 4.6 mmol/L [1.0-6.0]
creatinine 0.050 mmol/L [0.030-0.075]
glucose 3.5 mmol/L [3.5-5.5]

Which of the following initial intravenous fluid management options is the most appropriate for this patient?

A. Bolus of 0.225% saline + 3.75% dextrose at 20 mL/kg.

B. Bolus of 0.45% saline + 2.5% dextrose at 20 mL/kg.

C. Bolus of normal saline at 20 mL/kg.

D. Maintenance fluids plus rehydration for 10% dehydration over 24 hours, using 0.225% saline + 3.75%
dextrose.

E. Maintenance fluids plus rehydration for 10% dehydration over 24 hours, using 0.45% saline + 2.5%
dextrose.

Copyright © 2004 by The Royal Australasian College of Physicians


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QUESTION 57

The inheritance pattern shown in the pedigree above is best described as:

A. autosomal dominant inheritance with complete penetrance.

B. autosomal dominant inheritance with incomplete penetrance.

C. autosomal recessive inheritance with complete penetrance.

D. X-linked inheritance with incomplete penetrance.

E. X-linked recessive inheritance with complete penetrance.

QUESTION 58

A 16-year-old girl with type 1 (insulin-dependent) diabetes mellitus attends for a routine review. She attends
with her mother but asks to be seen by herself and then describes significant conflict with both parents. She
has discussed the possibility of leaving home with a school counsellor whom she has seen several times
over the past month. She acknowledges being variably compliant in taking her insulin and her glucometer
readings are high.

On examination you notice several superficial lacerations on her left forearm. She informs you that she has
frequent thoughts about killing herself but is adamant that she doesn’t want her parents informed.

Which of the following is the most appropriate course of action?

A. Admit her to hospital, informing her parents that you are doing so because of adolescent issues.

B. Carefully discuss her suicidal ideation, have her sign a contract that she will not harm herself
and review her the next day.

C. Contact the school counsellor and arrange for daily counselling to support the patient until your
review the following week.

D. Invite her mother to join the interview and inform the mother that you feel the patient is at risk.

E. Respect the patient’s wish for confidentiality, adjust her insulin and review her the next day.

Copyright © 2004 by The Royal Australasian College of Physicians


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QUESTION 59

A 10-year-old girl presents with primary nocturnal and diurnal enuresis. She wakes herself twice a night to
go to the toilet. If she sleeps through she is wet in the morning. Her underpants are often wet at the end of
the day, and she says she does not feel herself urinating.

She has always walked on her toes. Her performance at school is satisfactory. Her physical examination
shows a normal musculoskeletal system. Her gait is balanced when on tiptoe, but when asked to walk on
flat feet she can only walk with a wide-based gait. Her Achilles tendons are tight, she has very brisk ankle
jerks, 5 beats of ankle clonus bilaterally and bilateral upgoing plantar responses. Sensation is normal.

Her micturating cystourethrogram is shown below.

Which of the following is the most likely diagnosis?

A. Cerebral palsy.

B. Charcot-Marie-Tooth disease.

C. Friedreich ataxia.

D. Idiopathic toe-walker.

E. Spinal dysraphism.

Copyright © 2004 by The Royal Australasian College of Physicians


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QUESTION 60

A newborn infant is noted to have a rapid pulse but is not compromised. The electrocardiogram (ECG)
shown above demonstrates long periods of tachycardia with intermittent sinus beats.

Which one of the following is the most appropriate course of action?

A. Direct current (DC) cardioversion.

B. Facial ice water.

C. Intravenous adenosine.

D. Intravenous sotalol.

E. Intravenous verapamil.

Copyright © 2004 by The Royal Australasian College of Physicians


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QUESTION 61

A 12-year-old girl presents with a one-day history of fever associated with chills, rigors and night sweats.
She has a cough productive of green phlegm and associated with mild left-sided pleuritic pain. There was
no prodrome of upper respiratory tract illness and no evidence of sinusitis, otitis, gastrointestinal or urinary
symptoms. She has a four-year history of recurrent cough and wheeze following upper respiratory tract
infections and has been diagnosed as having asthma by her local doctor. Over the past two years she has
had one episode of otitis media, one episode of sinusitis and two lower respiratory tract infections, which
have responded to treatment with oral antibiotics. She is being managed with medium dose inhaled
corticosteroids on a regular basis with inhaled beta-agonists and short courses of oral corticosteroids added
during bouts of cough and wheeze.

