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2004 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 © 2005 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.

Copyright © 2005 by The Royal Australasian College of Physicians


2 P204

QUESTION 1
Which of the following vaccines would be most likely to be transmitted from a normal child to their
immunocompromised sibling?

A. Bacille Calmette-Guérin (BCG).

B. Influenza.

C. Measles-mumps-rubella (MMR).

D. Oral polio.

E. Varicella-zoster.

QUESTION 2
An eight-year-old boy is admitted with an episode of acute asthma. His oxygen saturation is 92% in
air. He is prescribed prednisolone 1 mg/kg and hourly salbutamol 12 puffs. Three hours later his
oxygen saturation in air has dropped to 89%. He looks well and is less distressed than when
admitted. He has widespread wheeze with good air entry.

Based on these findings, the most appropriate next step in his management is:

A. add ipratroprium bromide.

B. blood gas analysis.

C. change to intravenous salbutamol.

D. chest X-ray to rule out a pneumothorax.

E. reduce frequency of salbutamol.

QUESTION 3
A 13-year-old boy presents with nonspecific abdominal pain. The boy has a history of seizures. His
mother is known to have chronic renal failure. Physical examination shows a small 13-year-old who is
normotensive with small areas of hypopigmentation on his trunk. The abdominal pain quickly
subsides following hospital admission. A renal ultrasound scan shows enlarged kidneys and multiple
echogenic foci throughout both kidneys.

Which one of the following is the most likely explanation of the renal abnormality in this boy?

A. Dominant polycystic kidney disease.

B. Juvenile nephronophthisis.

C. Papillary necrosis.

D. Recessive polycystic kidney disease.

E. Renal angiomyolipomata.

Copyright © 2005 by The Royal Australasian College of Physicians


3 P204

QUESTION 4
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.

QUESTION 5
A 15-year-old girl is brought into the emergency room by friends after attending a birthday party. Her
friends are concerned because there has been an alteration in her conscious state. She is febrile and
is visibly flushed and sweating. Her heart rate is 120/minute and regular. Her blood pressure is
160/95 mmHg. Her neurological exam was notable for her being combative with small but reactive
pupils. During your examination she begins to have a generalised seizure.

She has a history of depression and is being managed by a psychiatrist.

You suspect an ingestion or intoxication.

Which of the following is the most likely cause?

A. Alcohol.

B. Ecstasy.

C. Marijuana.

D. Mushroom intoxication.

E. Tricyclic antidepressants.

QUESTION 6
A two-year-old boy is taken to the emergency department by his parents with rectal bleeding. He
passed about 100 mL of blood per rectum. The blood is slightly altered. There were no associated
abdominal pains, and the abdomen is soft and non-tender on examination. He has no cutaneous
stigmata or telangiectasia.

Which of the following is the most likely diagnosis?

A. Campylobacter infection.

B. Inflammatory bowel disease.

C. Intussusception.

D. Meckel diverticulum.

E. Polyp.

Copyright © 2005 by The Royal Australasian College of Physicians


4 P204

QUESTION 7

Parasternal long axis echocardiogram

Apical 4-chamber echocardiogram

Key: AO aorta
RA right atrium
LA left atrium
LV left ventricle
RV right ventricle

The echocardiograms shown above were obtained from an otherwise healthy three-month-old infant
presenting for assessment of a murmur. They show multiple intraventricular lesions.

Which of the following is the most likely diagnosis?

A. Neurofibromatosis type 1.

B. Noonan syndrome.

C. Proteus syndrome.

D. Sturge-Weber syndrome.

E. Tuberous sclerosis.

Copyright © 2005 by The Royal Australasian College of Physicians


5 P204

QUESTION 8

A five-year-old child has the karyotype shown above. What is the most likely phenotype at this age?

A. Ambiguous genitalia.

B. Developmental delay.

C. Normal female.

D. Normal male.

E. Short stature.

QUESTION 9
Unawareness of hypoglycaemia is predominantly due to failure of secretion of which one of the
following hormones?

A. Adrenaline.

B. Cortisol.

C. Glucagon.

D. Growth hormone.

E. Somatostatin.

Copyright © 2005 by The Royal Australasian College of Physicians


6 P204

QUESTION 10
A two-year-old boy from Nigeria immigrated a year ago. He presents to the emergency department
with a fever of 40°C. His mother says that he has known sickle cell disease diagnosed previously in
Africa. Initial examination reveals a sick child along with an initial full blood count showing a raised
neutrophil count with left shift.

The most likely organism causing his fever is:

A. Epstein-Barr virus.

B. Haemophilus influenzae type b.

C. Plasmodium falciparum.

D. Salmonella typhi.

E. Streptococcus pneumoniae.

QUESTION 11
A three-year-old girl is found floating face down in the family pool after being ‘missed’ for
approximately five minutes. Basic life support is commenced on the scene and on arrival in the
emergency department the girl is in asystole. She is apnoeic and pulseless, her temperature is 33°C
and the maximum estimated period of pulseless apnoea is 15 minutes. The child is rapidly intubated
and ventilated, intravenous access is gained and external cardiac compressions are continued.

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

A. Administer intravenous adrenaline.

B. Administer intravenous atropine.

C. Commence active warming measures.

D. Counsel the family and cease active resuscitative measures.

E. Immediate direct current (DC) defibrillation.

QUESTION 12
Which of the following is least consistent with night terrors?

A. Amnesia of the episode by the child.

B. Family history.

C. Occurrence in rapid eye movement (REM) sleep.

D. Occurrence in the first third of the night.

E. Onset at five years of age.

Copyright © 2005 by The Royal Australasian College of Physicians


7 P204

QUESTION 13
A 41-week gestation female infant was born by normal vaginal delivery with a birth weight of 3045 g
and head circumference of 33.5 cm. A rash on her limbs was noted on the first day of life. She
established breastfeeding very well. At 5 days of age, she was noted to be irritable and feeding
poorly. She developed left sided clonic jerks with eye deviation. These were controlled with
intravenous phenobarbitone.

The rash as illustrated above was described as an erythematous vesicular rash which was crusted in
places. It was present on the forearms and lower limbs.

The most likely cause of this rash would be:

A. congenital bullous ichthyosiform erythroderma.

B. congenital varicella.

C. epidermolysis bullosa.

D. herpes simplex virus infection.

E. incontinentia pigmenti.

Copyright © 2005 by The Royal Australasian College of Physicians


8 P204

QUESTION 14

The flow-volume loop shown above is most consistent with:

A. aberrant right subclavian artery.

B. asthma.

C. laryngeal web.

D. subglottic stenosis.

E. tracheomalacia.

Copyright © 2005 by The Royal Australasian College of Physicians


9 P204

QUESTION 15
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 16
A six-month-old boy presents with a two-month history of persistent vomiting, loose bowel motions,
poor weight gain, irritability after feeds and a persistent rash on his face and upper arms. He was born
at term, breastfed to two months of age, and subsequently changed to a cow’s milk-based formula.
Solids, including a wheat-based cereal, had been introduced from four months of age.

