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2000 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 © 2003 by The Royal Australasian College of Physicians

All Written Examination papers are copyright. They may not be reproduced in whole or part without written
permission from The Royal Australasian College of Physicians, 145 Macquarie Street, Sydney, Australia.
2 P200
Question 1

Which one of the following interventions has most consistently been shown to decrease the duration of
hospital stay with acute asthma?

A. Inhaled ipratropium bromide.

B. Inhaled salbutamol.

C. Intravenous salbutamol.

D. Oral prednisolone.

E. Oral theophylline.

Question 2

A 15-year-old boy has been on an anticonvulsant for three years. The dosage has been stable. He recently
noticed difficulties in seeing at night. A formal ophthalmological assessment demonstrated visual field
constriction.

Which one of the following anticonvulsants is most likely to be the cause of his symptoms?

A. Carbamazepine.

B. Gabapentin.

C. Lamotrigine.

D. Sodium valproate.

E. Vigabatrin.

Question 3

A term neonate presents with ‘jitteriness’ at three hours of age. The following recordings are made:

weight 3450 g (50th percentile)


length 50 cm (50th percentile)
head circumference 36 cm (50th percentile)
penile length 1.8 cm (<10th percentile)
plasma glucose 0.7 mmol/L

The remainder of the examination is normal.

The most likely cause is:

A. congenital adrenal hyperplasia.

B. 5 alpha-reductase deficiency.

C. hyperinsulinism.

D. hypopituitarism.

E. 45XO/46XY mosaicism.

Copyright © 2003 by The Royal Australasian College of Physicians


3 P200
Question 4

The following results are obtained from a 14-year-old boy, prior to elective hernia surgery, who gives a history of
excessive bleeding after dental extraction.

Bleeding time 6 minutes [2-9]


Prothrombin time 12 seconds [12-14]
Prothrombin time-international normalised ratio (PT-INR) 1.0 [0.9-1.2]
Activated partial thromboplastin time (APTT) 56 seconds [26-35]
Fibrinogen 2.4 g/L [1.8-4.0]

Mixing the patient's plasma with an equal volume of normal plasma normalises the APTT.

Which one of the following is the most likely diagnosis?

A. Antiphospholipid antibody syndrome.

B. Factor VII deficiency.

C. Haemophilia.

D. Recent aspirin ingestion.

E. Von Willebrand disease.

Question 5

The section of the renal biopsy shown was taken from an eight-year-old girl. She had presented with polyuria,
anaemia and growth failure.

Which one of the following is the most likely diagnosis?

A. Lead nephropathy.

B. Medullary cystic disease.

C. Nephrogenic diabetes insipidus.

D. Post-infectious glomerulonephritis.

E. Systemic lupus erythematosus.

Copyright © 2003 by The Royal Australasian College of Physicians


4 P200
Question 6

A six-year-old presents with the eruption shown on the right ear. It is itchy but not sore.

Which one of the following organisms is the most likely to be responsible?

A. Group A Streptococcus.

B. Herpes simplex virus.

C. Pseudomonas aeruginosa.

D. Staphylococcus aureus.

E. Varicella zoster virus.

Question 7

Second generation H1 receptor antagonists effectively relieve most of the symptoms of allergic
rhinoconjunctivitis.

Which one of the following symptoms is least effectively relieved?

A. Nasal congestion.

B. Nasal itch.

C. Ocular tearing.

D. Rhinorrhoea.

E. Sneezing.

Copyright © 2003 by The Royal Australasian College of Physicians


5 P200
Question 8

A six-month-old girl develops a chylothorax post-cardiac surgery. After two days her chest drain continues to
drain chylous fluid.

The most appropriate feed for the management of chylothorax in this infant is:

A. breast milk.

B. Isomil (soy milk formula).

C. Neocate (single amino acid infant formula).

D. Portagen (casein hydrolysate formula).

E. S26 (whole protein cow’s milk formula).

Question 9

In the pedigree shown above, III:3 is a woman of normal intelligence. She has a family history of mental
retardation. Her nephew IV:1 and her cousin III:1 have recently been diagnosed with Fragile X mental
retardation.

The risk that she is a Fragile X carrier is closest to:

A. 100%.

B. 50%.

C. 25%.

D. 1%.

E. nil.

Copyright © 2003 by The Royal Australasian College of Physicians


6 P200
Question 10

A 12-hour-old term male infant is transferred from a rural town to a level three neonatal unit with mild
respiratory distress and an oxygen requirement. The provisional diagnosis was transient tachypnoea of the
newborn. The chest radiograph shown below was taken on arrival. His oxygen saturation, measured from the
left foot, is 95%. The FiO2 is 0.45.

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

A. Insert a chest drain.

B. Organise a thoracotomy.

C. Pass a nasogastric tube.

D. Start intravenous flucloxacillin.

E. Ventilate to achieve respiratory alkalosis.

Question 11

Which one of the following vaccines is contraindicated in a child with anaphylactic egg allergy?

