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2005 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 Examinations Section, Education Department 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 © 2006 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 © 2006 by The Royal Australasian College of Physicians


2 P205

QUESTION 1
An eight-year-old boy presents with moderately severe cellulitis involving the left shin. The most
appropriate empiric antibiotic treatment would be:

A. benzylpenicillin plus flucloxacillin.

B. benzylpenicillin plus gentamicin.

C. cefotaxime.

D. flucloxacillin.

E. vancomycin.

QUESTION 2
An eight-year-old boy with attention deficit hyperactivity disorder (ADHD) and oppositional-defiant
disorder is being treated with stimulant medication, with benefits reported at both school and home.
What further functional improvement might be expected from adding intensive clinic-based
behavioural intervention to his stimulant medication therapy?

A. Improved compliance in the classroom.

B. Reduced hyperactivity.

C. Reduced impulsivity.

D. Reduced inattention.

E. Reduced oppositional/aggressive behaviour.

QUESTION 3

In the Salter-Harris classification of epiphyseal injuries in children (shown above), which type is most
likely to require urgent operative reduction?

A. Type I.

B. Type II.

C. Type III.

D. Type IV.

E. Type V.
Copyright © 2006 by The Royal Australasian College of Physicians
3 P205

QUESTION 4

Copyright © 2006 by The Royal Australasian College of Physicians


4 P205

QUESTION 4 (continued)
A healthy three-year-old girl presents with a squint. On examination, visual acuity is diminished in the
left eye. The magnetic resonance imaging (MRI) scan of her head is shown opposite. Which one of
the following inherited conditions is she most likely to have?

A. Familial retinoblastoma.

B. Neurofibromatosis type 1.

C. Sturge-Weber syndrome.

D. Tuberous sclerosis.

E. Von Hippel-Lindau disease.

QUESTION 5
A 14-year-old girl presents to the emergency department with a four-day history of headache and
blurring of vision. She has previously been well. She is on no medication.

On examination she is very confused and disorientated. Her blood pressure is 230/140 mmHg. Her
jugular venous pressure (JVP) is not elevated, heart sounds are normal and lung bases clear. Her
reflexes are generally brisk. Fundoscopy shows bilateral haemorrhages, exudates and papilloedema.

Which of the following is the most appropriate treatment?

A. Intramuscular hydralazine.

B. Intravenous frusemide.

C. Intravenous sodium nitroprusside.

D. Oral enalapril.

E. Oral nifedipine.

QUESTION 6
A seven-year-old girl is referred with a history of increasing daytime wetting, characterised by loss of
urine control when laughing and particularly when being tickled. Her classmates are causing
embarrassment by tickling her in the playground.

Her past history suggests no neurodevelopmental problems. She had a single urinary tract infection
at 18 months of age, followed by a normal renal ultrasound. Physical examination is normal.

Which of the following is the most appropriate therapy?

A. Behavioural therapy.

B. Imipramine.

C. Oxybutynin.

D. Pelvic floor exercises.

E. Vasopressin spray.

Copyright © 2006 by The Royal Australasian College of Physicians


5 P205

QUESTION 7
A six-year-old boy presents with a five-week history of polyuria and polydipsia. There is no family
history of autoimmune disease. He has otherwise been well and has not lost weight.

Investigations are as follows:

blood glucose 4.3 mmol/L [3.6 – 5. 4]


electrolytes normal

urinalysis negative glucose, negative ketones, negative protein


Specific Gravity 1.001 [1.002 – 1.035]

Which of the following tests would confirm the diagnosis?

A. Antibodies for type 1 (insulin-dependent) diabetes mellitus.

B. Magnetic resonance imaging (MRI) of brain.

C. Oral glucose tolerance test.

D. Renal ultrasound.

E. Water deprivation test.

QUESTION 8
An otherwise normal two-year-old girl requires surgical repair of a large secundum atrial defect. There
is no other family history of congenital heart disease. Her parents are concerned about the risk that
their next child will also have congenital heart disease. This risk is closest to:

A. 0.5%.

B. 2.5%.

C. 6%.

D. 12.5%.

E. 25%.

QUESTION 9
A mother notices low-grade rectal bleeding in her breast-fed daughter. The
three-week-old infant passes four to five semi-formed stools per day with visible streaks of blood and
some mucus. The infant is well and thriving.

What is the most likely diagnosis?

A Anal fissure.

B. Bacterial gastroenteritis.

C. Food protein proctocolitis.

D. Juvenile polyp.

E. Swallowed maternal blood.

Copyright © 2006 by The Royal Australasian College of Physicians


6 P205

QUESTION 10
A 28-week gestation infant, intubated since birth for moderate respiratory distress syndrome, has been
steadily improving and is now 48 hours old. The level of ventilatory support has been progressively
weaned and is currently as follows:

Mode: Synchronised intermittent positive pressure ventilation (SIPPV) (assist control)


fractional inspired oxygen concentration 0.24
peak inspiratory pressure (PIP) 20 cm H2O
positive end-expiratory pressure (PEEP) 6 cm H2O
ventilator rate 30/minute
inspiratory time 0.35 seconds

The most recent arterial blood gas is as follows:

pH 7.43 mmHg [7.34-7.43]


PaCO2 31 mmHg [31-42]
PaO2 68 mmHg [45-60]
bicarbonate 20 mmol/L [20-26]
base excess -1.6 [-5.0-5.0]

What would be the most appropriate next step?

A. Extubate to nasal continuous positive airways pressure (CPAP).

B. Make no ventilator changes.

C. Reduce inspiratory time to 0.3 seconds.

D. Reduce PIP by 2 cm H2O.

E. Wean rate to 20/minute.

QUESTION 11
A 16-year-old girl is referred for evaluation of daytime tiredness. She is reported to go to bed at 1.00
a.m. and to have difficulty rising in the morning for school. At weekends she sleeps until early
afternoon. No medical or psychiatric symptoms are detectable.

In addition to gradually advancing her bedtime to an earlier time, bright light therapy is recommended.
This is most effective if undertaken at which of the following time periods?

A. Early morning.

B. Late morning.

C. Mid afternoon.

D. Evening.

E. Prior to retiring.

Copyright © 2006 by The Royal Australasian College of Physicians


7 P205

QUESTION 12

Copyright © 2006 by The Royal Australasian College of Physicians


8 P205

QUESTION 12 (continued)
A nine-year-old girl with cystic fibrosis presents to clinic with a cough productive of brown sputum. Her
chest X-ray is shown opposite.

The most likely diagnosis is:

A. allergic bronchopulmonary aspergillosis.

B. atypical mycobacterium infection.

C. Burkholderia cepacia infection.

D. Staphylococcus aureus infection.

E. Stenotrophomonas maltophilia infection.

QUESTION 13
An eight-year-old girl presents with ketoacidosis and is diagnosed with type 1 (insulin-dependent)
diabetes mellitus.