A chest X-ray shows left basal opacification with air bronchograms and a diagnosis of pneumonia is made.
Sputum culture grows Streptococcus pneumoniae but blood culture is negative. The full blood count shows
a leucocytosis of 15.0 x 109 white cells/L [4.5-13.0] with a left shift and a neutrophilia of 14.0 x 109/L [1.5-8.0].
IgG, IgA and IgM levels are within normal range.

Which one of the following investigations is the most appropriate next step in the further assessment of any
underlying immune deficiency?

A. IgG subclass analysis.

B. Measurement of CH50.

C. Neutrophil function tests.

D. Specific pneumococcal antibodies.

E. T and B subset analysis.

QUESTION 62

Infection with which one of the following organisms is best described as having its peak incidence in the first
two years of life, with a secondary peak between age 15 and 24 years?

A. Bordetella pertussis.

B. Haemophilus influenzae type b.

C. Influenza virus.

D. Neisseria meningitidis.

E. Streptococcus pneumoniae.

Copyright © 2004 by The Royal Australasian College of Physicians


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QUESTION 63

A three-month-old boy presents to his local emergency department. It is noted that he has an elevated
respiratory rate and a chest X-ray is performed and is shown below.

The most likely diagnosis is:

A. congenital lobar emphysema.

B. cystadenomatoid malformation.

C. diaphragmatic hernia.

D. eventration of the diaphragm.

E. staphylococcal pneumonia.

Copyright © 2004 by The Royal Australasian College of Physicians


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QUESTION 64

A mother presents with her three-week-old son describing having heard a crack as she placed him in a baby
chair. An X-ray reveals a spiral mid-femoral fracture, and the rest of his skeletal survey is shown below.

He was born at 35 weeks gestation and had mild respiratory distress attributed to transient tachypnoea from
which he made an uneventful recovery. He is one of non-identical twins.

Family history reveals that his mother had undergone a parathyroidectomy five years earlier and takes
regular calcium supplements. His father had broken his femur in adult life, during a game of backyard
cricket.

The family is not known to Child Protection Services.

Which one of the following is the most likely diagnosis?

A. Hypocalcaemia due to maternal hypoparathyroidism.

B. Hypophosphatasia.

C. Non-accidental injury.

D. Osteogenesis imperfecta.

E. Rickets of prematurity.

Copyright © 2004 by The Royal Australasian College of Physicians


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QUESTION 65

A 15-year-old boy presents to the clinic with a three-month history of intermittent left knee pain at night
subsequent to being struck on the knee by a cricket ball which resulted in extensive bruising. One week
prior to presentation he noticed a swelling just above the knee. An X-ray of his left knee is shown below.

Which one of the following is the most likely diagnosis?

A. Aneurysmal bone cyst.

B. Chronic osteomyelitis.

C. Ewing sarcoma.

D. Osteochondroma.

E. Osteogenic sarcoma.

Copyright © 2004 by The Royal Australasian College of Physicians


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QUESTION 66

A 13-year-old boy presents with a two-week history of left-sided hip and knee pain following a cricket game.
The pain has worsened over the preceding two days following a fall from his bike.

On examination, the boy is afebrile and is not distressed, but is unable to weight bear on his left leg. He has
limited movement of his left hip in all directions secondary to pain and there is no evidence of swelling,
bruising or deformity over the hip or knee. An X-ray of his pelvis is shown below.

Which of the following is the most appropriate next diagnostic step?