A. Bacille Calmette-Guérin (BCG).

B. Influenza.

C. Measles-mumps-rubella (MMR).

D. Oral polio.

E. Whole cell pertussis.

Copyright © 2003 by The Royal Australasian College of Physicians


7 P200
Question 12

An 18-month-old boy has recurrent blue breath-holding episodes, followed on one occasion by a 15-second
generalised seizure.

The investigation most likely to be useful in directing therapy is:

A. electrocardiogram (ECG).

B. electroencephalogram (EEG).

C. iron studies.

D. plasma calcium.

E. plasma glucose.

Question 13

A three-year-old boy presents with a six-month history of polyarticular arthritis. He had been well until age 12
months when he required hospitalisation for left lower lobe pneumonia. Recurrent otitis media, intermittent
fevers and persistent diarrhoea developed in the second year of life. There was no history of oral thrush or
other fungal infections and no history of opportunistic infections. Developmental milestones and physical
growth were normal and immunisations were appropriate for age.

Physical examination shows a febrile boy who refuses to weight bear. He has purulent nasal discharge. The
lung fields are clear. Both knees are swollen, tender and warm with effusions and decreased range of
movement. Both ankles are tender with synovial swelling and there is a reduced range of movement.
Examination of the heart is normal. Skin examination is normal.

Which one of the following is the most likely diagnosis?

A. Chronic meningococcaemia.

B. Juvenile chronic arthritis.

C. Late onset hypogammaglobulinaemia (common variable immunodeficiency).

D. Rheumatic fever.

E. Yersinia arthritis.

Copyright © 2003 by The Royal Australasian College of Physicians


8 P200
Question 14

A three-year-old oncology patient is being treated with chemotherapy.

Which one of the following chemotherapy drugs, on extravasation, is most likely to have caused the
appearance as shown above?

A. Cyclophosphamide.

B. Cytosine arabinoside.

C. Ifosfamide.

D. Methotrexate.

E. Vincristine.

Copyright © 2003 by The Royal Australasian College of Physicians


9 P200
Question 15

A three-year-old boy was brought to your office for evaluation of multiple skin lesions, some of which are
shown in the photograph below. A presumptive diagnosis of neurofibromatosis 1 (NF-1) is made but he does
not yet fulfil diagnostic criteria for diagnosis.

Which one of the following is not one of the diagnostic criteria for NF-1?

A. Acoustic neuroma.

B. Family history of NF-1.

C. Inguinal freckling.

D. Lisch nodules.

E. Optic glioma.

Question 16

Which feature distinguishes hyper-IgE syndrome from severe atopic dermatitis?

A. Decreased number of peripheral blood CD8+ lymphocytes.

B. Distribution of the eczematous rash.

C. Extremely high serum IgE levels.

D. Negative delayed skin tests to Candida.

E. Staphylococcal abscesses in the axillary lymph nodes.

Copyright © 2003 by The Royal Australasian College of Physicians


10 P200
Question 17

A four-year-old child has a pneumonia with an effusion that is unresponsive to antibiotic therapy given
intravenously in appropriate doses (ceftriaxone, tobramycin and flucloxacillin) and formal surgical drainage of
the effusion/empyema. Five days after the surgery the child still has temperatures greater than 39°C and
looks unwell. Bacteroides fragilis is grown from the effusion.

A change to which one of the following antibiotics is likely to improve the child?

A. Ceftazidime.

B. Clindamycin.

C. Erythromycin.

D. Penicillin G.

E. Vancomycin.

Question 18

You are asked for a second opinion regarding a 10-year-old boy who has a long history of hyperactive,
impulsive, attention-seeking and destructive behaviour, both at home and at school. A paediatrician and a
child psychiatrist have previously diagnosed him as having attention deficit hyperactivity disorder (ADHD). He
responded poorly to dexamphetamine but concentration and attention have improved on methylphenidate. He
is currently on 30 mg/day. His weight is 35 kg.

Further assessment demonstrated average intelligence but with a significant language-based learning
disorder. He is at the 3rd percentile for receptive language and the 14th percentile for expressive language.
He is making progress at school with the provision of remedial help and an integration aide.

He also receives on-going counselling and cognitive behavioural management from his psychiatrist.

His parents are divorced and are unable to manage him consistently. His father is strict, distant and loses his
temper with his son. His mother is caring, finds it hard to set limits and is overwhelmed by his demands. The
boy dominates and intrudes on all aspects of family life. His father denigrates his ex-wife in front of the boy.

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

A. Alter medication regime.

B. Family therapy.

C. Foster care.

D. Individual parental guidance.

E. Transfer to a special school.

Copyright © 2003 by The Royal Australasian College of Physicians


11 P200
Question 19

A 10-year-old boy presents with a six-month history of progressive dyspnoea and palpitations. On
examination his respiratory rate is 35/minute with no overt distress. The liver is palpable 3 cm below the right
costal margin. Occasional crackles are audible in both bases. His chest X-ray demonstrated moderate
cardiomegaly. His electrocardiogram is shown below.