Which of the following autoimmune comorbidities is she most at risk of developing?

A. Addison disease.

B. Hypoparathyroidism.

C. Hypothyroidism.

D. Primary ovarian failure.

E. Vitiligo.

QUESTION 14
A three-year-old boy is brought to the emergency department of a small rural hospital 30 minutes after
being involved in an unwitnessed explosion at his family home. On examination he has sustained
facial burns with singeing of his eyebrows and eyelashes. He has a non-circumferential burn to the
anterior neck and his estimated percentage of body surface area (BSA) burnt is 5%. He is alert, pink
in air and in no respiratory distress. His parents feel that his voice is now ‘croaky’ and you notice a
hoarse cough.

Which of the following is the first priority in caring for this patient?

A. Commence intravenous fluids at maintenance.

B. Commence intravenous morphine infusion.

C. Prepare for endotracheal intubation.

D. Urgent ambulance transfer to a tertiary level paediatric hospital.

E. Urgent medical retrieval team to come to the patient.

Copyright © 2006 by The Royal Australasian College of Physicians


9 P205

QUESTION 15

A seven-year-old girl is brought into the emergency department with a generalised rash. Her arm is
shown above. This rash is most commonly found in association with:

A. administration of carbamazepine.

B. administration of cefaclor.

C. enterovirus infection.

D. herpes simplex virus (HSV) infection.

E. Mycoplasma pneumoniae infection.

QUESTION 16
A four-year-old boy presents with language impairment. His first words were at 18 months. He
exhibits anger when he is not understood. His preschool teacher reports that he has difficulty
following or understanding basic instructions, often responding inappropriately with talk about his
dinosaurs.

His conversation is difficult to follow, with confusing replies. E.g.:


Question: “What did you do at preschool?
Answer: “Time to get in car, and drive long way all way home”

He is heard with playmates responding unclearly. E.g.:


Statement: “I’m making a green snake with playdoh”
Reply: “Greg and Anthony go up the big red car on Wiggles TV”

His language problems are most likely due to:

A. dyspraxia.

B. hearing impairment.

C. intellectual impairment.

D. phonological delay.

E. semantic pragmatic disorder.

Copyright © 2006 by The Royal Australasian College of Physicians


10 P205

QUESTION 17
A male infant attends at six months of age following relief of neonatal bladder outlet obstruction. The
initial micturating cystourethrogram is shown below.

Which of the following findings is most suggestive of a poor long-term prognosis?

A. Nadir serum creatinine > 0.1 mmol/L.

B. Persistent bladder dilatation.

C. Persistent hydronephrosis.

D. Persistent ureteric reflux.

E. Poor urinary stream.

Copyright © 2006 by The Royal Australasian College of Physicians


11 P205

QUESTION 18
A previously well eight-year-old right-handed girl presents with progressive left-sided weakness and
slurred speech over a 24-hour period. Examination reveals facial and arm weakness. The child had a
viral illness with rash five weeks prior to the onset of the event. The computerised tomography (CT)
scan of her brain is shown below.

Which of the following viral exanthema have been associated with this clinical scenario?

A. Coxsackie.

B. Measles.

C. Parvovirus.

D. Rubella.

E. Varicella.

Copyright © 2006 by The Royal Australasian College of Physicians


12 P205

QUESTION 19
A term male infant with a birth weight of 2800 g is born at a level 2 rural hospital. He is noted to have
a large cleft palate and significant micrognathia. At two hours of age he is noted to be in severe
respiratory distress with marked subcostal and sternal recession. On auscultation, very poor breath
sounds are audible bilaterally. His condition is improved in the prone position, however he becomes
intermittently cyanosed and severe respiratory distress is punctuated by brief apnoeic episodes.

The most appropriate course of action would be:

A. administer head box oxygen.

B. administer oxygen via nasal prongs.

C. insert an endotracheal tube.

D. insert a nasopharyngeal tube.

E. insert an oral airway.

QUESTION 20
A three-year-old girl is admitted to hospital with a two-day history of purpuric rash on the buttocks.
Over the last day, she has also developed a painful, swollen left ankle.

On examination she has a temperature of 38°C, palpable purpura on her buttocks and calves, and a
warm, swollen left ankle. Her hands and feet are slightly swollen.

Admission investigations show:

haemoglobin 120 g/L [115-140]


white cell count 11.5 x 109/L [4.0-15.0]
platelets 410 x 109/L [150-450]
ESR 10 mm/hr [1-10]
C-reactive protein (CRP) 10 mg/L [< 3]
international normalized ratio (INR) 1.0 [0.8-1.2]
activated partial thromboplastin time (APTT) 30 seconds [25-38]
urinalysis normal

Over the next two days she develops intermittent, severe, colicky central abdominal pain. She has
non-bilious vomiting and passes blood per rectum. In between bouts of pain her abdomen is soft,
nondistended and generally tender with no guarding. There are no masses palpable.

The most appropriate next investigation is:

A. abdominal ultrasound.

B. air enema.

C. barium enema.

D. diagnostic laparoscopy.

E. stool culture.

Copyright © 2006 by The Royal Australasian College of Physicians


13 P205

QUESTION 21
A previously well seven-year-old Greek male presents with recent onset of pallor and dark urine. He is
on no medications. On examination he is afebrile and pale, with slight icterus and mild splenomegaly.
Full blood count reveals:

haemoglobin 82 g/L [120-155]


mean corpuscular volume (MCV) 98 fL [80-95]
white cell count 10.6 x109/L [3.5-9.5]
differential mild neutrophilia
platelet count 130 x109/L [150-400]
reticulocytes 5% [<2%]

His blood film is shown above. The most appropriate next investigation to confirm the diagnosis is:

A. direct antiglobulin test.

B. haemoglobin electrophoresis.

C. osmotic fragility test.

D. parvovirus B19 IgM.

E. serum haptoglobin.

Copyright © 2006 by The Royal Australasian College of Physicians


14 P205

QUESTION 22

A three-year-old girl presents with a two-month history of two lumps on the left side of her neck and
jaw as shown above. Which of the following is the most appropriate initial management?

A. Excision of the lesions.

B. Intravenous flucloxacillin.

C. Needle biopsy of one of the lesions.

D. Oral cephalexin.

E. Oral clarithromycin.

QUESTION 23
What is the most common sign of Fragile X syndrome in prepubertal boys?

