Royal College of Paediatrics and Child Health

1. Complete the following: Your full name (BLOCK LETTERS)………………………………………………

RCPCH Number………………………………………………………………………. Signature…………………………………………………………………………… 2. Check your surname (family name) and initials appear in the top left hand corner of the Answer Sheet. Check your candidate number is in the top right hand corner. Using the pencil provided, complete your response to each item on the Answer Sheet. 3. It is strictly forbidden to talk to, read the work of, or attempt in any way to communicate with, other candidates whilst the examination is in progress. Please exercise vigilance to ensure that no other candidate can attempt to copy your work. The College has tools which can identify copying of answers or collusion between candidates to share answers. In any situation the suspicion of guilt falls upon both parties until it can be proved otherwise. Breaches of these instructions, or misbehaviour in any other way, including continuing to write after the allotted time, may lead to suspension from the examination at the discretion of the invigilators. Serious breaches, such as cheating or colluding to gain advantage, could incur permanent suspension from College examinations. 4. Question papers and individual questions must not be copied or removed from the examination room. 5. Answer all the following 24 questions. 6. Time allowed: 1 hour.

Question 1

Erythema nodosum A B C D E characteristically leaves scarred areas after resolution consists of painless subcutaneous nodules on extensor surfaces has a recognized association with inflammatory bowel disease is a complication of poorly controlled insulin dependent diabetes mellitus is associated with the use of oral contraceptives

Question 2

In the developed world contra-indications to breast feeding include


a family history of eczema AIDS in the mother mother on Warfarin therapy the occurrence of haemorrhagic disease of the newborn in a previous infant the occurrence of secondary lactose intolerance in a previous infant

Question 3 Vesicoureteric reflux A B C D E implies bladder neck obstruction is a common cause of urinary tract infection in adolescent girls is attributed to an abnormally long intramural course of the ureter is excluded by a normal renal ultrasound examination is inherited in an autosomal recessive manner Question 4 Concerning child sexual abuse. A B adults frequently do not believe children’s allegations of sexual abuse intrafamilial abuse is generally less traumatic for the child than extra familial abuse it is a common cause of behavioural problems in childhood it is associated with precociously sexualised behaviour there is an increased risk to the child if one of the carers has been sexually abused as a child C D E .

Question 5 In a twin pregnancy A B feto-fetal transfusion is associated with hydrops fetalis the incidence of cerebral palsy is higher for a monozygotic than a dizygotic twin the perinatal mortality rate is higher for a monozygotic than a dizygotic twin there is an increased incidence of neonatal hypoglycaemia two separate placentae confirm dizygosity C D E Question 6 The following occur in individuals with Down’s syndrome more commonly than in the general population: A B C D E Acute lymphoblastic leukaemia Alzheimer’s disease Coeliac disease Hirschsprung’s disease Hypothyroidism .

children not attending school for emotional reasons are A B C D E less likely to come from large families more likely to have anxious parents more likely to have difficulties in reading more likely to show behavioural problems at school of lower intellectual ability .Question 7 Recognized findings in normal puberty include A B C D E acne vulgaris in girls asymmetrical breast enlargement in girls diffuse enlargement of the thyroid enlargement of the penis before the testes in boys gynaecomastia in boys Question 8 When compared with truants.

Question 9 It is true of deliberate self harm that A B C boys are more likely than girls to complete suicide in adolescence deliberate self harm can result in an improvement in family functioning in teenage girls deliberate self harm is generally indicative of physical or sexual abuse in the teenage years deliberate self harm occurs with equal frequency in males and females young people who attempt suicide commonly kill themselves later in life in the absence of therapeutic intervention D E Question 10 A 10-month-old boy is a “bottom shuffler”. The following would be expected: A B C D E A family history in a first degree relative Absent downward parachute reflex Dislike of the prone position Increased muscle tone in the legs Normal speech development .

He has “bottom-shuffled” from the age of 10months. At 36 hours of age he has developed central cyanosis. His five-year-old brother crawled at 9 months and walked at 12 months of age.BEST OF FIVE QUESTIONS Question 11 An infant is born at term weighing 3. What is the most likely diagnosis? SELECT ONE ANSWER ONLY A B C D E Anomalous pulmonary venous drainage Fallot’s tetralogy Hypoplastic left heart Pulmonary stenosis Transposition of the great arteries Question 12 A 14-month-old boy is not yet walking unaided. He cries immediately at birth. Apgar 9 at 1 minute.2Kg. What is the best action to take at this stage? SELECT ONE ANSWER ONLY A B C D E Measure his creatine kinase (CK) level Refer him for physiotherapy Request MRI brain scan Review him in three months Send blood for chromosome analysis . His cognitive development is normal.