A. Bone scan.

B. Frog-leg lateral X-ray of left hip.

C. Full blood count (FBC) and erythrocyte sedimentation rate (ESR).

D. Left knee X-ray.

E. Ultrasound of left hip.

Copyright © 2004 by The Royal Australasian College of Physicians


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QUESTION 67

A 13-year-old boy presents to the emergency department with sudden-onset left-sided chest pain and
vomiting. He has a history of a double outlet right ventricle, which was repaired in infancy with an
intracardiac baffle.

On examination his pulses are barely palpable, his heart rate is 190/minute, respiratory rate is 30/minute and
systolic blood pressure is 70 mmHg. He is alert but agitated and poorly perfused peripherally with a capillary
refill time of 4 seconds. A 12-lead electrocardiogram (ECG) is shown above.

Which of the following is the most appropriate acute management?

A. Elective cardioversion after prior endotracheal intubation.

B. Intravenous amiodarone.

C. Intravenous lignocaine.

D. Rapid intravenous bolus of adenosine.

E. Urgent cardioversion with prior sedation.

Copyright © 2004 by The Royal Australasian College of Physicians


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QUESTION 68

A six-year-old boy presents with a history of disruptive behaviours in class that appear to occur with little
provocation. The most recent episode followed a disagreement with his teacher over a change in the
seating arrangements. His work is above average generally, but he is not performing to his ability. He is
intolerant of his peers when they do not follow his plans at play, or even in cooperative project work. He has
only one child who he calls his friend, who shares his interest in dinosaurs. He knows most of the dinosaur
variants, has models of them, and his room is covered in their pictures.

His early milestones were within normal limits, including speech, but his mother describes him as having
been a difficult child. He often corrects his mother’s versions of home activities and is perturbed if she does
not agree. He has problems going to sleep at night, but maintains sleep well. He cannot maintain attention
or complete tasks that do not interest him and at these times can become quite fidgety. He can concentrate
for long periods when interested.

This clinical picture is most consistent with:

A. Asperger disorder.

B. attention deficit/hyperactivity disorder.

C. autism.

D. normal child.

E. oppositional defiant disorder.

Copyright © 2004 by The Royal Australasian College of Physicians


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QUESTION 69

A two-year-old black African child has recently emigrated from Uganda. He presents to the emergency room
pale and complaining of abdominal pain having been prescribed trimethoprim-sulfamethoxazole for
suspected urinary tract infection. Full blood count shows:

haemoglobin (Hb) 78 g/L [110-150]


white cell count (WCC) 15.3 x 109/L [4.0-12.0]
platelet count 475 x 109/L [150-400]

A photomicrograph of his peripheral blood film is shown below.

Which one of the following is the most likely diagnosis?

A. Autoimmune haemolytic anaemia.

B. Glucose-6-phosphate dehydrogenase deficiency.

C. Malaria.

D. Paroxysmal nocturnal haemoglobinuria.

E. Sickle cell anaemia.

QUESTION 70

A 15-year-old girl recently had unprotected sexual intercourse with a man known to be HIV (human
immunodeficiency virus)-positive.

Which of the following tests is most helpful in establishing whether she has been infected with HIV?

A. HIV antibodies measured by enzyme-linked immunosorbent assay (ELISA).

B. HIV antibodies measured by Western blot.

C. P24 antigen.

D. Qualitative polymerase chain reaction (PCR) for HIV DNA.

E. Quantitative HIV RNA viral load by reverse transcriptase (RT) PCR.

Copyright © 2004 by The Royal Australasian College of Physicians


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QUESTION 71

A three-year-old child with delayed language development, aggressive behaviour and seizures is brought to
see you for evaluation. His mother is concerned about the increasing size of a ‘birth mark’ on his forehead,
which is shown below.

What other findings are you most likely to find on clinical examination?

A. Adenoma sebaceum.

B. Axillary freckling.

C. Café-au-lait spots.

D. Depigmented patches.

E. Increased pigmentation in skin creases.

QUESTION 72

A 2.5 kg, one-week-old infant with Down syndrome is known to have a complete atrioventricular canal. He is
feeding well. He has a respiratory rate of 40/minute, no evidence of respiratory distress and an arterial
oxygen saturation of 91% in room air.