A. High-arched palate.

B. Long face.

C. Macro-orchidism.

D. Motor tics.

E. Poor eye contact.

Copyright © 2006 by The Royal Australasian College of Physicians


15 P205

QUESTION 24

Copyright © 2006 by The Royal Australasian College of Physicians


16 P205

QUESTION 24 (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 25
A nine-year-old boy is brought in by his mother, with a story of increasingly difficult behaviour at home,
and especially at school. He is in grade three. He is disruptive, calls out, distracts other children, and
consistently fails to complete written work. He has been lashing out at peers and the teacher, and
spends most of his lunchbreaks in class to catch up on work. His mother reports that his behaviour in
preschool and grade one presented few problems.

He shows strengths in maths and science, but struggles with reading and written work. He is left
handed, and his handwriting is particularly messy. When made to repeat work, he becomes angry
and has occasionally abused his teacher.

At home, there are constant battles to get him to sit down in the evening to do his homework with his
sister. He constantly interrupts his sister, and intentionally destroys her work.

The most likely primary diagnosis is:

A. attention deficit disorder (without hyperactivity).

B. autism spectrum disorder.

C. intellectual impairment.

D. oppositional defiant disorder.

E. specific learning disorder.

Copyright © 2006 by The Royal Australasian College of Physicians


17 P205

QUESTION 26
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.

QUESTION 27
Middle ear effusion is an essential criterion for the diagnosis of both acute otitis media and otitis media
with effusion. Compared to myringotomy as the gold standard, which diagnostic technique is most
accurate (i.e. has the highest sensitivity and specificity)?

A. Acoustic reflectometry.

B. Audiometry.

C. Otoscopy.

D. Pneumatic otoscopy.

E. Tympanometry.
Copyright © 2006 by The Royal Australasian College of Physicians
18 P205

QUESTION 28
A 14-year-girl presents with her first generalised seizure at 6 a.m. On direct questioning she has a 12-
month history of limb jerks, usually in the mornings, that often result in her breakfast being spilt. Her
examination is entirely normal.

Her electroencephalogram (EEG) is shown below.

A diagnosis of juvenile myoclonic epilepsy is made.

Which of the following anticonvulsants should not be prescribed?

A. Carbamazepine.

B. Clobazam.

C. Clonazepam.

D. Lamotrigine.

E. Topiramate.

Copyright © 2006 by The Royal Australasian College of Physicians


19 P205

QUESTION 29
A four-week-old infant presents with persistent diarrhoea. On examination the infant displays swollen
upper eyelids and ascites. His investigations are shown below.

Faecal microscopy:
fat globules +++
fatty acid crystals negative
white blood cells negative

Full blood count:

haemoglobin 130 g/L [90-180]


white cell count 5.5 x 109/L [5.0-19.5]
neutrophils 5.0 x 109/L [1.0-9.0]
lymphocytes 0.4 x 109/L [2.5-9.0]

serum albumin 18 g/L [29-45]

Which of the following is the most likely diagnosis?

A. Alpha-1-antitrypsin deficiency.

B. Coeliac disease.

C. Cystic fibrosis.

D. Intestinal lymphangiectasia.

E. Nephrotic syndrome.

QUESTION 30
A 16-year-old girl is brought to the emergency department by her mother following the ingestion of an
unknown quantity of paracetamol. Four hours post-ingestion her paracetamol serum levels are non-
toxic. She is poorly communicative but states that she does not feel life is worth living anymore and
that she had hoped she would be able to ‘end it all’. Her mother states that the girl has attempted
suicide previously and that she is currently under the care of a private psychiatrist with whom she has
an appointment in one week. The mother feels the girl is overly histrionic and attention seeking. The
girl is attempting to leave the department.

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

A. Detain under the mental health act.

B. Discharge home in care of her mother.

C. Refer back to private psychiatrist as planned.

D. Refer on to community mental health team semi-urgently.

E. Urgent psychiatric review in the emergency department.

Copyright © 2006 by The Royal Australasian College of Physicians


20 P205

QUESTION 31

A five-year-old boy is seen in the emergency department with a red, swollen left eye as shown above.
He has a fever and is moderately unwell. He has mild proptosis and restriction of eye movements.
The most important investigation to perform is:

A. blood cultures.

B. computerised tomography (CT) scan of the left orbit.

C. conjunctival swab.

D. lumbar puncture.

E. sinus X-rays.

QUESTION 32
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 severe neutropenia.

D. Use of monoclonal antibodies.

E. Use of steroids.
Copyright © 2006 by The Royal Australasian College of Physicians
21 P205

QUESTION 33
An eight-year-old boy is referred to you with tiredness and short stature. He has a long history of thirst
and nocturia. There is no family history of note. On examination he is short compared with his five-
year-old sister. Apart from obvious pallor, there are no other abnormal physical features.

Investigations show the following:


mid-stream urine 50 leucocytes
20 red cells
trace protein
no bacterial growth
haemogloblin 74 g/L [115-155]
serum creatinine 0.20 mmol/L [0.03-0.07]

What is the most likely diagnosis?

A. Familial juvenile nephronophthisis.

B. Medullary cystic disease.

C. Polycystic kidney disease.

D. Reflux nephropathy.

E. Renal Fanconi syndrome.

QUESTION 34

A newborn baby of Pacific Islander descent is found to have indeterminate gender. Birth weight was
3200 g and the baby is healthy. The phallus is short and with chordee. A urethra is visible at the base
of the phallic structure. There is a mass in each inguinal canal the size of a testis. The genitalia are
shown above.

The most likely diagnosis is:

A. female with congenital adrenal hyperplasia.

B. male with congenital adrenal hyperplasia.

C. true hermaphrodite.

D. Turner syndrome.

E. undervirilised male.
Copyright © 2006 by The Royal Australasian College of Physicians
22 P205

QUESTION 35
In a family in which two boys are affected by an X-linked disorder, a causative point mutation is
identified. On blood testing, the mutation is found in both boys but not demonstrated in the mother.
The most likely explanation for this finding is:

A. laboratory error.

B. maternal gonadal mosaicism for the mutation.

C. non-maternity.

D. recurrent new mutation.

E. skewing of X-inactivation in the mother’s blood.

QUESTION 36
An eight-year-old boy presents with a low-grade fever, irritability and unsteadiness. On further
questioning there is a seven-week history of double vision and ataxia.

Cranial nerve examination shows a left abducens nerve palsy and mild right facial weakness. He has
very brisk reflexes but no other pertinent findings. The computerised tomography (CT) scan of his
brain is shown below.

The CT is most consistent with:

A. brain abscess.

B. cerebellitis.

C. disseminated encephalomyelitis.

D. glioma.

E. stroke.
Copyright © 2006 by The Royal Australasian College of Physicians
23 P205

QUESTION 37
A three-week-old male infant is brought to the emergency department with a left sided groin lump
noticed by his parents during a nappy change today. On examination the baby is afebrile, thriving and
in no distress, and has an easily reducible left sided inguinal hernia.

Which of the following is the most appropriate next step in patient care?