The following immunological investigations were performed:

total serum IgE 7 kU/L [0-20]


total serum IgA 0.37 g/L [0.14-0.69]
radioallergosorbent assay to cow's milk <0.35 kU/L [<0.35]
antigliadin-IgG antibody 36 U/L [<20]
antigliadin-IgA antibody 6 U/L [<20]
tissue transglutaminase IgA antibody negative

Which of the following is the most likely diagnosis?

A. Coeliac disease.

B. Cow’s milk protein intolerance.

C. Cystic fibrosis.

D. Gastro-oesophageal reflux.

E. Lactose intolerance.

Copyright © 2005 by The Royal Australasian College of Physicians


10 P204

QUESTION 17
A mother with a history of genital herpes delivers a baby at term by normal vaginal delivery. Three
days after birth the infant is well, but is noted to have two small blistering lesions on the arm.
Investigations confirm herpes simplex virus type 2 from the skin lesions.

The most appropriate treatment would be:

A. intravenous aciclovir.

B. intravenous ganciclovir.

C. observation.

D. oral aciclovir.

E. oral famciclovir.

QUESTION 18
An eight-year-old child presents to a regional emergency department with a one-week history of
weakness in both legs, stumbling gait and complaints of numbness. The family is currently under
considerable stress with the suicide of a close relative and parental fighting. Neurological examination
reveals apparent reduction in power, variable sensory loss and normal deep tendon reflexes. The gait
is erratic.

Which of the following is the most likely diagnosis?

A. Conversion disorder.

B. Guillain-Barré syndrome.

C. Multiple sclerosis.

D. Transverse myelitis.

E. Viral myositis.

QUESTION 19
The occurrence of a second malignancy after successful treatment of a primary tumour is least likely
to be associated with:

A. Bloom syndrome.

B. cyclophosphamide.

C. Fanconi aplastic anaemia.

D. growth hormone treatment.

E. radiotherapy.

Copyright © 2005 by The Royal Australasian College of Physicians


11 P204

QUESTION 20
A 10-year-boy presents with an episode of acute left-sided loin pain. He passes bright red urine and
requires intravenous morphine for analgesia. A plain abdominal X-ray is shown below.

Which one of the following is most likely to play an important role in the development of this condition?

A. High sodium diet.

B. Hypokalaemia.

C. Hypomagnesaemia.

D. Increased urine citrate concentration.

E. Metabolic alkalosis.

Copyright © 2005 by The Royal Australasian College of Physicians


12 P204

QUESTION 21
A five-month-old baby boy returns for review of his congenital hypothyroidism. He continues to grow
along the 50th percentile for his length, weight and head circumference. He has been on an
appropriate dose of daily replacement with thyroid hormone (37.5 µg/day).

Repeat thyroid function tests (carried out at his visit) are as follows:

thyroxine (T4) 18 pmol/L [10-23]


thyroid-stimulating hormone (TSH) 153.0 mU/L [0.4-4.0]

The most likely explanation for the elevated TSH is:

A. expected result, as TSH can take many months to suppress.

B. iodine deficiency.

C. malabsorption.

D. poor parental compliance.

E. thyroid hormone resistance.

QUESTION 22
A seven-year-old boy wakes in the morning and cries out to his parents to ‘come quickly’. He
complains to his parents that the ‘room is spinning’. The symptoms seem to be aggravated by head
motion and change of position from lying down. He becomes pale, sweaty and nauseated whenever
he moves or tries to sit up in bed. He is helped to the bathroom because he has difficulty standing
and walking unsupported and vomits repeatedly. His parents bring him to the emergency department
soon afterwards.

On examination, he is found to be perfectly conscious and cooperative if left to lie still in bed. He has
left-beating nystagmus in all positions of gaze but otherwise no focal neurologic findings. His hearing
is normal. He has a mild upper respiratory tract infection.

The most likely diagnosis is:

A. acute disseminated encephalomyelitis (ADEM).

B. acute labyrinthitis.

C. acute vestibular neuritis.

D. cerebellar ataxia.

E. Menière’s disease.

Copyright © 2005 by The Royal Australasian College of Physicians


13 P204

QUESTION 23

A three-week-old infant girl presents with a scaly rash consisting of erythematous patches and
plaques which involves the bridge of her nose and her cheeks, as shown above. Her mother noticed
that the rash had appeared the day after several hours of sun exposure. Further history revealed that
the pregnancy had been complicated by the development of a maternal hip effusion at 36 weeks
gestation. Maternal antinuclear antibody (ANA) was 1:160. The infant had a platelet count of 90 x
109/L [150-600] at birth which returned to normal by two weeks of age. Physical examination was
normal apart from the facial rash.

The most useful blood test on the infant to determine the cause of the rash would be:

A. anti-cardiolipin antibody.

B. antinuclear antibody.

C. anti-platelet antibody.

D. anti-Ro (SS-A) autoantibody.

E. parvovirus serology.

Copyright © 2005 by The Royal Australasian College of Physicians


14 P204

QUESTION 24
A couple who are first cousins are concerned about the risk of birth defects in their future children.
There is no known family history of genetic disease.

Their risk of having a baby with a birth defect is closest to:

A. 1%.

B. 2.5%.

C. 5%.

D. 10%.

E. 25%.

QUESTION 25
A 13 and a half-year-old girl is seen for short stature. She is on the 3rd percentile for height and the
10th percentile for weight. Her midparental height is on the 75th percentile. She is not dysmorphic,
puberty is Tanner stage 5 and she began her menses at 12 years of age.

She and her parents are wanting to maximise her final height.

What would be the most appropriate next step in her management?

A. Advise her epiphyses are likely to be fused and that growth is almost complete.

B. Advise she has constitutional growth delay and is likely to continue to grow.

C. Arrange for growth hormone secretion studies.

D. Investigate for Turner syndrome.

E. Measure anti-endomysial antibodies for coeliac disease.

QUESTION 26
Which of the following vaccines is most likely to produce a reaction in a child with a known
anaphylactic reaction following exposure to egg protein?

A. Hepatitis B.

B. Inactivated poliomyelitis.

C. Influenza.

D. Measles-mumps-rubella.

E. Varicella-zoster.

Copyright © 2005 by The Royal Australasian College of Physicians


15 P204

QUESTION 27
A 12-year-old boy is referred for evaluation of excessive daytime tiredness. He was recently found
asleep in a school examination. There was no history of hyperphagia or sexual precocity. A
polysomnogram did not reveal any evidence of obstructive sleep apnoea syndrome.