Which one of the following is the most appropriate course of action?

A. Administer oxygen.

B. Commence diuretics.

C. Observation.

D. Refer for pulmonary artery band.

E. Refer for surgical correction.

Copyright © 2004 by The Royal Australasian College of Physicians


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QUESTION 73

An 18-month-old girl presents with vaginal bleeding. Examination reveals Tanner stage 3 breast
development and no pubic hair. There is a pigmented lesion on her buttock as seen in the photograph
below.

Which of the following is the most likely finding on investigation?

A. Delayed bone age.

B. Elevated luteinising hormone (LH) and follicle-stimulating hormone (FSH).

C. Elevated serum testosterone.

D. Large ovarian cyst on pelvic ultrasound.

E. Pituitary tumour on cerebral magnetic resonance imaging (MRI) scan.

QUESTION 74

A four-year-old girl with Alagille syndrome (intrahepatic hypoplasia of bile ducts) and long-standing
cholestatic jaundice presents with a broad-based ataxic gait. On examination her tendon reflexes are
absent.

Which of the following is the most likely cause?

A. Folate deficiency.

B. Hypothyroidism.

C. Posterior fossa tumour.

D. Vitamin B12 deficiency.

E. Vitamin E deficiency.

Copyright © 2004 by The Royal Australasian College of Physicians


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QUESTION 75

The karyotype shown above is from a 10-year-old boy.

Regarding this child’s behaviour, which one of the following is most likely?

A. Attention deficit/hyperactivity disorder.

B. Autism.

C. Conduct disorder.

D. Normal child.

E. Obsessive-compulsive disorder.

QUESTION 76

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.

C. Intraventricular haemorrhage (grade three to four).

D. Patent ductus arteriosus.

E. Periventricular leukomalacia.

Copyright © 2004 by The Royal Australasian College of Physicians


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QUESTION 77

A nine-year-old girl presents to hospital with dysuria and abdominal pain. She has a past history of urinary
tract infections. Examination shows a well-grown child. Blood pressure is 120/75 mmHg.

Her blood chemistry reveals the following:

creatinine 0.20 mmol/L [0.04-0.08]


urea 14.0 mmol/L [3.2-7.2]

Her dimercaptosuccinic acid (DMSA) scan is shown below.

Which of the following is the most appropriate management for this child?

A. Antibiotic prophylaxis.

B. Bladder training programme.

C. Commence a beta blocker.

D. Low protein diet.

E. Salt restriction.

QUESTION 78

A five-year-old boy presents with a 10-day history of purulent nasal discharge associated with fever and
intermittent cough. His symptoms have failed to respond to a seven-day course of oral amoxycillin. He has
had three similar episodes in the past year.

The most appropriate initial investigation is:

A. chest X-ray.

B. computed tomography (CT) scan of the facial sinuses.

C. culture of the nasal discharge with determination of antibiotic sensitivities.

D. plain X-ray of the facial sinuses.

E. serum immunoglobulin levels.

Copyright © 2004 by The Royal Australasian College of Physicians


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QUESTION 79

A four-year-old boy presents with pallor, irritability, dark urine and fever following a mild viral-like illness
associated with diarrhoea seven days earlier. He has a strong family history of hereditary spherocytosis. A
full blood count is performed and is as follows:

haemoglobin (Hb) 79 g/L [110-140]


white cell count (WCC) 23 x 109/L [5-17]
platelet count 110 x 109/L [150-400]

The blood film is shown below.

Which of the following is the most likely diagnosis?

A. Autoimmune haemolytic anaemia.

B. Haemolysis secondary to hereditary spherocytosis.

C. Haemolytic uraemic syndrome.

D. Henoch-Schönlein purpura.

E. Septicaemia.

Copyright © 2004 by The Royal Australasian College of Physicians


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QUESTION 80

A two-year-old boy presents with irritability, a limp, reluctance to walk and the facial appearance shown
above with proptosis of the right eye. A full blood count shows:

haemoglobin (Hb) 80 g/L [105-140]


white cell count (WCC) 9.3 x 109/L [6.0-17.5]
platelet count 100 x 109/L [150-400]

Which one of the following is the most likely diagnosis?