A. Elective surgical repair after 12 months of age.

B. Elective surgical repair after two years of age.

C. Reassure parents of likely spontaneous resolution prior to 12 months of age.

D. Semi-urgent operative repair in a week.

E. Urgent operative repair.

QUESTION 38

A 14-year-old girl is admitted following an episode of loss of consciousness at school. She has a two-
day history of fever. The day after admission she requires fluid resuscitation and admission to the
intensive care unit after an episode of cardiovascular collapse on the ward. Her electrocardiogram
(ECG) is shown above. What is the most likely diagnosis?

A. Acute anterior myocardial infarction.

B. Cardiomyopathy.

C. Hyperkalaemia.

D. Hypokalaemia.

E. Pericarditis.

Copyright © 2006 by The Royal Australasian College of Physicians


24 P205

QUESTION 39
A four-year-old boy, who started talking at around 18 months, has speech that is difficult for strangers
to understand. His family can understand him around 80% of the time. He seems to follow
instructions well, but consistently leaves sounds out of his words. He shows frustration when other
children make fun of his speech.

When tested, he can produce all consonant sounds by themselves, but when he looks at a picture
book he makes the following errors:
Car > dar
Book > boo
Sun > dun
Hat > ha
Fishing > bittin
Five > bye

The most likely cause of his speech disorder is:

A. dysarthria.

B. dysphonia.

C. hearing impairment.

D. intellectual impairment.

E. phonological delay.

QUESTION 40
A previously well 10-month-old infant is admitted to hospital with a four-day history of increasing
cough, fever and rapid breathing. Chest X-ray shows a right upper lobe pneumonia and he is started
on intravenous antibiotics. Blood cultures grow Streptococcus pneumoniae. By day two his fever has
settled, but on day five he is noted to be rather pale and lethargic.

Blood tests show the following:

haemogloblin 75 g/L [105-135]


white cell count 6.2 x 109/L [6.0-15.0]
platelet count 50 x 109/L [150-400]
serum creatinine 0.23 mmol/L [0.02-0.06]

What is the most likely diagnosis?

A. Acute lymphoblastic leukaemia.

B. Aplastic crisis.

C. Autoimmune haemolytic anaemia.

D. Drug-induced haemolysis.

E. Haemolytic-uraemic syndrome.

Copyright © 2006 by The Royal Australasian College of Physicians


25 P205

QUESTION 41
A 36-week gestation infant is born to a primigravid woman who had been well throughout her
pregnancy. At delivery, her male infant is unexpectedly found to have microcephaly,
hepatosplenomegaly and a purpuric rash. A magnetic resonance imaging (MRI) brain scan is
performed on day three and the axial T1- and T2-weighted images are displayed below.

What is the most likely diagnosis?

A. Cytomegalovirus (CMV).

B. Herpes simplex virus (HSV).

C. Rubella.

D. Syphilis.

E. Toxoplasmosis.

QUESTION 42
A six-month-old child presents with high fever and poor feeding. Which of the following findings in the
child would be the most valid reason for not performing a lumbar puncture?

A. Bulging fontanelle.

B. Glasgow coma score of 12.

C. Inability to abduct the right eye.

D. Marked irritability.

E. Petechial rash.

Copyright © 2006 by The Royal Australasian College of Physicians


26 P205

QUESTION 43
A six-week-old girl is referred to hospital for assessment of stridor, first noted a week previously. She
was born at term by normal vaginal delivery and weighed 2400 g. She required no resuscitation and
is bottle-fed and thriving.

On examination she is afebrile, alert and has a normal cry. There are no dysmorphic features.
Biphasic stridor is heard in all positions, with a mild increase in respiratory work. Her facial
appearance is shown below.

What is the most likely diagnosis?

A. Bilateral vocal cord paralysis.

B. Bronchomalacia.

C. Laryngomalacia.

D. Subglottic haemangioma.

E. Vascular ring.

QUESTION 44
A seven-year-old girl has a six-week history of urticaria occurring most days. She is otherwise well.
She had an allergy to eggs when an infant. There is a family history of asthma and a maternal aunt
has lupus erythematosus. Antinuclear antibody testing was positive with a titre of 1 in 80, with a
speckled pattern.

The most likely cause of her urticaria is:

A. autoimmune connective tissue disease.

B. autoimmune thyroid disease.

C. IgE-mediated food allergy.

D. recent viral infection.

E. sensitivity to food chemicals and preservatives.

Copyright © 2006 by The Royal Australasian College of Physicians


27 P205

QUESTION 45
A 14-year-old girl presents with jaundice, arthralgia and pruritus over the past week. She has recently
returned from a trip to South-East Asia.

Her liver function and serology results are shown below:

bilirubin 175 µmol/L [0-15]


alanine aminotransferase (ALT) 1350 U/L [<55]
alkaline phosphatase (ALP) 687 U/L [100-350]
gamma glutamyltransferase (GGT) 425 U/L [0-40]
total protein 70 U/L [57-80]
albumin 24 g/L [33-47]

Epstein-Barr Virus (EBV)-IgG positive


Epstein-Barr Virus (EBV)-IgM negative
hepatitis A virus (HAV)-IgM negative
hepatitis B surface antigen (HBsAg) negative
anti-hepatitis B core antibody (anti-HBc) positive
anti-hepatitis C virus antibody (anti-HCV) negative
antinuclear antibody (ANA) negative
smooth muscle antibody positive

What is the most likely diagnosis?

A. Acute hepatitis A.

B. Acute hepatitis B.

C. Autoimmune hepatitis.

D. Epstein-Barr virus hepatitis.

E. Systemic lupus erythematosus.

QUESTION 46
An eight-week-old girl presents for investigation of jaundice. She was born at term, and her birth
weight was 3800 g. She is breast-fed, thriving and appears generally well and alert. Examination of
the heart is normal. Her mother describes the infant’s stools as mustard-coloured to three weeks of
age, but becoming very pale over time. The gallbladder is not seen on two fasting abdominal
ultrasounds, but normal intrahepatic ducts are seen.

Which of the following is the most likely diagnosis?

A. Alagille syndrome.

B. Alpha-1-antitrypsin deficiency.

C. Biliary atresia.

D. Choledochal cyst.

E. Gallstones.

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QUESTION 47

A five-year-old child has the karyotype shown in the figure. 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 48
A 13-year-old boy is on the verge of expulsion from school. He is disruptive in class, often makes
provocative, sometimes sexual comments to teachers and swears repeatedly. Recently a teacher
found numerous drawings of naked women in his school journal. He has been suspended on several
occasions following retaliatory aggression towards other pupils. He repeated third grade after tests
showed he had an IQ of 85 with significant language delay. At home he is uncooperative, defiant and
often angry. He rarely settles to any activity and never completes his homework. His parents
separated when he was an infant following domestic violence and parental substance abuse. He only
occasionally sees his father with whom he has a troubled relationship. His medical history includes a
fractured foot and arm in separate childhood accidents but no history of head trauma.