. His temperature is 37o and his pharynx red and injected. He lies on the examination couch with his hip flexed and externally rotated.Question 13 A 4-year-old boy complains of pain in the groin and has been walking with a limp for two days. What is the best next action? SELECT ONE ANSWER ONLY A Admit for hip traction B Advise strict bed rest for 10 days C Prescribe simple analgesia and observe him D Request emergency joint aspiration E Warn the parents that he is likely to develop Perthe’s disease.

Start intravenous antibiotics Take a swab from a purpuric lesion D E . Which is the best action to be taken next in the Emergency Department? SELECT ONE ANSWER ONLY A B C Notify the Public Health department Perform a lumbar puncture Prescribe chemoprophylaxis for the staff who have been in contact with him. The fontanelle is flat. Intravenous access is obtained with difficulty and a bolus of normal saline is given. evolving purpura and poor peripheral perfusion.Question 14 A 7-month-old boy presents with fever.

she says she feels weak.Question 15 A 14-year-old girl complains of recurrent abdominal pain for the last 6 months. What is the most probable diagnosis? SELECT ONE ANSWER ONLY A B C D E Anorexia nervosa Coeliac disease Crohn’s disease Juvenile idiopathic arthritis Turner’s syndrome Question 16 A 6-month-old boy is brought to the Emergency Department because he is not using his right arm. thin and prepubertal. swollen knees and poor appetite. and arrange Fracture Clinic review the following day Arrange a radioisotope bone scan Discharge home for supervision by the Health Visitor Take out an Emergency Protection Order Telephone Social Services . His mother says he rolled off a sofa 3 days ago. On examination she is clinically anaemic. Examination is otherwise unremarkable. What is the most appropriate to take action now? SELECT ONE ANSWER ONLY A B C D E Apply backslab. She goes to school every day. 2 friends have overtaken her in height in the last year. She is also suffering from mouth ulcers. He is found to have a spiral fracture of the right humerus.

What is the management option? SELECT ONE ANSWER ONLY A B C D E Advise gargling with soluble aspirin Advise that he should not attend school for two days Advise the parents that the condition needs no treatment Prescribe nasal decongestants Prescribe oral penicillin . He has no fever and the only abnormal findings are a red throat. runny nose and cough.Question 17 A previously well 10-year-old boy is brought by his parents with a very painful throat of 2 days duration.

What is the most likely diagnosis? SELECT ONE ANSWER ONLY A B C D E Coeliac disease Constipation Giardiasis Inflammatory bowel disease Threadworm infestation . saying he is being bullied because he smells. His mother tried a milkfree diet without benefit. producing small amounts of soft offensive stools. His height and weight are on the 50th centile. He refuses to be examined but his pants are seen to contain smelly faeces with no blood or mucus. He complains that he gets abdominal pain after meals. He is often unaware that he is opening his bowels. He is visiting the toilet several times a day.Question 18 A 6-year-old boy presents with a complaint of persistent diarrhoea. He soils his pyjamas and refuses to go to school.

On examination he has bilateral red bulging tympanic membranes. Routine antenatal care identified no problem or need for intervention. He is treated with antibiotics. What is the most likely cause of the jaundice? SELECT ONE ANSWER ONLY A B C D E ABO incompatibility Congenital hypothyroidism Prematurity Rhesus incompatibility Urinary tract infection . What is the most important issue to discuss with his parents now? SELECT ONE ANSWER ONLY A B C D E That he will have a long-term hearing loss That he will have a short-term hearing loss The immediate risk of mastoiditis The need for adenoidectomy The long-term risk of cholesteatoma Question 20 A first-born baby girl has an atraumatic normal delivery at 35 weeks gestation. At 18 hours of age she is well but jaundiced. His pain and fever settle but residual middle ear effusions are found.Question 19 A 3-year-old boy presents with ear ache and fever.

Her cheeks are red and she is pale around her mouth. Fever is recorded up to 38. Her tongue and lips are red and pus is noted on her tonsils. . feverish and off her food. He is miserable with conjunctivitis and fever of 38. respiratory rate of 40/minute and capillary refill time of 2 seconds: Blood total white blood count 15 x 109/l neutrophil counts 11 x 109/l 2 This Question Continues on the next page. His 3-year-old brother has recently started nursery.5º and she has a heart rate of 150/minute. She has a rash which covers her entire body and is variable but more marked when she is febrile.EXTENDED MATCHING QUESTIONS Question 21 This is a list of diagnoses: A B C D E F G H I J Kawasaki disease Measles Meningococcal disease Mycoplasma infection Pneumococcal meningitis Pneumococcal pneumonia Scalded skin syndrome Scarlet fever TB meningitis Toxic Shock Syndrome Choose the most likely diagnosis for each of the following: SELECT ONE ANSWER ONLY FOR EACH QUESTION Note: Each answer may be used more than once 1 A 10-month-old infant presents with a 1-day history of a confluent blanching rash which started on his face and now covers his entire body.5º. The illness started with runny nose and cough five days previously. An 18-month-old girl presents with a 3-day history of being unwell.