The most appropriate next step is:

A. a computed tomography (CT) scan of the brain.

B. a multiple sleep latency test.

C. electroencephalogram (EEG).

D. HLA typing.

E. psychological assessment.

QUESTION 28
A 37-week gestation infant is noted to develop central cyanosis shortly after oral feeds on the third day
of life. Examination reveals a normal baby with no evidence of cyanosis or tachypnoea. A chest X-ray
shows a normal sized heart and clear lung fields.

The most likely diagnosis is:

A. congenital cyanotic heart disease.

B. congenital laryngeal cleft.

C. gastro-oesophageal reflux.

D. seizures.

E. tracheo-oesophageal fistula.

QUESTION 29
A two-year-old girl is referred to you for assessment of possible language delay. She has
approximately 30 single words in her vocabulary, but no two-word combinations. She has bilateral
glue ear (otitis media with effusion), and a recent hearing test showed a 30dB HL (hearing loss) pure
tone average in the left ear and a 15dB HL pure tone average in the right ear. Physical examination is
otherwise normal. She is too clingy for formal developmental assessment but her non-language
developmental milestones, as reported by her mother, seem normal.

What would be the best estimate of the chance of language delay at school entry?

A. 10%.

B. 33%.

C. 50%.

D. 67%.

E. 90%.

Copyright © 2005 by The Royal Australasian College of Physicians


16 P204

QUESTION 30
A seven-year-old girl presents with a history of bleeding gums after she cleans her teeth. Examination
of her mouth reveals evidence of gingivitis as shown below.

A defect of which component of immune function is most likely to be associated with this clinical
presentation?

A. B cells.

B. Complement.

C. Natural killer cells.

D. Neutrophils.

E. T cells.

QUESTION 31
A four-year-old boy with severe haemophilia A and a high titre factor VIII inhibitor needs surgery. The
peri-operative replacement coagulation product of choice is:

A. cryoprecipitate.

B. fresh frozen plasma.

C. recombinant activated factor VII.

D. recombinant factor VIII.

E. recombinant factor IX.

Copyright © 2005 by The Royal Australasian College of Physicians


17 P204

QUESTION 32
An 11-year-old boy presents to the emergency department following a fall onto his outstretched left
arm whilst rollerblading. On examination his left hand is neurovascularly intact and there is no
deformity. His X-ray is shown below.

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

A. Apply backslab and review in one week.

B. Closed reduction in the emergency department.

C. Closed reduction in the operating theatre.

D. Open reduction.

E. Urgent orthopaedic review in the emergency department.

Copyright © 2005 by The Royal Australasian College of Physicians


18 P204

QUESTION 33
A three-month-old boy, 10% dehydrated with rotavirus diarrhoea, has a serum sodium of 166 mmol/L
[135-145]. He is normotensive, has just passed urine and when weighed two days ago was 5 kg.
Intravenous fluid is commenced.

Which of the following is the most appropriate regimen?

A. 0.18% saline, 4% dextrose and 20 mmol/L potassium chloride at 35 mL/hour.

B. 0.18% saline, 4% dextrose and 20 mmol/L potassium chloride at 50 mL/hour.

C. 0.45% saline, 2.5% dextrose and 20 mmol/L potassium chloride at 50 mL/hour.

D. 0.9% saline and 20 mmol/L potassium chloride at 35 mL/hour.

E. 0.9% saline and 20 mmol/L potassium chloride at 50 mL/hour.

QUESTION 34
A 12-year-old boy presents with chafed and reddened hands as a result of frequent washing. His
father is an infectious disease physician. The boy describes intrusive thoughts about infection with
Pseudomonas and scrupulously cleans the family bathroom each time before using it. He is
concerned about his father bringing home contaminants and has become increasingly isolated from
other members of the family.

The best treatment will be multimodal. The component with the best evidence of efficacy is:

A. clomipramine.

B. cognitive-behaviour therapy.

C. family therapy.

D. sertraline.

E. venlafaxine.

QUESTION 35
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.

Copyright © 2005 by The Royal Australasian College of Physicians


19 P204

QUESTION 36
A 14-year-old boy complains of heel pain of six months’ duration. The following X-ray is obtained.

Which of the following is the most likely cause of his heel pain?

A. Ankylosing spondylitis.

B. Calcaneal osteomyelitis.

C. Hypermobile pes planus.

D. Reflex sympathetic dystrophy.

E. Sever disease (Achilles tendonitis).

QUESTION 37
A term newborn infant is noted to be tachypnoeic from delivery. On examination on day 1 he is also
noted to have prominent pulses and an active precordium. His liver is palpable 4 cm below the costal
margin. No murmurs are audible. His arterial oxygen saturation is 98% in room air.

Which of the following is the most likely diagnosis?

A. Aneurysm of the vein of Galen.

B. Group B streptococcal sepsis.

C. Hypoplastic left heart.

D. Patent (persistent) ductus arteriosus.

E. Thyrotoxicosis.

Copyright © 2005 by The Royal Australasian College of Physicians


20 P204

QUESTION 38
A 26-year-old woman has a baby with Down syndrome. Subsequent investigations reveal that the
woman is a carrier of a balanced Robertsonian translocation involving chromosomes 14 and 21. Her
karyotype is 45,XX,t(14;21). In a subsequent pregnancy, she declines the offer of prenatal testing.

If the pregnancy goes to term, the most likely outcome is a baby with:

A. an attenuated form of Down syndrome due to mosaic trisomy 21.

B. Down syndrome.

C. intrauterine growth retardation due to maternal isodisomy 14.

D. normal phenotype.

E. severe malformations due to trisomy 14.

QUESTION 39
A 12-month-old girl is referred by her general practitioner because of failure to thrive. Her weight was
on the 50th percentile at six months but had fallen to the 10th percentile at one year. She had a moist
cough at nine months which lasted 10 days. Neonatal immunoreactive trypsin screening was
negative.

On examination she has buttock and thigh wasting. A full blood examination reveals a mild
leucocytosis and her electrolyte profile demonstrates the following:

serum sodium 120 mmol/L [135-145]


serum potassium 2.0 mmol/L [3.5-5.0]
serum chloride 90 mmol/L [90-110]

The most appropriate next investigation is:

A. anti-endomysial antibody.

B. serum and urinary osmolality.

C. serum 17-OH progesterone.

D. sweat test.

E. urinary sodium and potassium.

Copyright © 2005 by The Royal Australasian College of Physicians


21 P204

QUESTION 40

Copyright © 2005 by The Royal Australasian College of Physicians


22 P204

QUESTION 40 (continued)
An eight-year-old girl is referred to hospital because of progressive pallor for three months. In the past
four weeks, she has developed painful lesions on her feet, as shown opposite. There is no past
medical history of note.