Which one of the following is the most likely diagnosis?

A. Anomalous origin of the left coronary artery from the pulmonary artery.

B. Idiopathic dilated cardiomyopathy.

C. Incessant atrial tachycardia.

D. Kawasaki disease with associated ischaemia.

E. Viral myocarditis.

Copyright © 2003 by The Royal Australasian College of Physicians


12 P200
Question 20

Two sisters developed a febrile illness with coryza and sore throat. They were both started on amoxycillin.
One week later this rash (shown below) appeared on their arms, and the older girl aged 10, complained of stiff
joints.

Which one of the following is the most likely cause?

A. Drug reaction.

B. Enterovirus infection.

C. Erythema infectiosum (fifth disease).

D. Roseola infantum (sixth disease).

E. Scarlatina.

Question 21

A 14-month-old infant has been dependent on parenteral nutrition since birth due to surgical resection secondary
to volvulus of the small bowel. He currently receives 30% of his caloric requirement by the parenteral route and
the remainder as Pregestimil® via a nasogastric tube. On examination he is icteric. He has 3 cm of
splenomegaly, the liver is not palpable and there is no ascites.

His blood tests reveal:

bilirubin (total) 120 µmol/L [<10]


bilirubin conjugated 96 µmol/L [<10]
alanine aminotransferase (ALT) 203 U/L [10-50]
gamma glutamyltransferase (GGT) 593 U/L [5-24]
albumin 23 g/L [34-52]

Abdominal ultrasound shows a small liver with normal intra and extra hepatic ducts and an enlarged spleen. A
Doppler study of his portal vessels shows blood flowing from the liver to the spleen.

Copyright © 2003 by The Royal Australasian College of Physicians


13 P200
Question 21 (continued)

The most effective intervention to arrest the progression of his liver disease would be to:

A. administer chenodeoxycholic acid.

B. administer phenobarbitone.

C. administer rifampicin.

D. cease parenteral nutrition.

E. perform a portacaval shunt.

Question 22

Pre-symptomatic genetic testing is now available for many inherited disorders.

Which one of the following would be the most appropriate reason for testing a nine-year-old child?

A. Medical intervention can alter the disorder's natural history.

B. Parental anxieties can be relieved.

C. Parents want to take out life insurance on the child.

D. The child wants to be tested.

E. The child's carrier status can be determined.

Question 23

A four-year-old boy presents with the sole symptom of a generally dry cough of four months duration, which
has been affecting his sleep. He is well grown and there are no localising or generalised signs. He has not
responded to nebulised salbutamol prescribed by his general practitioner. His blood count and chest X-ray
are normal.

Which one of the following is the most appropriate management?

A. Bedroom humidification.

B. Erythromycin.

C. Inhaled corticosteroids.

D. No therapy.

E. Oral steroids.

Copyright © 2003 by The Royal Australasian College of Physicians


14 P200
Question 24

A four-month-old boy is investigated following a urinary tract infection. The micturating cystourethrogram is
shown below.

The appearance is least consistent with:

A. high-grade vesico-ureteric reflux.

B. neuropathic bladder.

C. posterior urethral valves.

D. triad or “Prune Belly” syndrome.

E. vesico-ureteric junction obstruction.

Copyright © 2003 by The Royal Australasian College of Physicians


15 P200
Question 25

A 14-year-old obese boy presents with a velvety, pigmented rash on his axillae and neck (shown below).

Which one of the following investigations is the most relevant for his future management?

A. Fasting serum cholesterol/triglyceride.

B. Fasting serum insulin/glucose ratio.

C. Plasma leptin.

D. Serum adrenocorticotrophic hormone (ACTH)/cortisol.

E. Serum thyroid-stimulating hormone.

Copyright © 2003 by The Royal Australasian College of Physicians


16 P200
Question 26

A four-year-old child presents to the emergency department with a two-day history of multiple bruises and a
bleeding nose, two weeks after an upper respiratory tract infection. His past medical history is unremarkable. On
examination, in addition to the features described in the history, there is a widespread petechial rash noted mainly
over the trunk but there are no other abnormal features. Full blood count shows the following results:

haemoglobin 117 g/L [110-150]


mean corpuscular volume 79 fL [75-90]
red cell morphology normal
platelet count <10 x 109/L [150-400]
white cell count 9.8 x 109/L [5.0-14.5]
differential:
lymphocytes 5.8 x 109/L [1.5-10.0]
neutrophils 3.8 x 109/L [1.0-8.0]
monocytes 0.2 x 109/L [0.2-1.2]

Which one of the following treatments will result in the most rapid rise in the platelet count?

A. Anti-D immunoglobulin.

B. Danazol.

C. Dexamethasone.

D. Intravenous immunoglobulin.

E. Prednisolone.

Question 27

Which one of the following factors is most likely to be associated with the occurrence of late-onset
haemorrhagic disease (vitamin K deficiency bleeding)?