A. Haemophilia.

B. Langerhans cell histiocytosis.

C. Neuroblastoma.

D. Non-accidental injury.

E. Orbital rhabdomyosarcoma.

Copyright © 2004 by The Royal Australasian College of Physicians


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QUESTION 81

A 12-year-old girl has been absent from school for the past six weeks, following sporadic attendance since
the start of the year. She describes feeling panicky every time she approaches the school gates. She
began secondary school this year and says that she doesn’t like the teachers or other pupils. She enjoyed
primary school, achieved good academic levels and had two close friends, one of whom has gone to a
different secondary school.

She is an only child and her mother presents as anxious and ineffectual, and recalls some difficulties getting
her daughter to school at the beginning of each primary school year. Her father had more success by driving
her to school in previous years, but over the last few weeks his patience has been exhausted and believes
her year-level coordinator has not given much support. He raises the possibility of a fresh start at another
local school. The girl wishes to enrol in the same school as her friend.

Which of the following is the most appropriate recommendation?

A. Change schools.

B. Cognitive-behavioural therapy.

C. Commence a selective serotonin reuptake inhibitor (SSRI).

D. Distance education.

E. Parental counselling.

QUESTION 82

An 18-month-old boy presents with a history of two episodes of having suddenly collapsed to the ground
while running. He was found to be pallid on both occasions, with no spontaneous movements and no
apparent respirations. On both occasions his parents gave him cardio-pulmonary resuscitation. Normal
respiration was restored after a few minutes, and he was tired for some hours after each event. After the
second occasion, he was admitted to hospital for observation and investigation. He has a normal
developmental history and has never had any serious illnesses recognised. There is no family history of
epilepsy.

This clinical presentation would be most consistent with:

A. atonic seizures.

B. breath holding episodes.

C. cardiac arrhythmia.

D. exercise-induced anaphylaxis.

E. hypoglycaemia.

Copyright © 2004 by The Royal Australasian College of Physicians


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QUESTION 83

A 14-year-old girl presents with bitemporal hemianopia. Her magnetic resonance imaging (MRI) scan is
shown above. She has grown poorly for five years and has a history of polydipsia and polyuria. Her height
is <1st percentile, weight on the 3rd percentile and she has no signs of puberty.

Investigations reveal:

computed tomography (CT) scan of head mass as seen on MRI, no calcification


free thyroxine (free T4) 8 pmol/L [10-20]
thyroid-stimulating hormone (TSH) 2.50 mU/L [0.03-4.50]
urea and electrolytes normal
urine specific gravity 1.02 [1.05-1.25]
beta human chorionic gonadotrophin detected

Which one of the following is the most likely diagnosis?

A. Craniopharyngioma.

B. Germinoma.

C. Glioma.

D. Haemangioma.

E. Hamartoma.

Copyright © 2004 by The Royal Australasian College of Physicians


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QUESTION 84

A child born at term is brought to his paediatrician at three months of age because of daily clusters of brief
forward jerks of the limbs, head and trunk. General examination is normal with the exception of moderate
truncal hypotonia. A T2-weighted magnetic resonance imaging (MRI) scan is shown below.

Which of the following is the most likely diagnosis?

A. Hydrocephalus.

B. Krabbe disease.

C. Leigh disease.

D. Lissencephaly.

E. Tuberous sclerosis.

QUESTION 85

An eight-year-old boy with achondroplasia is referred for evaluation of snoring. On examination he has large
tonsils. An overnight polysomnogram demonstrates five episodes per hour of non-obstructive oxygen
desaturation to less than 90%.