Initial investigations show the following:

haemoglobin 89 g/L [110-140]


white cell count 6 x 109/L [4-11]
neutrophils 4.0 x 109/L [1.4-4.6]
lymphocytes 1.0 x 109/L [1.4-4.6]
eosinophils 0.20 x 109/L [<0.45]
monocytes 0.13 x 109/L [0.20-0.80]
platelet count 100 x 109/L [150-400]
erythrocyte sedimentation rate (ESR) 80 mm/hr [1-10]
serum creatinine 0.05 mmol/L [0.05-0.08]

Which one of the following investigations is most likely to assist in the diagnosis?

A. Angiotensin-converting enzyme.

B. Anti-neutrophil cytoplasmic antibodies.

C. Antinuclear antibodies.

D. Direct Coombs test.

E. Rheumatoid factor.

QUESTION 41
A seven-month-old girl plays with a 15-month-old boy who has a cough and fever. The next day the
boy develops a morbilliform rash. A blood sample shows he has IgM antibodies to measles. You see
the girl the following day, two days after the initial contact.

What is the most appropriate course of action for the girl?

A. Administer normal human immunoglobulin alone and defer measles-mumps-rubella (MMR)


immunisation until the usual recommended time.

B. Administer normal human immunoglobulin and MMR vaccine concurrently, but in different
sites.

C. Immunise with MMR vaccine immediately.

D. Reassure the parents it is unlikely that their daughter will develop measles because of
maternal antibodies.

E. Warn the parents that their daughter is likely to develop measles, but that it is too late to do
anything.

Copyright © 2005 by The Royal Australasian College of Physicians


23 P204

QUESTION 42
A 13-year-old girl presents to your office with a six-month history of daily headaches. The headaches
are present on waking and on occasions are associated with vomiting without nausea. She has had
intermittent double vision and transient episodes of loss of vision lasting seconds only. She is taking
tetracyclines for acne.

On examination, she is moderately obese, afebrile, and has no neurocutaneous stigmata. She has a
moderate amount of facial acne. Her blood pressure is 105/65 mmHg. Her extraocular movements
show a partial left sixth nerve palsy and she has gross papilloedema. There are no other abnormal
findings.

A T2-weighted magnetic resonance imaging (MRI) scan of her brain is shown below.

The most likely diagnosis is:

A. aqueductal stenosis.

B. benign intracranial hypertension (BIH).

C. craniopharyngioma.

D. meningioma.

E. temporal lobe tumour.

Copyright © 2005 by The Royal Australasian College of Physicians


24 P204

QUESTION 43
A nine-year-old girl is seen with polyuria and polydipsia. She is dehydrated and on routine
assessment is found to have the following blood test results:

glucose 38.2 mmol/L [3.8-6.2]


sodium 130 mmol/L [134-143]
potassium 4.2 mmol/L [3.5-5.6]
pH 7.12 [7.35-7.45]
bicarbonate 9 mmol/L [18-29]
creatinine 0.035 mmol/L [<0.074]

The most likely explanation for the low serum sodium level is:

A. Addison disease.

B. diabetes insipidus.

C. malnutrition.

D. pseudohyponatraemia.

E. renal sodium losses.

QUESTION 44
A term male infant with a birth weight of 3000 g is born to a 28-year-old Caucasian primigravid
woman. His Apgar scores are 8 at 1 minute and 9 at 5 minutes. No resuscitation is required. Within
an hour of delivery the infant develops widespread petechiae. A cranial ultrasound reveals a left sided
grade 2 intraventricular haemorrhage.

A full blood count reveals the following:

haemoglobin 127 g/L [135-215]


white cell count 12.6 x 109/L [5.0-21.0]
platelet count 8 x 109/L [150-400]

The mother’s platelet count was 236 x 109/L [150-400].

Which of the following is the most likely diagnosis?

A. Alloimmune thrombocytopenia.

B. Autoimmune thrombocytopenia.

C. Congenital cytomegalovirus (CMV) infection.

D. Group B streptococcal infection.

E. Wiskott-Aldrich syndrome.

Copyright © 2005 by The Royal Australasian College of Physicians


25 P204

QUESTION 45
A breastfed four-week-old girl is taken to hospital because of several episodes of rectal bleeding with
most bowel motions. The infant is passing four stools daily with visible streaks of bright red blood and
mucus. The infant is otherwise well and thriving.

Stool testing reveals the following findings:

red blood cells +++


white blood cells +
fat globules +
fatty acid crystals negative
reducing sugars 0.25%

Which of the following is the most likely diagnosis?

A. Allergic proctocolitis.

B. Anal fissure.

C. Bacterial gastroenteritis.

D. Juvenile polyp.

E. Swallowed maternal blood.

QUESTION 46

The distribution of joint involvement indicated by the red colour in the diagram above is most
characteristic of which form of childhood arthritis?

A. HLA B27-associated arthropathy.

B. Polyarticular juvenile idiopathic arthritis.

C. Psoriatic arthritis.

D. Rheumatic fever.

E. Systemic lupus erythematosus.

Copyright © 2005 by The Royal Australasian College of Physicians


26 P204

QUESTION 47
Diagnosis of a major depressive disorder according to the Diagnostic and Statistical Manual, 4th
edition (DSM-IV) requires a number of symptoms to have been present nearly every day during the
same two-week period.

Which of the following symptoms is least helpful in the diagnosis of adolescent depression?

A. Anhedonia (feeling of loss of pleasure in all, or almost all, activities).

B. Depersonalisation (feeling of being detached from oneself).

C. Impaired concentration.

D. Irritable mood.

E. Marked change in appetite.

QUESTION 48
Serological evidence of recent streptococcal infection is least likely to be associated with which of the
following manifestations of rheumatic fever?

A. Carditis.

B. Erythema marginatum.

C. Migratory polyarthritis.

D. Subcutaneous nodules.

E. Sydenham chorea.

QUESTION 49
Infusion of cryoprecipitate is principally indicated for the replacement of:

A. anti-thrombin.

B. factor IX.

C. fibrinogen.

D. IgG.

E. protein C.

Copyright © 2005 by The Royal Australasian College of Physicians


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QUESTION 50
An 11-year-old boy is admitted to hospital because he has been lethargic for the past three to four
weeks. He appears to be thirsty all the time with recent weight loss. He has been getting up to pass
urine three times each night for the past two weeks. There is no history of drug ingestion or infection.
There is no past history of note. Clinical examination is unremarkable.