A. Breastfeeding.

B. Formula feeding.

C. Maternal anticonvulsants.

D. Post-natal antibiotic administration.

E. Prematurity.

Question 28

A previously well two and a half-year-old girl, whose parents are divorced, returns from weekend access with
her father. On return home the child is a little more demanding than usual but is otherwise behaviourally
normal. At bed-time the mother notices that her daughter has a significantly reddened vulva.

Which one of the following is the most likely diagnosis?

A. Candidiasis.

B. Child sexual abuse.

C. Lichen sclerosis.

D. Non-specific vulvovaginitis.

E. Straddle injury.

Copyright © 2003 by The Royal Australasian College of Physicians


17 P200
Question 29

An eight-year-old boy presents with behavioural problems and a noted deterioration in his performance at school.
Examination reveals mild unsteadiness of gait and a slight brown discolouration of the gums. A computed
tomography (CT) scan of his head is shown below.

Which one of the following is most likely to establish a diagnosis?

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

B. Ophthalmological examination.

C. Plasma very-long chain fatty acid ratio.

D. Serum lead level.

E. White cell lysosomal enzymes.

Question 30

A four-year-old girl has had a sore, swollen left knee for one month. She is noted to have the abnormality
shown in the photograph below, on examination of her eyes.

Copyright © 2003 by The Royal Australasian College of Physicians


18 P200
Question 30 (continued)

Which one of the following tests is most likely to be positive?

A. Antinuclear antibody (ANA).

B. Extractable nuclear antigen (ENA).

C. Human leucocyte antigen B27 (HLA-B27).

D. Rheumatoid factor (RF).

E. Serum angiotensin-converting enzyme (ACE).

Question 31

A 15-year-old girl presents with a three-year history of school avoidance, attending approximately one week
per month. She held a scholarship in secondary school but this was withdrawn due to poor attendance.

At home, she spends her day watching television, drinking alcohol or smoking marijuana. She has a few
friends but is reluctant to leave the house. She is preoccupied with her body and feels herself to be a freak
because she perceives asymmetry in her facial appearance. She panics in social situations, believing that
other people see this appearance. She is volatile and flies into a rage if she is thwarted. She hates herself,
has grazed her wrists and there are scars from cigarette burns on her arms. She denies suicidal ideation.

At night, she finds it difficult to fall asleep, worries about being attacked and often checks the door and window
locks. She has frequent nightmares and on waking, she thinks she hears strangers in her room.

Her parents divorced eight years ago and do not get on well. She lives with her mother and brother, the latter
having similar but less severe difficulties. He is now at university. Her mother is anxious and ineffectual and it
is clear that the children control the family.

Which one of the following diagnoses best explains this picture?

A. Affective disorder (depression).

B. Borderline personality disorder.

C. Obsessive-compulsive disorder.

D. Panic disorder.

E. Schizophrenia.

Question 32

Which one of the following would not be consistent with a diagnosis of night terrors?

A. Associated somnambulism.

B. Associated sweating and pupillary dilatation.

C. Inability to recall the event.

D. Multiple episodes per night.

E. Occurrence at age seven years.

Copyright © 2003 by The Royal Australasian College of Physicians


19 P200
Question 33

A 13-year-old boy is brought to the emergency room following an intentional ingestion of battery acid 15
minutes previously. He complains of abdominal pain. On examination he is pale with a pulse rate of
100/minute, respiratory rate of 30/minute and a systolic blood pressure of 120 mmHg. He has upper
abdominal tenderness with no obvious rebound tenderness. Bowel sounds are present and normal in
character.

Which one of the following is the most appropriate immediate management?

A. Administer antacid.

B. Administer corticosteroids.

C. Administer ipecac.

D. Insert a nasogastric tube and suction gastric contents.

E. Perform a gastroscopy.

Question 34

A nine-month-old boy, who has been fully immunised, presents with a pneumonia and has the following results:

IgG 1.1 g/L [2.1-12.2]


IgA <0.10 g/L [0.17-1.20]
IgM 0.15 g/L [0.32-1.40]
IgE <5 kU/L [0-35]

Lymphocyte markers:

CD3 (T cells) 93% [53-71]


CD4 (T helper) 68% [28-52]
CD8 (T suppressor) 24% [13-31]
CD19 (B cells) 0% [19-38]
natural killer (NK) cells 4% [3-12]

His pneumonia is most likely to be due to which one of the following organisms?

A. Escherichia coli.

B. Haemophilus influenzae type b.

C. Mycoplasma pneumoniae.

D. Pneumocystis carinii.

E. Staphylococcus aureus.

Question 35

An eight-month-old breast-fed baby girl is brought to the emergency department with a 10-day history of
vomiting, irritability and weight loss. The baby developed normally until six months of age but since then her
development has regressed and she is no longer able to sit unsupported.