Which of the following medications is most likely to be helpful?

A. Fluoxetine.

B. Haloperidol.

C. Methylphenidate.

D. Risperidone.

E. Sodium valproate.

Copyright © 2006 by The Royal Australasian College of Physicians


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QUESTION 49

A four-year-old boy is reviewed in clinic because of a flare-up of his atopic eczema. He has not
responded to his usual emollients and topical steroids.

On examination his temperature is 37°C. He is irritable, and has extensive whole-body eczema with
excoriation and crusting. The lesions around his mouth are shown above.

The most appropriate treatment is:

A. aciclovir.

B. flucloxacillin.

C. more potent topical steroid.

D. mupirocin ointment.

E. pimecrolimus cream.

QUESTION 50
A four-year-old boy with a hereditary anaemia presents with progressive pallor and lethargy of one-
week duration. On physical examination he is normotensive but tachycardic and has moderate
splenomegaly but no clinical jaundice. The following blood tests are performed:

haemoglobin 41 g/L [115-155]


white cell count 12.1 x109/L [4.5-14.5]; normal differential
platelets 175 x109/L [150-400]
reticulocytes 1% [<2%]

Which one of the following viruses is most likely to be responsible for the boy’s clinical presentation?

A. Cytomegalovirus (CMV).

B. Epstein-Barr virus (EBV).

C. Hepatitis B virus (HBV).

D. Human immunodeficiency virus (HIV).

E. Parvovirus B19.

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QUESTION 51
A six-year-old Sudanese male presents to emergency appearing toxic with a temperature of 39.4oC.
He has a three-day history of fevers and a 24-hour history of left elbow pain and swelling. Blood tests
at this time are as follows:

haemoglobin 70 g/L [115-155]


white cell count 18.9 x 109/L [4.5-14.5]
absolute neutrophil count 10500 [1500-8000]
platelets 530 x 109/L [150-400]
reticulocytes 15.5% [<2%]
C-reactive protein (CRP) 90 mg/L [0-10]

A photomicrograph of the blood film is shown above. Which of the following organisms is most likely
to cause this clinical presentation?

A. Escherichia coli.

B. Haemophilus influenzae.

C. Salmonella enteritidis.

D. Staphylococcus epidermidis.

E. Yersinia enterocolitica.

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QUESTION 52

Copyright © 2006 by The Royal Australasian College of Physicians


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QUESTION 52 (continued)

A 12-year-old girl has striae over her abdomen and breasts. Her blood pressure is 130/90 mmHg.
She has Tanner stage 2 breasts and pubic hair. Her growth charts are shown above and opposite.

Which of the following is the most likely diagnosis?

A. Autoimmune hypothyroidism.

B. Cushing syndrome.

C. Polycystic ovarian syndrome.

D. Prader-Willi syndrome.

E. Simple obesity.

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QUESTION 53
A 10-year-old boy presents with fever, right-sided earache and a swelling behind his right ear (as
shown below). He has a purulent discharge from his right external meatus and the tympanic
membrane cannot be visualised. He has been on oral amoxycillin for one week without improvement.

Which of the following is the most likely diagnosis?

A. Acute mastoiditis.

B. Acute otitis externa.

C. Cholesteatoma.

D. Periauricular cellulitis.

E. Postauricular lymphadenitis.

QUESTION 54
An infant is born at term by normal vaginal delivery. A cloudy cornea of the right eye only is noted at
initial examination. The most likely diagnosis is:

A. Chlamydia trachomatis infection.

B. congenital glaucoma.

C. herpes simplex virus (HSV) infection.

D. mucopolysaccharidosis.

E. retinoblastoma.

Copyright © 2006 by The Royal Australasian College of Physicians


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QUESTION 55

A 20-month-old girl presents with delayed development. Her gross motor skills are moderately
delayed and her speech and fine motor skills are mildly delayed. On examination she has
macrocephaly, mild hepatosplenomegaly, a lumbar gibbus, mild generalised camptodactyly and her
facial appearance is as shown above. The most likely diagnosis is:

A. Beckwith-Wiedemann syndrome.

B. Down syndrome.

C. Gaucher disease, type II (neuronopathic type).

D. Mucopolysaccharidosis type I (Hurler syndrome).

E. Sialidosis.

QUESTION 56
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.

Copyright © 2006 by The Royal Australasian College of Physicians


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QUESTION 57

Copyright © 2006 by The Royal Australasian College of Physicians


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QUESTION 57 (continued)
A five-year-old boy presents with blisters on his palms and soles (shown opposite) and ulcers in his
mouth. This rash is most likely to be caused by which of the following viruses?

A. Coxsackie A16.

B. Epstein-Barr (EBV).

C. Herpes simplex virus (HSV) type 1.

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

E. Parvovirus B19.

QUESTION 58
A nine-month-old girl is referred by her general practitioner because of recurrent events occurring on a
daily basis over the last two weeks. The episodes are stereotyped and consist of her stopping what
she is doing, flexing at her trunk, and pressing her hands above her inguinal region. There is
associated tremulousness and jaw rigidity. The events last one to two minutes with her becoming red
in the face and grunting. She seems to be preoccupied and gets distressed if touched or moved.
After the event, the child goes to sleep. The events never occur in sleep.

The most likely diagnosis is:

A. dystonia.

B. frontal lobe seizures.

C. gastroesophageal reflux.

D. infantile masturbation.

E. urinary infection.

QUESTION 59
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 © 2006 by The Royal Australasian College of Physicians


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QUESTION 60

An 11-year-old girl has undergone a T-cell depleted unrelated bone marrow transplant for relapsed
acute lymphoblastic leukaemia. Recovery is complicated by slow neutrophil engraftment, grade 3
acute graft-versus-host disease requiring high dose methylprednisolone, and persistent fevers. The
computerised tomography (CT) scan of her chest, performed at day +50 post-transplantation, is shown
above.

Which one of the following pathogens is most likely to be responsible for the CT scan findings?