His initial investigations show the following:

serum:
sodium 135 mmol/L [135-146]
potassium 3.0 mmol/L [3.5-5.0]
urea 16.0 mmol/L [3.2-7.7]
creatinine 0.29 mmol/L [0.04-0.08]
glucose 3.5 mmol/L [2.5-7.0]
urinalysis 1+ protein, no blood, moderate glucose
urine microscopy 40 white cells, <10 red cells, no bacteria, no growth

The most likely diagnosis in this patient is:

A. acute glomerulonephritis.

B. acute interstitial nephritis.

C. acute tubular necrosis.

D. diabetes insipidus.

E. Goodpasture syndrome.

QUESTION 51
Which of the following conditions overlaps least with chronic fatigue syndrome?

A. Anxiety.

B. Depression.

C. Fibromyalgia.

D. Hypothyroidism.

E. Irritable bowel syndrome.

Copyright © 2005 by The Royal Australasian College of Physicians


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QUESTION 52
A 10-year-old boy with cyanotic congenital heart disease presents with a two-week history of throbbing
bifrontal headache, worse in the morning, associated with low-grade fever.

Investigations are as follows:

haemoglobin 201 g/L [110-150]


white cell count 10.4 x 109/L [4.0-11.0]
platelet count 250 x 109/L [150-400]
erythrocyte sedimentation rate (ESR) 5 mm/hr [0-20]
serum C-reactive protein 6 mg/L [<8]

An image from a non-contrast computed tomography (CT) scan of his brain is shown below.

Which of the following is the most likely diagnosis?

A. Cerebral abscess.

B. Congenital cystic lesion.

C. Embolic stroke.

D. Intracerebral haemorrhage.

E. Tumour.

Copyright © 2005 by The Royal Australasian College of Physicians


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QUESTION 53

Copyright © 2005 by The Royal Australasian College of Physicians


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QUESTION 53 (continued)
An eight-month-old girl presents with a history of cough and recurrent chest infections. A clinical
photograph and chest X-ray of the patient are shown opposite.

Which one of the following is the most likely cause of this infant’s clinical presentation?

A. Lymphoma.

B. Neuroblastoma.

C. Retinoblastoma.

D. Sarcoidosis.

E. Thymoma.

QUESTION 54

An 11-year-old boy has the facial appearance shown above. He has a history of cleft palate repair
and has borderline developmental delay.

Which of the following is the most likely diagnosis?

A. Fetal alcohol syndrome.

B. Fragile X syndrome.

C. Kabuki make-up syndrome.

D. Myotonic dystrophy.

E. Velocardiofacial syndrome.

Copyright © 2005 by The Royal Australasian College of Physicians


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QUESTION 55
Following a normal pregnancy a male infant has a normal vaginal delivery at term in the presence of
clear liquor. Immediately following delivery, he is in severe respiratory distress with marked subcostal
and sternal recession. A normal cry is heard. A soft, high-pitched, biphasic stridor is audible.

The most likely cause of this infant’s respiratory distress is:

A. bilateral abductor vocal cord paralysis.

B. laryngo-oesophageal cleft.

C. lingular cyst.

D. severe laryngomalacia.

E. unilateral vocal cord paralysis.

QUESTION 56
A 14-month-old boy is brought to see you by his mother for advice about his diet and which foods
should be avoided because of his allergies. At seven months of age, following his first exposure to
egg, he developed perioral urticaria within 10 minutes which resolved after 15 minutes. There were no
other symptoms. At 12 months of age, 5 minutes after ingestion of a small amount of peanut butter on
toast, he developed generalised erythema, cough and seemed distressed. No medical attention was
sought and the symptoms resolved spontaneously over 30 minutes. He has not had egg or peanut
since these reactions and has not been exposed to other nut products. He drinks soymilk because his
mother believes this is better for allergies than cow’s milk, however he can eat yoghurt and ice cream
without any obvious symptoms. He had atopic dermatitis on the face and flexures until 12 months of
age but this has resolved. Allergen skin prick tests show:

Allergen Wheal diameter (mm)


Cow’s milk 5
Egg white 0
Peanut 9
Cashew nut 9
Soy 3

Histamine control 5
Saline control 0

On the basis of the history and the results of skin prick tests the most appropriate advice would be to
avoid:

A. peanut alone.

B. peanut and cashew nut.

C. peanut, cashew nut and cow’s milk.

D. peanut, cashew nut, cow’s milk and soy.

E. peanut, cashew nut, cow’s milk, soy and egg.

Copyright © 2005 by The Royal Australasian College of Physicians


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QUESTION 57
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 58
An infant is noted on day 2 of life to be cyanosed. The arterial oxygen saturation is 88% in room air.
The remainder of the examination is normal, including normal cardiac and respiratory examinations.

Which of the following is the most likely diagnosis?

A. Alveolar capillary dysplasia.

B. Extralobar sequestration.

C. Tetralogy of Fallot.

D. Totally anomalous pulmonary venous return.

E. Transposition of the great arteries.

Copyright © 2005 by The Royal Australasian College of Physicians


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QUESTION 59
A four-year-old boy is referred to you for investigation of persistent diarrhoea and poor weight gain.
The following results are obtained:

haemoglobin 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 antibody 88 U/L [<50]
antigliadin-IgA antibody 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.

QUESTION 60
A 12-year-old girl presents with signs and symptoms of pyelonephritis. Despite being treated for five
days with an appropriate dose of oral cephalexin, a midstream urine culture is positive for enterococci.

The most likely explanation for the lack of response to the prescribed antibiotic is:

A. antibiotic resistance.

B. inadequate duration of therapy.

C. lack of tissue penetration.

D. oral rather than intravenous therapy.

E. poor compliance.

QUESTION 61
Acute splenic sequestration crisis is most likely in sickle cell disease if:

A. the child has folate deficiency.

B. the child is less than two years of age.

C. the reticulocyte count is less than 5%.

D. the spleen is not enlarged clinically.

E. the underlying haemoglobinopathy is due to Haemoglobin SC disease.

Copyright © 2005 by The Royal Australasian College of Physicians


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QUESTION 62
A 10-year-old boy is referred with concerns regarding his behaviour. His teachers are concerned that
he is easily distracted, has a poor attention span and appears to have low self-esteem. He often
appears ‘blank’ and seems to miss instructions. Over the past six months he has been increasingly
defiant towards teachers, and he has begun acting the ‘class clown’. He has had two detentions this
term for inappropriate behaviour.

At home he has been moody and at times aggressive toward his parents. He was an ‘easy child’ until
he was seven or eight years old, but has been increasingly unhappy since. He has never really
enjoyed school.

He had language delay identified at age three, and had some speech therapy. Otherwise his
developmental milestones were achieved age-appropriately.