She is afebrile, pale and listless. Her weight is 6.5 kg (3-10th percentile), length 68 cm (50th percentile) and
head circumference is 43 cm (10-50th percentile). She is generally hypotonic and has brisk reflexes with
positive Babinski responses. Abdominal examination is normal.

Copyright © 2003 by The Royal Australasian College of Physicians


20 P200
Question 35 (continued)

Investigations show:

haemoglobin 98 g/L [95-140]


mean corpuscular volume 106.5 fL [70.0-85.0]
mean corpuscular haemoglobin 34.9 pg [24.0-36.0]
white cell count 5.8 x 109/L [5.0-17.0]
neutrophils 1.1 x 109/L [1.0-8.0]
occasional hypersegmented neutrophils seen on blood film
platelet count 445 x 109/L [150-600]

sodium 145 mmol/L [135-145]


chloride 99 mmol/L [95-110]
potassium 4.5 mmol/L [3.5-5.5]
bicarbonate 26 mmol/L [22-26]
urea 6.9 mmol/L [1.3-6.6]
creatinine 0.045 mmol/L [0.020-0.050]
glucose 4.3 mmol/L [2.5-5.5]

Urine metabolic screen gross increase in methylmalonic acid and homocystine

Which one of the following is the most likely diagnosis?

A. Cobalamin C deficiency.

B. Glutaric aciduria type II.

C. Homocystinuria.

D. Methylmalonic acidaemia.

E. Vitamin B12 deficiency.

Question 36

Copyright © 2003 by The Royal Australasian College of Physicians


21 P200
Question 36 (continued)

An 11-year-old girl is referred because of recurrent severe asthma and very high doses of inhaled steroids and
repeated courses of oral steroids (eight months on oral steroids in the last 12 months). She complains of severe
shortness of breath with minimal exercise. She has gained 7 kg in the past 12 months. She has missed four
months of school in the past year because of respiratory illness. Her lung function tests are normal. During an
exercise test which she terminated at six minutes of bicycling, she was noted to have ‘severe distress’ associated
with stridor and inspiratory and expiratory wheezes. Her flow volume loops (tidal volumes) during exercise are
shown (see previous page) and exhibit a saw-tooth appearance.

The most likely diagnosis is:

A. exercise induced asthma.

B. obliterative bronchiolitis.

C. psychogenic asthma.

D. recurrent spasmodic croup.

E. unstable asthma.

Question 37

A neonate with Down syndrome is found to have hepatosplenomegaly. A photograph of the cord blood film is
shown below.

Full blood count results show:

haemoglobin 160 g/L [140-225]


nucleated red cell count 5/100 white cells [<20]
white cell count 110 x 109/L [9-30]
platelet count 150 x 109/L [150-600]

Copyright © 2003 by The Royal Australasian College of Physicians


22 P200
Question 37 (continued)

The most likely diagnosis is:

A. acute erythroleukaemia.

B. acute lymphoblastic leukaemia.

C. acute megakaryoblastic leukaemia.

D. congenital infection.

E. transient abnormal myelopoiesis.

Question 38

The most significant hurdle to the eradication of measles in Australia and New Zealand is the:

A. emergence of mutant strains.

B. lack of herd immunity.

C. presence of an animal reservoir.

D. presence of several different serotypes.

E. vaccine susceptibility to disruption of the “cold chain”.

Question 39

Which anti-arrhythmic drug is inappropriate in the treatment of the arrhythmia with which it is paired?

A. Atrial flutter: sotalol.

B. Atrial tachycardia in Wolff-Parkinson-White syndrome: flecainide.

C. Prolonged QT syndromes: propranolol.

D. Sinus node dysfunction: digoxin.

E. Ventricular tachycardia in cardiomyopathy: amiodarone.

Question 40

Which one of the following has been most clearly demonstrated to be effective in the treatment of depression
in young people?

A. Cognitive behavioural therapy.

B. Desipramine.

C. Exercise.

D. Fluoxetine.

E. Interpersonal therapy for adolescents.

Copyright © 2003 by The Royal Australasian College of Physicians


23 P200
Question 41

A 30-year-old mother and her five-year-old son are both HIV (human immunodeficiency virus)-positive. She is
well and takes all her own medication reliably. She is pregnant and would like to know what are the chances of
her baby developing HIV infection. She understands that both baby and she will be treated with the best available
current treatments.

The risk of the baby acquiring HIV is closest to:

A. 90%.

B. 70%.

C. 50%.

D. 30%.

E. 10%.

Question 42

An eight-year-old boy is being investigated for short stature and headache. A magnetic resonance imaging
(MRI) scan is obtained and is shown below.

Which one of the following is the most likely diagnosis?

A. Aneurysm.

B. Craniopharyngioma.

C. Metastatic tumour.

D. Optic glioma.

E. Pituitary adenoma.

Copyright © 2003 by The Royal Australasian College of Physicians


24 P200
Question 43

A two-year-old boy presents with a three-month history of frequent, loose stools and failure to thrive. His diet
consists of three bottles of cows’ milk per day and two small meals, usually a Vegemite® sandwich for lunch,
and chicken nuggets and chips or plain pasta for dinner.