The most appropriate next step is:

A. adenotonsillectomy.

B. computed tomography (CT) scan of chest.

C. lateral airways X-ray of neck.

D. lung function testing.

E. magnetic resonance imaging (MRI) scan of brainstem and upper cervical cord.

Copyright © 2004 by The Royal Australasian College of Physicians


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QUESTION 86

A nine-month-old boy presents after a three-minute tonic-clonic seizure, associated with a fever of 39°C. He
is fully immunised. The infant has a number of small ulcers on the tip of the tongue and on the gingival
mucosa of the lower incisors. The following day the infant develops weakness of his left leg.

The infant is most likely to be infected with:

A. cytomegalovirus (CMV).

B. enterovirus 71.

C. Epstein-Barr virus (EBV).

D. human herpes virus 6 (HHV-6).

E. poliovirus type 3.

QUESTION 87

A male infant is born at term, weighing 2200 g. He is noted to have profound hypotonia and absent reflexes.
He has moderately severe hepatomegaly. His facial appearance is shown above.

The most likely diagnosis is:

A. myotonic dystrophy.

B. Prader-Willi syndrome.

C. spinal muscular atrophy.

D. trisomy 21.

E. Zellweger syndrome.

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QUESTION 88

A six-month-old girl presents with a short history of fever (38°C) and exacerbation of her facial eczema, as
shown in the photograph above. She has a strong family history of asthma.

Initial treatment with oral flucloxacillin and topical 1% hydrocortisone ointment shows no improvement.

Which of the following is most likely to improve her condition?

A. Intravenous aciclovir.

B. Intravenous amoxycillin/clavulanic acid.

C. Intravenous flucloxacillin.

D. More potent topical steroids.

E. Wet saline dressings.

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QUESTION 89

A 12-year-old boy presents with a three-month history of lethargy and diarrhoea. Over the past weeks he
has intermittently observed bright red blood in his stools.

On examination he appears tired and pale. His weight is 43 kg (5th percentile) and his height is 169 cm
(50th percentile). His abdomen is mildly tender in the left iliac fossa. No masses can be palpated. He has a
firm liver edge 2 cm below the costal margin and his spleen is palpable 1 cm below the costal margin. The
remainder of the examination is unremarkable.

Blood tests show:

haemoglobin (Hb) 86 g/L [115-155]


white cell count (WCC) 12.4 x 109/L [4.5-13.5]
platelet count 683 x 109/L [150-400]
erythrocyte sedimentation rate (ESR) 55 mm/hr [0-20]
total bilirubin 28 µmol/L [0-17]
alanine aminotransferase (ALT) 112 U/L [5-45]
gamma glutamyltransferase (GGT) 212 U/L [5-24]
alkaline phosphatase (ALP) 610 U/L [200-495]

The colonoscopic findings (sigmoid colon) are shown below.

Which one of the following is the most likely cause of the hepatic pathology?

A. Alpha-1-antitrypsin deficiency.

B. Amoebiasis.

C. Bacterial cholangitis.

D. Hepatic fibrosis.

E. Primary sclerosing cholangitis.

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QUESTION 90

You interview a 15-year-old girl with a history of child sexual abuse. She often fights with her mother and
stepfather and they describe a worsening in her behaviour over the past six months. She has outbursts of
anger after slight provocation, is sensitive to loud noises and stays up after they have gone to bed. She is
performing badly at school. At times she seems normal and can enjoy going out, but her irritability has left
her with few friends.

When interviewed by herself, the girl is alert and shows no features of thought disorder. She startles at
noises from outside the consulting room. She describes difficulties getting to sleep and concentrating at
school but denies any drug use. She then tells you that she frequently hears male voices at home and
school making derogatory comments about her and telling her to cut herself. The voices, which she doesn’t
recognise, have been occurring for months and often follow fights with her parents.