The school arranged psychometric testing. On the Wechsler Intelligence Scale for Children-Third
Revision he had a full-scale intelligence quotient (IQ) of 82, with a performance scale score of 104 and
a verbal scale score of 72. On academic achievement testing his arithmetic score was within the
average range, but his reading and spelling scores were both more than two standard deviations
below the mean. His literacy level was assessed at two years below his current grade level. The
educational psychologist noted that he was reluctant to attempt some tasks.

Which of the following is the most likely primary diagnosis?

A. Attention deficit/hyperactivity disorder.

B. Depression.

C. Intellectual disability.

D. Primary generalised epilepsy with absence seizures.

E. Specific learning disability.

QUESTION 63
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 © 2005 by The Royal Australasian College of Physicians


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QUESTION 64

An eight-year-old boy presents with a two-month history of fever, night sweats, abdominal pain, aching
joints and weight loss of 2 kg. He has developed the rash shown above over the last two weeks. He
was previously well.

Examination shows the rash but no other significant clinical findings.

Which of the following is the most likely diagnosis?

A. Dermatomyositis.

B. Henoch-Schönlein purpura.

C. Parvovirus infection.

D. Polyarteritis nodosa.

E. Tuberculosis.

Copyright © 2005 by The Royal Australasian College of Physicians


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QUESTION 65
A 14-year-old girl complains of tiredness. She has no significant past medical history and denies any
medications. Apart from being thin, there are no abnormal findings on examination. Her blood
pressure is 105/70 mmHg.

Results of investigations are listed below.

Serum biochemistry:

sodium 138 mmol/L [135-145]


potassium 2.3 mmol/L [3.4-5.0]
chloride 85 mmol/L [103-109]
creatinine 0.10 mmol/L [0.06-0.12]

Arterial blood gases:

pH 7.50 [7.34-7.45]
PaO2 95 mmHg [80-100]
PaCO2 42 mmHg [35-45]
bicarbonate 39 mmol/L [22-28]

Urinary biochemistry:

sodium 30 mmol/L
potassium 42 mmol/L
chloride 13 mmol/L

The most likely explanation for these results is:

A. Bartter syndrome.

B. occult diuretic use.

C. occult laxative use.

D. primary hyperaldosteronism.

E. self-induced vomiting.

QUESTION 66
An 18-month-old child presents after swallowing a 20-cent piece. At which of the following anatomical
sites is the foreign body most likely to become impacted?

A. Duodeno-jejunal junction.

B. Gastro-oesophageal junction.

C. Ileocaecal valve.

D. Oesophagus at level of cricoid.

E. Pylorus.

Copyright © 2005 by The Royal Australasian College of Physicians


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QUESTION 67
A four-year-old boy presents with worsening back pain, which is more severe at night. The pain first
started about three weeks previously after a minor upper respiratory infection and was initially
intermittent. There has not been any recent history of fever. He had previously been well, with no
significant infections other than otitis media.

Examination reveals tenderness over the lumbar spine at L2/3, limited straight leg raising and a loss of
the normal lumbar lordosis. His erythrocyte sedimentation rate (ESR) is 60 mm/hr and his C-reactive
protein is 4 mg/L [<8].

A magnetic resonance imaging (MRI) scan of his spine is shown below.

The most likely diagnosis is:

A. ankylosing spondylitis.

B. discitis.

C. epidural abscess.

D. osteoid osteoma.

E. tumour.

Copyright © 2005 by The Royal Australasian College of Physicians


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QUESTION 68
A four-year-old boy with human immunodeficiency virus (HIV) infection has a six-month history of mild
exertional dyspnoea, but is otherwise well. His CD4 counts are consistently in the normal range for
age and his viral load is 10,000 copies/mL.

His chest is clear to auscultation and his oxygen saturation is 92% in air. He has generalised
lymphadenopathy and finger clubbing. The rest of his physical examination is normal. His chest X-ray
is shown below.

Which of the following is the most likely diagnosis?

A. Atypical mycobacterial infection.

B. Cytomegalovirus pneumonitis.

C. Lymphoid interstitial pneumonitis.

D. Pneumocystis carinii pneumonia.

E. Tuberculosis.

Copyright © 2005 by The Royal Australasian College of Physicians


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QUESTION 69
The most common adverse effect of methylphenidate is:

A. appetite suppression.

B. headache.

C. sleep difficulty.

D. tics.

E. withdrawn behaviour.

QUESTION 70
The parents of a two-year-old boy seek advice about their past reproductive and family history. They
have recently immigrated from Vietnam. The pedigree is as shown below. There have been four
miscarriages, all between six and eight weeks of gestation. Their first child (III:4) was born with
multiple congenital anomalies and had severe developmental delay. He died aged two years, of
unspecified causes. No other information is available about him. The only other family history of note
is that the deceased child’s uncle (II:1) also had developmental delay and died in childhood. The
surviving child (III:6) is normal.

Which of the following investigations is most likely to prove useful for counselling about future
children?

A. Haemoglobin electrophoresis of both parents.

B. Karyotypes of both parents.

C. Maternal fragile X triplet repeats.

D. Maternal lupus serology.

E. Maternal plasma very long chain fatty acids.

Copyright © 2005 by The Royal Australasian College of Physicians


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QUESTION 71

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.

QUESTION 72
Which of the following symptoms or signs would be least likely in a child with Kawasaki disease?

A. Arthritis.

B. Erythema of buttocks.

C. Jaundice.

D. Purulent conjunctivitis.

E. Right hypochondrial tenderness.

Copyright © 2005 by The Royal Australasian College of Physicians


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QUESTION 73
An asymptomatic four-year-old boy is referred to you for assessment. He had previously undergone
an echocardiogram, which was reported to show an isolated, restrictive, perimembranous ventricular
septal defect (VSD) and a left to right shunt across the VSD with a pressure gradient of 90 mmHg. His
blood pressure was 110/60 mmHg. His electrocardiogram (ECG) is shown below.

Which of the following conclusions is most justifiable based upon the available data?

A. The ECG is consistent with the echocardiogram and the VSD is large.

B. The ECG is consistent with the echocardiogram and the VSD is small.

C. The ECG is not consistent with the echocardiogram and there may be unrecognised left heart
obstruction.

D. The ECG is not consistent with the echocardiogram and there may be unrecognised right
heart obstruction.

E. The ECG should be repeated as the limb leads are crossed.

Copyright © 2005 by The Royal Australasian College of Physicians


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QUESTION 74
Antenatal maternal smoking is least associated with which one of the following effects in children?