Stool culture is negative for bacterial pathogens.


Stool reducing substances are detected at 0.25%.

A wet preparation of the stool is shown below.

The most likely cause for his symptoms is:

A. coeliac disease.

B. cow’s milk protein enteropathy.

C. pancreatic insufficiency.

D. post-gastroenteritis enteropathy.

E. small intestinal bacterial overgrowth.

Question 44

Which one of the following sets of urinary electrolytes is most likely to be found in established pyloric
stenosis?

Sodium Potassium Chloride


pH
(mmol/L) (mmol/L) (mmol/L)
A. 30 40 0 8

B. 5 5 30 6

C. 40 40 80 8

D. 110 5 60 8

E. 35 45 5 6

Copyright © 2003 by The Royal Australasian College of Physicians


25 P200
Question 45

Stevens-Johnson syndrome is most likely to occur with which one of the following anticonvulsant drugs?

A. Carbamazepine.

B. Lamotrigine.

C. Phenytoin.

D. Sodium valproate.

E. Vigabatrin.

Question 46

A 10-year-old girl presents with a recurrent persistent distressing cough of four months duration. The cough
does not occur during sleep, but starts on awakening and fluctuates in intensity and frequency throughout the
day. Her mother describes the cough as very loud. The cough has been present daily and it started with an
upper respiratory tract infection. There was a similar episode 12 months ago at the same time of the year.
The cough was not associated with wheeze, dyspnoea or any sputum production. Her chest X-ray is normal.

Which one of the following is the most likely diagnosis?

A. Cough variant asthma.

B. Episodic asthma.

C. Pertussis.

D. Post-viral chronic bronchitis.

E. Psychogenic cough.

Copyright © 2003 by The Royal Australasian College of Physicians


26 P200
Question 47

An eight-year-old previously well girl presents with a four-week history of increasing pallor, shortness of breath
and easy bruising. Her parents are vegetarians. Physical examination confirms marked pallor, extensive
petechial rash over lower limbs with bruising of various ages on trunk and limbs. There was no
lymphadenopathy present and the rest of her examination was unremarkable. Full blood count showed:

haemoglobin 48 g/L [115-150]


platelet count <10 x 109/L [150-400]
white cell count 0.9 x 109/L [5.0-14.5]
differential:
neutrophils 0.1 x 109/L [1.0-8.0]
lymphocytes 0.8 x 109/L [1.5-10.0]

A photograph of her bone marrow trephine biopsy is shown below.

Which one of the following is the most likely diagnosis?

A. Idiopathic aplastic anaemia.

B. Myelodysplastic syndrome.

C. Paroxysmal nocturnal haemoglobinuria.

D. Parvovirus infection.

E. Vitamin B12 deficiency.

Copyright © 2003 by The Royal Australasian College of Physicians


27 P200
Question 48

A 12-year-old girl presents with a six-month history of pain and colour change in her fingers when exposed to
cold. The fingers go white in the cold, then blue and become red and painful when they are warmed up.

Examination on a warm day reveals a well, appropriately grown 12-year-old girl with normal peripheral pulses
and puffy fingers but no trophic changes in the skin. Nail-fold capillaroscopy is performed (shown below).
The photograph on the left shows a normal control (A) and the photograph on the right is of the patient’s nail
fold capillaroscopy (B).

A B

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

A. Mixed connective tissue disease.

B. Primary Raynaud phenomenon.

C. Rheumatoid arthritis.

D. Scleroderma.

E. Systemic lupus erythematosus.

Copyright © 2003 by The Royal Australasian College of Physicians


28 P200
Question 49

You have been asked to review the biochemical profile of a 13-year-old girl who is undergoing nasogastric feeding
for severe anorexia nervosa, which was initiated three days earlier. You calculate that she is receiving 100
calories per hour. She had normal biochemistry on admission.

Her current biochemical profile is:

sodium 135 mmol/L [134-142]


potassium 2.7 mmol/L [3.5-4.5]
chloride 98 mmol/L [96-110]
urea 1.0 mmol/L [2.1-6.5]
creatinine 0.02 mmol/L [0.03-0.08]
glucose 2.4 mmol/L [3.5-5.4]
calcium 1.99 mmol/L [2.10-2.60]
phosphate 0.8 mmol/L [1.1-1.8]
albumin 30 g/L [35-50]

This picture is most likely to be due to which one of the following?

A. Addisonian crisis.

B. Diuretic abuse.

C. Laxative abuse.

D. Secondary renal tubular acidosis.

E. The enteral nutrition.

Question 50

Which one of the following cardiac lesions would be an unexpected finding in a baby with a 22q11 deletion?