A. Aspergillus fumigatus.

B. Candida albicans.

C. Klebsiella pneumoniae.

D. Scedosporium prolificans.

E. Staphylococcus aureus.

Copyright © 2006 by The Royal Australasian College of Physicians


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QUESTION 61
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:

blood 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 62

A seven-year-old unimmunised girl presents with a day-long history of being unwell, complaining of
pain on the left side of her neck, and difficulty moving her head which she holds stiffly. She has noisy
breathing on inspiration. Her temperature is 38oC. She has some mild diffuse neck swelling. Her
neck muscles are tight and she can only just open her mouth. Her X-ray is shown above. The most
likely diagnosis is:

A. bacterial tracheitis.

B. cervical lymphadenitis.

C. epiglottitis.

D. paratonsillar abscess.

E. retropharyngeal abscess.
Copyright © 2006 by The Royal Australasian College of Physicians
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QUESTION 63
A 4800 g female infant is delivered by emergency caesarean section following an obstructed labour.
Her mother’s pregnancy had been uncomplicated. The infant is in an excellent condition at delivery.
A true blood glucose performed at 10 minutes of age is 1.5 mmol/L [<2.5]. In the management of the
infant’s hypoglycaemia, the most appropriate next step is:

A. administer 10% dextrose intravenously at 12.0 mL/hr.

B. administer 10% dextrose intravenously at 20.0 mL/hr.

C. administer intramuscular glucagon.

D. commence feeds at 36 mL per feed three hourly.

E. insert a nasogastric tube and commence 5% dextrose at 12 mL/hr.

QUESTION 64
A 13-month-old boy presents to the emergency department with a one-week history of intermittent
vomiting and increasing lethargy. Over the preceding day his parents feel he has had increasing
respiratory difficulty. His examination reveals deep sighing respiration with severe dehydration. He is
afebrile with acute otitis media. The initial blood chemistry is demonstrated.

sodium 133 mmol/L [133-143]


potassium 4.8 mmol/L [3.8-6.0]
chloride 101 mmol/L [95-110]
bicarbonate 5.0 mmol/L [18-24]
anion gap 31.8 [< 18.0]
glucose 29.5 mmol/L [3.5-5.5]
pH 7.09 [7.36-7.44]
pCO2 22 mmHg [35-45]
base excess -23 mmol/L [0-2]

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

A. Intravenous insulin infusion.

B. Intravenous fluids – 5% dextrose.

C. Intravenous fluids – 0.9% saline.

D. Intravenous fluids – 0.45% saline + 2.5% dextrose.

E. Subcutaneous insulin injection.

Copyright © 2006 by The Royal Australasian College of Physicians


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QUESTION 65
A normal but shy 12-year-old girl with overly protective parents presents with recurrent abdominal
pain. She has missed school for the last four months. She is occasionally constipated. Clinical
examination is unremarkable. Baseline investigations, including abdominal X-ray, abdominal
ultrasound and urinary examination, are also normal. The clinical treatment or factor most likely to
influence the duration of her symptoms is:

A. parental insight and encouragement of independence.

B. prescription of fluoxetine.

C. prescription of lactulose.

D. prescription of pizotifen.

E. self management / pain distraction strategies.

QUESTION 66
A two-and-a-half-year-old boy is referred with concerns regarding aggressive behaviour. He often
appears “blank” when spoken to, and is non-compliant with instructions. He has 10 to 20 single
words, and a couple of two-word combinations. There were a few words he used some months ago
that he is no longer saying. He likes being with other children but does not play cooperatively,
frequently fighting over toys. He is good at puzzles, can work the DVD player at home, and
particularly likes trains.

He is active and difficult to engage. He does not carry out your instruction to “give the book to
mummy”. He points to two of four named body parts. When given a crayon and invited to copy a
circle he scribbles on the paper. He plays with the train set in your office and seems to quickly make
up an elaborate game, chatting incomprehensibly to himself. Physical examination and audiology
assessment are normal.

What is the most likely primary diagnosis?

A. Acquired epileptic aphasia.

B. Attention deficit hyperactivity disorder (ADHD).

C. Autistic spectrum disorder.

D. Intellectual disability.

E. Specific language impairment.

QUESTION 67
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 © 2006 by The Royal Australasian College of Physicians
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QUESTION 68
A three-year-old girl was diagnosed with nephrotic syndrome three months ago. She was initially
responsive to steroids but quickly relapsed when steroids were discontinued. She has now been on
daily prednis(ol)one (2 mg/kg) for 30 days without a significant improvement in her proteinuria. Her
renal function and blood pressure remain normal. Her renal biopsy is consistent with minimal-change
disease.

Which of the following is the most appropriate next treatment?

A. Azathioprine.

B. Chlorambucil.

C. Cyclophosphamide.

D. Levamisole.

E. Vincristine.

QUESTION 69

You review a three-day-old term female infant for a rash. The mother had a first trimester
spontaneous abortion three years ago. The mother has been generally well, but she has had a de-
pigmented skin lesion over her calf throughout her life, and has poor dentition. The baby’s rash is
shown above.

The most likely diagnosis is:

A. epidermolysis bullosa.

B. herpes simplex virus (HSV) infection.

C. ichthyosis.

D. incontinentia pigmenti.

E. zinc deficiency.

Copyright © 2006 by The Royal Australasian College of Physicians


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QUESTION 70

An adolescent presents with dyspnoea. His chest X-ray is shown above.

Which of the following is the most likely diagnosis?

A. Bilateral pleural effusions.

B. Bilateral lobar consolidation.

C. Bronchopneumonia.

D. Pulmonary oedema.

E. Viral pneumonitis.

Copyright © 2006 by The Royal Australasian College of Physicians


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QUESTION 71
A six-year-old boy presents with a six-month history of swallowing problems and speech change. His
mother says that his speech is less clear and that fluids occasionally come out of his nose when he is
drinking.

A photograph of his mouth is shown below.

What is the most likely diagnosis?

A. Anterior horn cell disorder.

B. Arnold-Chiari malformation.

C. Cervical cord tumour.

D. Myasthenia gravis.

E. Myotonic dystrophy.

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QUESTION 72
A 10-week-old baby boy has been failing to thrive since birth. His birth weight was 3300 g. He now
weighs 3400 g. He is breastfed and is reported to feed well.

Investigations are as follows:

plasma sodium 122 mmol/L [134 – 143]


plasma potassium 6.8 mmol/L [3.4 – 5.0]
urea 6.9 mmol/L [< 6.0]
creatinine 0.060 mmol/L [< 0.062]
17-hydroxyprogesterone 1.7 mmol/L [< 5.2]

Which of the following is the most likely diagnosis?

A. Adrenal hypoplasia.

B. Congenital adrenal hyperplasia.

C. Inappropriate antidiuretic hormone (ADH) secretion.

D. Posterior urethral valves.

E. Urinary tract infection.

QUESTION 73
A 13-year-old girl presents with a fractured ankle requiring surgical fixation.