A. Decreased lung compliance.

B. Decreased maximal expiratory flow.

C. Increased risk of lower respiratory tract infections.

D. Increased risk of sudden infant death syndrome.

E. Increased risk of wheezing.

QUESTION 75
A 10-year-old girl with a longstanding history of migraine, on no medications, presents with severe
headache and left upper limb weakness.

Which of the following medications should not be used at this point?

A. Codeine.

B. Cyproheptadine.

C. Dihydroergotamine.

D. Ibuprofen.

E. Propranolol.

QUESTION 76
A previously well six-year-old girl presents for assessment of pubertal development. On examination
her height is above the 97th percentile and her weight is on the 25th percentile. She has Tanner
stage 3 breast development. Pubic hair is Tanner stage 1. She has no skin markings. Investigation
shows her bone age is equivalent to that of an eight-year two-month-old girl.

Which of the following is the most likely diagnosis?

A. Adrenal tumour.

B. Congenital adrenal hyperplasia.

C. Ovarian cyst.

D. Pituitary hamartoma.

E. Premature thelarche.

Copyright © 2005 by The Royal Australasian College of Physicians


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QUESTION 77
A five-year-old girl presents with a two-day history of fever to 38°C axillary and a swollen, tender right
knee. She has previously been well, and has had no rash and no previous episodes of joint pain. On
examination, she is febrile (37.9°C) and flushed. She has a heart rate of 100/minute with normal heart
sounds. She has shotty cervical lymphadenopathy, but no palpable liver or spleen. Her right knee is
warm, swollen, red, and slightly tender. She has no effusion clinically. She can straighten her leg and
flex the right knee, but there is pain at the extreme of knee flexion.

Her blood test results are as follows:

haemoglobin 112 g/L [110-140]


white cell count 10.8 x 109/L [4.0-11.0]
differential:
neutrophils 3.5 x 109/L [1.0-4.0]
lymphocytes 7.3 x 109/L [3.0-8.0]
platelet count 170 x 109/L [150-400]
erythrocyte sedimentation rate (ESR) 18 mm/hr [<10]

Which of the following is the most likely diagnosis?

A. Acute leukaemia.

B. HLA B27-associated arthritis.

C. Pauci-articular juvenile idiopathic arthritis.

D. Septic arthritis.

E. Viral arthritis.

QUESTION 78
An active six-year-old boy has a clear cut school refusal problem. Which of the following is most likely
to be effective?

A. Change in school.

B. Family therapy.

C. Gradual exposure to school.

D. Parental presence in the classroom.

E. Sertraline.

Copyright © 2005 by The Royal Australasian College of Physicians


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QUESTION 79
A one-week-old full term baby girl is noted to be tachypnoeic. Her chest X-ray is shown below.

The most likely diagnosis is:

A. cardiac failure.

B. congenital cystic adenomatous malformation.

C. congenital lobar emphysema.

D. diaphragmatic hernia.

E. staphylococcal pneumonia.

Copyright © 2005 by The Royal Australasian College of Physicians


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QUESTION 80

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 © 2005 by The Royal Australasian College of Physicians


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QUESTION 81
A newborn is receiving assist-control ventilation with the following ventilator settings:

peak inspiratory pressure 17 cmH2O


positive end-expiratory pressure 4 cmH2O
back-up ventilator rate 20/minute
inspiratory time 0.5 seconds

The infant’s spontaneous breathing rate is 40/minute.

The number of breaths per minute which are assisted by the ventilator is which one of the following?

A. 0.

B. 20.

C. 25.

D. 40.

E. 60.

QUESTION 82
A 13-year-old boy with focal segmental glomerulosclerosis presents to hospital with a four-day history
of vomiting and diarrhoea. He has not passed urine for at least 12 hours. Six weeks before, he had a
serum creatinine of 0.11 mmol/L. He has been on 40 mg frusemide daily and an angiotensin-
converting enzyme (ACE) inhibitor.

On examination, he is well-perfused, moderately oedematous, with a pulse of 110/minute and blood


pressure of 90/60 mmHg. His biochemistry on admission shows serum creatinine 0.50 mmol/L [0.05-
0.08] and sodium 130 mmol/L [135-145]. His serum albumin was 12 g/L [35-50].

Which of the following would be the most appropriate next step in management?

A. Dialysis.

B. Fluid restriction.

C. Increase dose of frusemide.

D. Maintenance intravenous fluids.

E. Volume replacement with concentrated albumin solution.

Copyright © 2005 by The Royal Australasian College of Physicians


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QUESTION 83
A six-year-old boy presents with a sore throat, high fever and anorexia. The appearance of his mouth
and tongue is shown below.

The most likely organism responsible for this picture is:

A. Candida albicans.

B. Coxsackievirus A16.

C. Epstein-Barr virus.

D. Fusobacterium necrophorum.

E. herpes simplex virus.

QUESTION 84
A previously settled breastfed infant of four weeks demonstrates increasing crying behaviour over a
week. The infant continues to feed well, though fussily, and continues to gain weight. The baby
effortlessly vomits small amounts of milk four or five times a day. Faeces are watery, yellow and
occasionally explosive. The perianal skin is normal.

The change of behaviour is most likely to be associated with:

A. change in the mother’s diet.

B. gastro-oesophageal reflux.

C. lactose intolerance.

D. normal variation in infant behaviour.

E. urinary tract infection.

Copyright © 2005 by The Royal Australasian College of Physicians


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QUESTION 85
A six-year-old girl presents with a six-month history of staring spells associated with eye flickering and
lip smacking movements. An electroencephalogram (EEG) is performed and is shown below.

Which of the following anticonvulsants is most appropriate?

A. Carbamazepine.

B. Clonazepam.

C. Phenytoin.

D. Sodium valproate.

E. Vigabatrin.

Copyright © 2005 by The Royal Australasian College of Physicians


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QUESTION 86

Copyright © 2005 by The Royal Australasian College of Physicians


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QUESTION 86 (continued)
A nine-year-old boy presents to the emergency department with chest pain. He had cardiac surgery in
infancy, but the parents are vague about the diagnosis. His electrocardiogram (ECG) is shown
opposite.

The most likely cardiac lesion was:

A. atrioventricular canal defect.

B. hypoplastic right ventricle.

C. perimembranous ventricular septal defect.

D. tetralogy of Fallot.

E. truncus arteriosus.

QUESTION 87
Which one of the following confers the greatest risk for the development of fungal infection in a patient
undergoing chemotherapy?

A. Central venous lines.

B. Long-term antibiotics.

C. Prolonged neutropenia.

D. Use of monoclonal antibodies.

E. Use of steroids.

QUESTION 88
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 © 2005 by The Royal Australasian College of Physicians


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QUESTION 89
A 12-year-old boy with longstanding asthma presents with a six-week history of increased cough and
dyspnoea. The cough comes on suddenly in the day, but not usually at night. It lasts for a minute or
two, during which time he finds it hard to get his breath. Usually his asthma is well controlled on
regular betamethasone by inhaler two puffs twice daily, and he rarely needs to use his salbutamol
puffer. For the last month, however, he has often had to stop when playing soccer because of a bout
of prolonged coughing.