A. Infradiaphragmatic totally anomalous pulmonary venous return.

B. Interrupted aortic arch.

C. Pulmonary atresia, ventricular septal defect and major aorto-pulmonary collaterals.

D. Tetralogy of Fallot.

E. Truncus arteriosus.

Question 51

Which one of the following measures is most effective in preventing neonatal early onset group B
streptococcal infection?

A. Antibiotics (single intramuscular dose) given after delivery to babies of colonised mothers.

B. Antibiotics given during pregnancy to colonised mothers at 28 weeks gestation.

C. Antibiotics given during pregnancy to colonised mothers with group B streptococcal antigenuria.

D. Maternal intrapartum antibiotics to colonised mothers.

E. Vaginal antiseptic douches before and during delivery to intrapartum colonised mothers.

Copyright © 2003 by The Royal Australasian College of Physicians


29 P200
Question 52

A five-year-old boy presents with a one-week history of fever and malaise. He has a mild cough, but no
dyspnoea or tachypnoea and no chest signs. His chest X-ray is shown below.

The chest X-ray shows which one of the following?

A. Cryptococcoma.

B. Hydatid cyst.

C. Lung abscess.

D. Pneumatocele.

E. Round pneumonia.

Copyright © 2003 by The Royal Australasian College of Physicians


30 P200
Question 53

A 15-year-old boy presents following a syncopal episode outside the headmaster’s office prior to being
reprimanded. The above rhythm strip (A) was obtained by the ambulance officers upon their arrival and the
attached 12 lead electrocardiogram (B) was obtained the following day.

Which one of the following is the most likely diagnosis?

A. Arrhythmogenic right ventricular dysplasia.

B. Congenitally corrected transposition of the great arteries.

C. Hyperparathyroidism.

D. Hypoparathyroidism.

E. Long QT syndrome.

Copyright © 2003 by The Royal Australasian College of Physicians


31 P200
Question 54

The tympanogram shown below was obtained from the right ear of a six-year-old child.

Examine the five air-conduction audiograms shown below. Which one of these audiograms is most likely to
have been obtained from the same ear as the tympanogram?

Copyright © 2003 by The Royal Australasian College of Physicians


32 P200
Question 55

Which one of the following has most consistently been shown to be associated with an increased risk of
sudden infant death syndrome?

A. Bottle feeding.

B. Exposure to cigarette smoke.

C. Non-immunisation.

D. Room sharing (baby sleeping in own cot in same room as parents).

E. Supine sleeping position.

Question 56

A 13-year-old boy with severe spastic quadriplegia is referred for consideration of placement of a gastrostomy
tube to aid with feeding. He has scoliosis and chronic lung disease.

Which one of the following factors would be a contraindication to percutaneous endoscopic gastrostomy tube
placement in this patient?

A. Oropharyngeal incoordination.

B. Past history of appendicectomy.

C. Recurrent constipation.

D. Severe gastro-oesophageal reflux.

E. Severe generalised hypertonia.

Question 57

A five-year-old girl is referred with day and night wetting. Her neuro-developmental history is otherwise
normal and bowel training was established prior to three years.

The history reveals that her pants are constantly wet and her teacher has already expressed concern
regarding comments from other children.

Physical examination is normal and urine culture shows no evidence of infection.

A renal ultrasound is suggestive of a duplex right kidney and a normal left kidney, but is otherwise
unremarkable.

Which one of the following is the next most appropriate investigation?

A. Intravenous pyelogram.

B. Micturating cystourethrogram.

C. Nuclear imaging with diuretic washout.

D. Referral for psychological assessment.

E. Urodynamic studies.

Copyright © 2003 by The Royal Australasian College of Physicians


33 P200
Question 58

The cytokine likely to be responsible for proliferation of the cells indicated in the photograph above is:

A. granulocyte colony-stimulating factor (G-CSF).

B. granulocyte-monocyte colony-stimulating factor (GM-CSF).

C. interleukin 1 (IL-1).

D. interleukin 2 (IL-2).

E. interleukin 5 (IL-5).

Question 59

A six-year-old boy, previously well, has a one-week history of rhinitis followed by cough and fever. His chest X-
ray is shown below.

Copyright © 2003 by The Royal Australasian College of Physicians


34 P200
Question 59 (continued)

The abnormality shown is most likely to be due to which one of the following?

A. Hamartoma.

B. Metastatic lesion.

C. Neuroblastoma.

D. Pneumonia.

E. Tuberculosis.

Question 60

Prophylactic surfactant (given within 15 minutes of birth) has been compared to rescue surfactant (given
immediately after intubation for established hyaline membrane disease), in several controlled trials.

The use of prophylactic surfactant as opposed to rescue surfactant in very low birthweight infants has been shown
to decrease the incidence of which one of the following?

A. Air-leak syndrome.

B. Bronchopulmonary dysplasia.

C. Intraventricular haemorrhage (grade three to four).

D. Patent ductus arteriosus.

E. Periventricular leukomalacia.

Question 61

In an asymptomatic person with human immunodeficiency virus (HIV) infection, which one of the following is the
best predictor of the future rate of decline of immune function?