Her presentation is most consistent with a primary diagnosis of:

A. depression.

B. dissociative disorder.

C. post-traumatic stress disorder.

D. schizophrenia.

E. substance abuse.

QUESTION 91

A 25-week gestation baby girl, birth weight 720 g, was ventilated from birth. She received surfactant,
intravenous antibiotics for five days, and was given parenteral nutrition because of feed intolerance. At 28
days of age, she became pale and lethargic. Her blood count was:

haemoglobin (Hb) 152 g/L [140-180]


white cell count (WCC) 14.2 x 109/L [5.0-15.0]
platelet count 92 x 109/L [150-400]

You are called to say that blood cultures are growing a yeast, probably Candida. Chest X-ray is unchanged,
urine and cerebrospinal fluid (CSF) microscopy is normal, and renal ultrasound is normal.

Which of the following is the most appropriate treatment?

A. Amphotericin B.

B. Fluconazole.

C. Flucytosine.

D. Itraconazole.

E. Miconazole.

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QUESTION 92

A three-day-old baby, of European parents, has penoscrotal hypospadias as shown above. No gonads are
palpable.

Which one of the following is the most likely diagnosis?

A. Androgen insensitivity syndrome.

B. Aromatase deficiency.

C. Bilateral anorchia.

D. Congenital adrenal hyperplasia.

E. Hypopituitarism.

QUESTION 93

A term newborn infant is noted to be episodically cyanotic. On day 3, he has a normal physical examination
with a resting arterial oxygen saturation of 96% in room air. Periodically his saturation is noted to fall to 80%.

Which one of the following is the most likely diagnosis?

A. Apnoea.

B. Seizures.

C. Tetralogy of Fallot.

D. Totally anomalous pulmonary venous return.

E. Transposition of the great arteries.

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QUESTION 94

A three-year-old boy presents with a four-week history of irritability and fever. He was previously well and is
appropriately immunised. He has a five-year-old sister who is well. There is no history of overseas travel.

At the start of the illness he was diagnosed with pharyngitis and prescribed amoxycillin. After taking the
amoxycillin for five days, the fevers persisted and a truncal rash appeared. The amoxycillin was stopped
and the rash resolved, but has reappeared intermittently, especially when he is highly febrile (see
photograph shown below).

Examination shows a miserable, irritable boy who is febrile (38.4°C), tachycardic (140/minute), with bilateral
cervical lymphadenopathy and dry cracked lips. His spleen is tippable. He has a 2/6 ejection systolic
murmur at the apex which does not radiate. The remainder of the physical examination is normal.

Investigations show:

haemoglobin (Hb) 85 g/L [110-140]


white cell count (WCC) 24.8 x 109/L [4.0-11.0]
neutrophils 18.2 x 109/L [1.0-4.0]
platelet count 720 x 109/L [150-500]
erythrocyte sedimentation rate (ESR) 110 mm/hr [<20]
IgG 14.1 g/L [4.2-11.9]
IgA 2.3 g/L [0.2-1.6]
IgM 2.1 g/L [0.4-1.9]

Which one of the following is the most likely diagnosis?

A. Epstein-Barr virus infection.

B. Kawasaki disease.

C. Mycoplasma pneumoniae infection.

D. Rheumatic fever.

E. Systemic onset juvenile chronic arthritis.

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QUESTION 95

A three-month-old boy is referred to clinic because an antenatal ultrasound showed a dilated left renal pelvis.
This is confirmed by postnatal ultrasound. His left renal pelvic diameter is 25 mm [<5]. He is well and has
had no urinary tract infections. A diethylene pentacetic acid (DTPA) renogram is shown above.

The most appropriate next step in management is:

A. cystourethroscopy.

B. micturating cystourethrogram.

C. nephrostomy.

D. pyeloplasty.

E. ureteric stent.

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QUESTION 96

A five-year-old girl with spina bifida attends a birthday party at which she eats several peanuts, some
chocolate crackles and a banana, then proceeds to blow up a balloon which she has been given. Ten
minutes after blowing up the balloon, she complains of an itchy mouth, then develops angioedema of both
lips and a widespread urticarial rash. She is brought to the emergency department where she is found to be
in mild respiratory distress with wheeze and dyspnoea. The urticarial rash has faded. She is treated with a
single dose of intramuscular adrenaline and all her symptoms resolve within 20 minutes.