Full blood examination shows:

haemoglobin 105 g/L [120-160]


red cell count 5.6 x 1012/L [4.0-5.7]
mean cell volume 62 fL [80-97]
white cell count 12.5 x 109/L [4.0-11.0]
platelet count 390 x 109/L [150-400]

Haemoglobin (Hb) studies:

HbA2 5.2% [1.8-3.5]


HbF 1.2% [0-2.0]
HbH preparation no HbH bodies seen
Hb electrophoresis no abnormal Hb bands seen

The most likely explanation for her anaemia is:

A. α-thalassaemia trait.

B. β-thalassaemia trait.

C. congenital sideroblastosis.

D. iron-deficiency anaemia.

E. sickle cell trait.

Copyright © 2006 by The Royal Australasian College of Physicians


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QUESTION 74

Copyright © 2006 by The Royal Australasian College of Physicians


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QUESTION 74 (continued)
A nine-month-old girl presents to the emergency department with clusters of brief jerking movements
which are increasing. She has eight to ten pale patches over her trunk and limbs but is otherwise
thriving and developmentally normal. A magnetic resonance imaging (MRI) scan of her brain is shown
opposite.

What is the most likely diagnosis?

A. Hypomelanosis of Ito.

B. Incontinentia pigmenti.

C. Neurofibromatosis.

D. Sturge-Weber syndrome.

E. Tuberous sclerosis.

QUESTION 75
A five-year-old girl presents with a history of regression of language and motor skills. Examination
shows deficits in cognition, language, and motor development. She has bilateral lower limb hypertonia
with mild distal weakness, absent deep tendon reflexes and extensor plantar responses. She is very
ataxic when walking.

Magnetic resonance imaging (MRI) of her brain is shown below.

Which of the following is the most likely diagnosis?

A. Adrenoleukodystrophy.

B. Krabbe disease.

C. Leigh disease.

D. Metachromatic leukodystrophy.

E. Tuberous sclerosis.

Copyright © 2006 by The Royal Australasian College of Physicians


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QUESTION 76

A three-year-old boy presents with episodes of loss of consciousness related to exercise and also
minor trauma. During the episodes he becomes pale, his eyes may roll upwards and he has had
urinary and faecal incontinence. His electrocardiogram (ECG) is shown above. What is the most
likely diagnosis?

A. Aortic stenosis.

B. Breath holding episodes.

C. Long Q -T syndrome.

D. Primary pulmonary hypertension.

E. Seizure disorder.

QUESTION 77
A male infant is found to have supravalvular aortic stenosis. What is the best way of confirming
whether he has Williams syndrome?

A. Detailed clinical examination.

B. FISH for microdeletion on 7p.

C. Karyotype.

D. Measurement of plasma calcium.

E. TBX1 mutation analysis.

Copyright © 2006 by The Royal Australasian College of Physicians


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QUESTION 78
A six-month-old boy is taken by ambulance to the emergency department after an episode of collapse
and unresponsiveness at home. He presents with profuse vomiting and watery diarrhoea which
contains a small amount of blood. On arrival in hospital his heart rate is 160/minute, and his blood
pressure 60/30 mmHg. He is afebrile, his breathing is normal, and he has no rashes. He is
resuscitated with intravenous fluids. He was exclusively breast-fed until two months and was then
changed to a cow’s milk formula. He commenced a range of weaning solids from five months of age,
and had tried chicken meat for the first time one hour before his collapse. His arterial blood gas
analysis is shown below.

pH 7.1 [7.34-7.43]
bicarbonate 12 mmol/L [20-26]
base excess -8 [-5-5]

Which of the following is the most likely diagnosis?

A. Bacterial gastroenteritis.

B. Food anaphylaxis.

C. Food protein-induced enterocolitis.

D. Fulminant septicaemia.

E. Intussusception.

QUESTION 79
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.

Copyright © 2006 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 © 2006 by The Royal Australasian College of Physicians


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QUESTION 81
A four-year-old boy is referred because of short stature.

Investigations show:
plasma creatinine 0.05 mmol/L [0.04-0.08]
plasma phosphate 0.8 mmol/L [1.2-1.7]
plasma bicarbonate 16 mmol/L [22-26]
fasting plasma glucose 4.8 mmolL [3.0-6.5]
pH 7.29 [7.35-7.45]
pCO2 33 mmHg [32-40]
urinalysis 1+ protein, 2+ glucose

A radiograph of his wrist is shown above.

Which one of the following is the most likely diagnosis?

A. Renal Fanconi syndrome.

B. Renal osteodystrophy.

C. Renal tubular acidosis.

D. Vitamin D-resistant rickets.

E. X-linked hypophosphatemic rickets.

Copyright © 2006 by The Royal Australasian College of Physicians


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QUESTION 82

The pattern of joint involvement indicated by the red colour 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.

QUESTION 83
A one-year-old boy has infection with Enterobius vermicularis (threadworm/pinworm). Which of the
following is the most appropriate first-line treatment?

A. Co-trimoxazole.

B. Ivermectin.

C. Metronidazole.

D. Permethrin.

E. Pyrantel.

QUESTION 84
A toddler is admitted following ingestion of a strong alcoholic drink. The most common serious
complication is:

A. acute hepatitis.

B. cerebral oedema.

C. dehydration.

D. hypoglycaemia.

E. pancreatitis.

Copyright © 2006 by The Royal Australasian College of Physicians


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QUESTION 85
A four-year-old girl is seen in diabetes clinic. It is four months since she was diagnosed with type 1
(insulin-dependent) diabetes mellitus and coeliac disease. Her parents report marked behavioural
problems and temper tantrums, associated with diabetes treatment and dietary restrictions.

On examination extensive hairloss is noted as shown in the photograph above.

What is the most likely diagnosis?

A. Alopecia areata.

B. Telogen effluvium.

C. Tinea capitis.

D. Traction alopecia.

E. Trichotillomania.

QUESTION 86
A seven-year-old boy presents with a four-month history of dry hacking cough which is maximal in the
morning and resolves during sleep. A sibling has asthma and his parents are very anxious about the
aetiology of the cough. Pulmonary function testing demonstrates a forced vital capacity (FVC) of 90%
predicted, forced expiratory volume in 1 second (FEV1) of 86% predicted, and maximum mid-
expiratory flow rate (MMEF) of 62% predicted. His chest X-ray is normal. A histamine challenge test
shows a 14% fall in FEV1.

The most appropriate next step in management is:

A. antibiotics.

B. behavioural therapy.

C. bronchoscopy.

D. high resolution computerised tomography (CT) scan of chest.

E. inhaled steroids.

Copyright © 2006 by The Royal Australasian College of Physicians


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QUESTION 87

Copyright © 2006 by The Royal Australasian College of Physicians


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QUESTION 87 (continued)
A term infant is noted to have a 3/6 long systolic murmur at the left sternal edge shortly after elective
caesarean section. He is otherwise well. His arterial oxygen saturation is 85% in room air. His chest
X-ray and electrocardiogram (ECG) are shown opposite. What is the most likely diagnosis?