The following results are obtained:

haemoglobin 112 g/L [110-140]


9
white cell count 18.6 x 10 /L [4.0-11.0]
9
neutrophils 2.5 x 10 /L [1.0-4.0]
9
lymphocytes 14.1 x 10 /L [3.0-7.0]
eosinophils 1.1 x 109/L [<0.4]
platelet count 240 x 109/L [150-400]
chest X-ray hyperinflation of both lungs, no added shadowing
lung function tests within normal limits

Which of the following is the most likely explanation of his symptoms?

A. Chlamydia pneumoniae infection.

B. Chronic sinusitis.

C. Mycoplasma pneumoniae infection.

D. Pertussis.

E. Poor control of asthma.

QUESTION 90
A previously healthy six-month-old boy presents with a two-week history of worsening vomiting. He
was born at term and his birth weight was 3400 g. He was fully breastfed until five months of age,
when weaning solids were introduced, starting with rice cereal and apple. On examination, his liver is
palpable 4 cm below the costal margin.

The most likely diagnosis is:

A. food protein allergy.

B. galactosaemia.

C. hereditary fructose intolerance.

D. methylmalonic acidaemia.

E. pyloric stenosis.

Copyright © 2005 by The Royal Australasian College of Physicians


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QUESTION 91

A three-year-old boy presents with a 10-day history of cough and fever unresponsive to oral
antibiotics. His chest X-ray is shown above.

Which of the following best explains the appearance shown on the X-ray?

A. Left-sided consolidation and pleural effusion.

B. Left-sided pulmonary abscess.

C. Obstruction of right main bronchus.

D. Right-sided pneumothorax.

E. Unilateral left-sided pulmonary oedema.

Copyright © 2005 by The Royal Australasian College of Physicians


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QUESTION 92

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.

QUESTION 93
A child presents with a sore throat. Which of the following clinical features is least likely in Group A
streptococcal tonsillitis?

A. Age 10 years.

B. Cough.

C. Exudate.

D. Fever >39°C.

E. Tender enlarged cervical lymph nodes.

Copyright © 2005 by The Royal Australasian College of Physicians


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QUESTION 94

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.

Copyright © 2005 by The Royal Australasian College of Physicians


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QUESTION 95
A four-week-old girl presents with prolonged neonatal jaundice and poor weight gain. On examination,
a small and firm liver is found and the spleen is palpable 2 cm below the left costal margin. She also
has a harsh 3/6 systolic murmur radiating widely.

The following liver function tests were obtained:

total bilirubin 85 µmol/L [0-15]


conjugated bilirubin 65 µmol/L [0-5]
alanine aminotransferase (ALT) 45 U/L [<55]
alkaline phosphatase (ALP) 455 U/L [100-350]
gamma glutamyltransferase (GGT) 256 U/L [0-225]
albumin 31 g/L [29-45]
total protein 68 g/L [50-71]

A liver biopsy will most likely reveal which one of the following histological features?

A. Bile duct hypoplasia.

B. Bridging necrosis.

C. Inclusion bodies.

D. Lymphocellular infiltrate.

E. Milk glass hepatocytes.

QUESTION 96
The dose of methylphenidate for effective treatment of children with combined-type attention
deficit/hyperactivity disorder (with both attention deficit and hyperactivity) is best determined by ratings
of symptoms from the:

A. child.

B. parents.

C. peers.

D. physician.

E. teacher.

Copyright © 2005 by The Royal Australasian College of Physicians


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QUESTION 97
A five-month-old boy presents with chronic diarrhoea, failure to thrive and recent onset cough
associated with feeding intolerance. Blood test results show:

haemoglobin 98 g/L [110-150]


white cell count 14 x 109/L [4-11]
differential:
neutrophils 11 x 109/L [1-7]
lymphocytes 3 x 109/L [1-4]
platelet count 90 x 109/L [150-400]
IgG 9.0 g/L [3.3-6.4]
IgA 0.67 g/L [0.30-0.70]
IgM 1.90 g/L [0.25-0.60]

A chest X-ray was taken and is shown below.

Which one of the following is the most likely cause of this clinical presentation?

A. Human immunodeficiency virus (HIV) infection.

B. Hyper IgM syndrome.

C. Severe combined immunodeficiency.

D. Wiskott-Aldrich syndrome.

E. X-linked agammaglobulinaemia.

Copyright © 2005 by The Royal Australasian College of Physicians


57 P204

QUESTION 98
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 99
It is considered inappropriate to perform predictive genetic testing on young children for Huntington
disease, an adult-onset neurodegenerative disorder. Which of the following is the most important
reason for this?

A. Positive status for a Huntington disease mutation would block the child’s future access to life,
mortgage and income protection insurance.

B. Such testing is a violation of the child’s autonomy, in that they lose the freedom to choose
whether to have the test later in life.

C. The main reason for testing adults for Huntington disease is to allow mutation carriers the
option of prenatal diagnosis, an issue which is irrelevant in childhood.

D. There is no currently available treatment for Huntington disease.

E. The testing process would place excessive psychological stress on a child, as children lack
the emotional maturity to cope with such testing.

Copyright © 2005 by The Royal Australasian College of Physicians


58 P204

QUESTION 100
A multigravida is induced by artificial rupture of the membranes and syntocinon infusion at 41 weeks
gestation. After 16 hours of labour she is noted to be fully dilated. Ninety minutes later, after four
unsuccessful attempts at delivery by vacuum extraction, she is taken to the operating theatre for an
emergency Caesarean section. At delivery a 3800 g male infant is in poor condition requiring full
resuscitation. He is transferred, intubated and ventilated, to an intensive care unit. At 12 hours of age
he deteriorates with pallor and poor perfusion. His haemoglobin is 95 g/L and mean arterial blood
pressure is 30 mmHg. Extensive bruising is noted over his head. His head circumference is 38 cm.
His pupils are unable to be examined due to marked oedema of his upper eyelids.

The most likely cause for his deterioration is blood loss due to:

A. cephalohaematoma.

B. intracerebral haemorrhage.

C. intraventricular haemorrhage.

D. subaponeurotic haemorrhage.

E. subdural haemorrhage.

Copyright © 2005 by The Royal Australasian College of Physicians


59 P204

2004 FRACP Written Examination

Paediatrics & Child Health

Paper 2 – Clinical Applications

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

Copyright © 2005 by The Royal Australasian College of Physicians

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