Which of the following would be the most important next step in her ongoing management?

A. Advice to exclude banana, chocolate and peanuts from her diet.

B. Provision of an adrenaline auto-injector and education on its use.

C. Provision of oral antihistamines to manage a recurrence of the urticarial rash.

D. Provision of oral corticosteroids to manage a delayed-type hypersensitivity reaction.

E. Radioallergosorbent test (RAST) for diagnosis of latex allergy.

QUESTION 97

In paediatric acute lymphoblastic leukaemia, which one of the following factors is most predictive of a poor
prognosis?

A. Age greater than 10 years.

B. Male gender.

C. Poor induction response at day 28.

D. T cell immunophenotype.

E. White cell count >50 x 109/L.

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QUESTION 98

A 15-year-old girl presents with a four-day history of increasing difficulty with vision. She initially noticed
some pain around her right eye, then difficulty reading. Her symptoms progressed fairly rapidly over the next
48 hours to the point where she can only count fingers out of her right eye.

Examination reveals a right afferent pupillary defect, mild blurring of the right disk margin, and severely
impaired vision. Her left eye is normal, as is the rest of her neurological examination.

Past history is significant for an episode of tinnitus and vertigo, which lasted for about one week one year
ago, and an episode of numbness of her left arm lasting two weeks six months ago. Both these episodes
resolved spontaneously.

A magnetic resonance imaging (MRI) scan of her brain is performed and is shown below.

Which one of the following is the most likely diagnosis?

A. Acute disseminated encephalomyelitis.

B. Multiple sclerosis.

C. Subacute sclerosing panencephalitis.

D. Systemic lupus erythematosus (SLE).

E. Toxoplasmosis.

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QUESTION 99

A two-month-old girl is admitted to hospital for treatment of a high fever and profuse diarrhoea. Intravenous
rehydration is commenced. Stool cultures reveal infection with Salmonella enteritidis. On day 3 of the
illness her fever persisted. She becomes increasingly irritable and has a prolonged generalized tonic-clonic
seizure on day 4.

Which of the following is the most likely cause of the seizure?

A. Hypernatraemia.

B. Hypocalcaemia.

C. Hypoglycaemia.

D. Hyponatraemia.

E. Meningitis.

QUESTION 100

A 12-year-old boy is on long-term cyclosporin therapy after a renal transplant. He has been stable on the
same dose of cyclosporin for the last six months. At a routine follow up visit his mother reports that he has
been complaining of headaches and has pins and needles in his hands. You notice that he has a tremor and
find that he has developed hypertension since your last assessment.

Addition of which of the following medications to his treatment regimen is most likely to have caused his
symptoms?

A. Carbamazepine.

B. Erythromycin.

C. Isoniazid.

D. Phenobarbitone.

E. Rifampicin.

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2003 FRACP Written Examination

Paediatrics & Child Health

Paper 2 – Clinical Applications

Answers

1. E 34. B 67. E
2. C 35. A 68. A
3. A 36. A 69. B
4. E 37. D 70. D
5. C 38. B 71. D
6. B 39. A 72. C
7. E 40. E 73. D
8. D 41. A 74. E
9. E 42. B 75. D
10. B 43. E 76. A
11. E 44. A 77. A
12. C 45. A 78. B
13. B 46. B 79. C
14. E 47. D 80. C
15. E 48. C 81. B
16. B 49. E 82. C
17. A 50. D 83. B
18. D 51. C 84. D
19. E 52. C 85. E
20. B 53. E 86. B
21. D 54. E 87. E
22. C 55. E 88. A
23. B 56. C 89. E
24. B 57. B 90. C
25. D 58. A 91. A
26. A 59. E 92. D
27. E 60. D 93. A
28. E 61. A 94. E
29. B 62. D 95. D
30. B 63. C 96. B
31. C 64. D 97. C
32. C 65. E 98. B
33. D 66. B 99. E
100. B

Copyright © 2004 by The Royal Australasian College of Physicians