A. Critical pulmonary stenosis.

B. Ebstein anomaly.

C. Persistent fetal circulation.

D. Tetralogy of Fallot.

E. Tricuspid atresia.

QUESTION 88
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.

QUESTION 89
A 12-year-old girl with type 1 (insulin-dependent) diabetes mellitus presents with a 12-month history of
episodes of diarrhoea, flatulence and intermittent dull abdominal pains. Her insulin requirements over
the past year have fluctuated significantly. She noticed that drinking cow’s milk increases her
abdominal symptoms. She has not previously had any gastrointestinal problems, and her weight has
remained stable.

Which of the following investigations will most likely reveal the correct diagnosis?

A. Colonoscopy.

B. Lactose breath hydrogen test.

C. Serum IgE antibody to cow’s milk protein.

D. Small bowel biopsy.

E. Stool microscopy for parasites.

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QUESTION 90

Copyright © 2006 by The Royal Australasian College of Physicians


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QUESTION 90 (continued)

An eight-year-old boy with a large café-au-lait spot has recurrent fractures. His X-rays are shown
above and opposite. The most common association with this clinical picture is:

A. hyperplastic reticuloendothelial tissue.

B. hyperthyroidism.

C. hypothyroidism.

D. increased growth hormone levels.

E. precocious puberty.

Copyright © 2006 by The Royal Australasian College of Physicians


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QUESTION 91

A 16-month-old girl has a history of Pierre Robin sequence with cleft palate repair at six months. She
has high myopia and mild high-tone sensorineural deafness. She has moderate joint hypermobility.
Her facial appearance is shown above. The most likely diagnosis is:

A. CHARGE association.

B. Ehlers-Danlos syndrome.

C. Marfan syndrome.

D. Stickler syndrome.

E. Velocardiofacial syndrome.

QUESTION 92
What is the most common motive given by adolescents who have deliberately cut themselves?

A wish to:

A. die.

B. get my own back on someone.

C. get relief from a terrible state of mind.

D. punish myself.

E. see if someone really loved me.

Copyright © 2006 by The Royal Australasian College of Physicians


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QUESTION 93
A term male infant is delivered vaginally following a vacuum extraction which results in a small
cephalhaematoma. There is no family history of significance. At birth the infant is in good condition
with Apgar scores of 7 at one minute and 9 at five minutes. His birth weight is 3600 g and head
circumference is 35.5 cm. He establishes breastfeeding very well and is discharged to home at 72
hours of age.

At six days of age, he becomes irritable with poor feeding. He develops severe non-bile-stained
vomiting and presents to the emergency department where he is noted to be pale, apnoeic and
hypotonic. His head circumference is 37 cm and his fontanelle is tense. Following intubation and
ventilation, the following investigations are performed:

haemoglobin 85 g/L [140-200]


white cell count 18.7 x109/L [6.0-18.0]
platelets 252 x x109/L [150-400]

Coagulation screen:

international normalised ratio (INR) 1.3 [0.8-1.5]


activated partial thromboplastin time (APTT) > 200 seconds [27-69]
fibrinogen 3.0 g/L [1.9 – 4.3]

Cranial ultrasound shows no abnormalities.

The most likely diagnosis is:

A. disseminated intravascular coagulation.

B. haemophilia A.

C. haemorrhagic disease of the newborn.

D. herpes encephalitis.

E. non-accidental injury.

QUESTION 94
A 10-day-old male neonate presents with fever associated with an inguinal node abscess. Following
surgical incision and drainage, cultures grew Staphylococcus aureus. He is treated with flucloxacillin
for 14 days with full recovery. However, he has persistent neutropenia (absolute neutrophil count
(ANC) < 100). The most likely cause of this clinical picture is:

A. chronic benign neutropenia.

B. cyclic neutropenia.

C. post-viral neutropenia.

D. severe congenital neutropenia.

E. Shwachman-Diamond syndrome.

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59 P205

QUESTION 95

A previously well seven-year-old boy presents with a rash on his chest as shown above. Which of the
following is the most likely explanation for the development of this rash?

A. Chickenpox as an infant.

B. Hodgkin lymphoma.

C. Recent contact with a child with chickenpox.

D. Recent varicella vaccine.

E. Type 1 (insulin-dependent) diabetes mellitus.

QUESTION 96
A ten-year-old boy presents with facial swelling, hypertension, proteinuria and haematuria.
Complement levels are 0.7 mg/dL [0.8-1.8]; antistreptolysin-O titre (ASOT) and anti-DNase are
positive. He is excreting 500 mg of urinary protein in 24 hours [<200]. Anti-nuclear antibodies are
negative, and he has no other symptoms or signs suggesting autoimmune phenomena. After initial
treatment with fluid restriction, diet and antihypertensives, his urinary sediment improves, and blood
pressure returns to normal. At one month he is reassessed.

Which of the following would most strongly indicate the need for renal biopsy?

A. Creatinine of 0.11 mmol/L [0.05 – 0.10].

B. Haematuria.

C. Hypertension.

D. Hypocomplementaemia.

E. Proteinuria of > 200 mg/24 hours.


Copyright © 2006 by The Royal Australasian College of Physicians
60 P205

QUESTION 97

A four-year-old boy presents with a painful left knee followed by a rash as shown above. He
commenced cefaclor syrup for a cold five days ago. The most likely diagnosis is:

A. erythema multiforme.

B. IgE-mediated drug allergy.

C. IgE-mediated food allergy.

D. immune complex-mediated drug reaction.

E. juvenile chronic arthritis.

QUESTION 98
An eight-week-old formula-fed baby is referred because he has been crying excessively since four
weeks of age. He pulls up his legs, arches his back and goes red in the face. He is most distressed
in the evenings, but can cry at any time of day.

He possets after feeds but has not been vomiting, has had no diarrhoea or eczema, and is thriving.

What is the most appropriate first step?

A. Change to a cow’s milk-free formula.

B. Change to a lactose-free formula.

C. Discuss normal infant sleep and cry patterns.

D. Start anti-reflux therapy.

E. Test for urinary tract infection.

Copyright © 2006 by The Royal Australasian College of Physicians


61 P205

QUESTION 99
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.

Copyright © 2006 by The Royal Australasian College of Physicians


62 P205

QUESTION 100
A 14-year-old girl presents with intermittent knee pain following a netball injury. An X-ray of her knee
is shown below.

The most likely diagnosis is:

A. aneurysmal bone cyst.

B. Ewing sarcoma.

C. neuroblastoma.

D. osteogenic sarcoma.

E. osteomyelitis.

Copyright © 2006 by The Royal Australasian College of Physicians


63 P205

2005 FRACP Written Examination

Paediatrics & Child Health

Paper 2 – Clinical Applications

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

Copyright © 2006 by The Royal Australasian College of Physicians