Question 21 continued 3 An 18-month-old girl. recently arrived from Nigeria. respiratory rate 30/minute and capillary refill time of 2 seconds. Blood total white blood count 15 x 109/l neutrophil count 12 x 109/l . Her heart rate is 160/minute. cracked lips and swollen hands. has conjunctivitis. presents with a 1-week history of fever with rigors. She is irritable. She has a widespread erythematous rash covering her whole body. She has red tonsils and one small cervical lymph node.

There is a swelling in the left upper quadrant of the abdomen. . A blood count shows pan-cytopaenia. There is a swelling in the left upper quadrant of the abdomen. A blood count shows pan-cytopaenia. Skeletal survey shows wide-spread abnormalities in the long bones. 2 This question continues on the next page. Skeletal survey shows wide-spread abnormalities in the long bones. A 4-year old girl presents with fever and limping which had been ascribed to “growing pains”. He is clinically anaemic with enlarged lymph nodes in the neck.Question 22 This is a list of diagnoses: A B C D E F G H I J Acute lymphoblastic leukaemia Congenital bone cysts Infectious mononucleosis Juvenile idiopathic arthritis (JIA) Langerhans cell histiocytosis Neuroblastoma Non-accidental injury Osteogenic sarcoma Osteomyelitis Rickets Choose the most likely diagnosis for each of the following: SELECT ONE ANSWER ONLY FOR EACH QUESTION Note: Each answer may be used more than once 1 A 4-year old boy presents with fever and limping which has been ascribed to “growing pains”. She is clinically anaemic with bilateral proptosis.

She is found to have tender swollen wrists.Question 22 continued 3 A 14-month-old girl presents with sore throat and fever up to 39. and she often refuses to feed. . preferring juice. She is very fretful and is not walking or pulling up to stand.4⁰. She looks pale and her head appears large. Her parents say that she eats poorly. Skeletal survey shows abnormal epiphyses.

His twin brother had died at 3 months of age. Her friends and family have noticed that she sometimes hesitates in mid-sentence and looks vague for a brief moment. He appeared to be unconscious for approximately 1 minute and then promptly fully recovered. A similar event which lasted only a few seconds occurred 6 months ago during a cross-country run. the death certificate recorded the cause as Sudden Unexpected Death in Infancy (SIDS). several times a day.Question 23 This is a list of investigations: A B C D E F G H I J Cranial CT scan Cranial MRI scan Electrocardiogram Electroencephalogram Electroretinogram Lumbar puncture Post-ictal serum prolactin level Rectal biopsy Visual evoked responses Videotelemetry Choose the investigation which is most likely to provide a diagnosis for the following: SELECT ONE ANSWER ONLY FOR EACH QUESTION Note: Each answer may be used more than once 1 An 8-year-old boy collapsed while competing during his school sports day for the 2nd year in succession. A 14-year-old girl is making poor school progress. 2 This question continues on the next page .

He has a right 6th nerve palsy and is mildly ataxic.Question 23 continued 3 A 7-year-old boy developed a squint following a tonsillectomy 3 months ago. .

Neurological examination is normal.Question 24 This is a list of diagnoses: A B C D E F G H I J Benign paroxysmal vertigo Complex partial seizures Daydreams Hyperventilation Idiopathic generalised epilepsy Migraine Night terrors Non-epileptic seizures Simple partial seizures Syncope Choose the most likely diagnosis for each of the following: SELECT ONE ANSWER ONLY FOR EACH QUESTION Note: Each answer may be used more than once 1 A 4-year-old boy with learning difficulties has infrequent episodes in which he looks frightened. She remains fully conscious during these episodes. 2 This question continues on the next page. following which he seems tired. as was her EEG during an episode. . goes pale and swallows repeatedly for 15-30 seconds. who are very worried about the episodes and have kept her off school since they began three weeks ago. She lives with her pregnant single mother and grandmother. A 12-year-old girl has episodes of twitching of her right leg accompanied by pain and parasthesiae for minutes to hours at a time.

She felt hot. then she dropped to the ground and briefly jerked all limbs. She was unreachable for 10-20 seconds. nauseated.Question 24 Continued 3 A 12-year-old girl has had three episodes of collapse during assembly at school. and sounds seemed louder to her. There was a short period of confusion before she recovered. End of Paper .

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