A. CD4+ lymphocyte count.

B. CD8+ lymphocyte count.

C. p24 antigenaemia.

D. Plasma HIV RNA concentration.

E. Serum β2 microglobulin concentration.

Question 62

You are asked to review a 15-year-old boy regarding his short stature. He was treated for medulloblastoma at
age six with cranio-spinal irradiation. His height was on the 50th percentile at diagnosis. At age 11, when puberty
was first noticed, his height was 140 cm (25th percentile). He is now 156 cm tall and his arm span is 167 cm. His
father's height is 172 cm and his mother's height is 158 cm. Preliminary investigations include:

bone age 15 years


free thyroxine (free T4) 9 pmol/L [8-18]
thyroid-stimulating hormone (TSH) 9 mU/L [<4]
insulin-like growth factor 1 (IGF-1) 15 pmol/L [20-60]

Copyright © 2003 by The Royal Australasian College of Physicians


35 P200
Question 62 (continued)

The major cause of his short stature is:

A. attenuated pubertal growth spurt.

B. attenuated spinal growth.

C. familial short stature.

D. growth hormone deficiency.

E. hypothyroidism.

Question 63

A two-month-old girl had a murmur identified at birth. To your assessment now, she is pink and thriving. She
shows no signs of respiratory distress or other signs of heart failure. The S2 is single and there is a long
systolic murmur heard loudest at the left sternal edge. Her chest X-ray is normal and her ECG is shown
above.

Which one of the following is the most likely diagnosis?

A. Aortic stenosis.

B. Atrial septal defect.

C. Physiological peripheral pulmonary stenosis.

D. Small ventricular septal defect.

E. Tetralogy of Fallot.

Copyright © 2003 by The Royal Australasian College of Physicians


36 P200
Question 64

A 16-year-old intellectually disabled boy, living in a community residential home, is brought to you for re-
evaluation of longstanding epilepsy and autistic features. His seizures have been well controlled over the last
two years. He had early-onset epilepsy and has been given a diagnosis of autism. You notice unusual
fingernails, which are shown below.

Which one of the following is the most likely diagnosis?

A. Fabry disease.

B. Lesch-Nyhan syndrome.

C. Neurofibromatosis.

D. Tuberous sclerosis.

E. Von Hippel-Lindau disease.

Question 65

A 14-year-old boy in the second year of secondary schooling has always been anxious, insecure and isolated but
has had no previous panic or phobic symptoms. He has a few friends, but at times he behaves in an
inappropriate manner. At school, he is an average student. His teachers believe he is immature but otherwise
normal.

For the last two years, he has been masturbating, preoccupied with sexual matters and has interfered with his
parents' conversations with other adults. He worries that whenever his parents go out, they are having affairs with
other people. Over the last four months he has become irritable, moody and angrily reacts to even mild criticism
from his older brothers. He has developed a fear of germs and of being contaminated. After he has emptied his
bowels he has to have a shower and he worries about stepping on dirty band-aids. He also worries about being
attacked when he rides his bike and has to repeatedly check his windows at night, to ensure that they are locked
but even so, he finds it difficult to sleep. He spends large amounts of time with his mother but worries that if she
touches his clothes, she may become pregnant. He mostly believes that these fears are "silly" but cannot stop
worrying.

Which one of the following is the most likely diagnosis?

A. Anxiety disorder.

B. Depression.

C. Obsessive-compulsive disorder.

D. Phobic disorder.

E. Schizophrenia.

Copyright © 2003 by The Royal Australasian College of Physicians


37 P200
Question 66

In Kawasaki disease, which one of the following laboratory findings would be the least likely?

A. Aseptic meningitis.

B. Elevated serum transaminases.

C. Sterile pyuria.

D. Thrombocytopenia.

E. Toxic granulation of neutrophils.

Question 67

A four-month-old infant presents with biphasic stridor since day one of life and an unusual cry, which has been
described as ‘quiet’. The infant sucks and swallows normally. Growth and development are also normal.

The most likely cause of the stridor is:

A. infantile larynx (laryngomalacia).

B. lingual cyst.

C. subglottic haemangioma.

D. vascular ring.

E. vocal cord lesion.

Question 68

An orthopaedic surgeon was asked to see this teenager because of her foot deformities. The surgeon is
concerned about her lack of facial animation and refers her to you. Her photograph is shown below. You note
that her mother has the same expression and that the maternal grandfather recently had bilateral cataract
surgery.

Copyright © 2003 by The Royal Australasian College of Physicians


38 P200
Question 68 (continued)

This family’s disorder is characterised by which one of the following phenomena?

A. Anticipation.

B. Genomic imprinting.

C. Germinal mosaicism.

D. Lyonisation.

E. Uniparental disomy.

Question 69

A three-year-old boy presents with a three-day history of complaining of a ‘sore bottom’, which is intensely
itchy. He complains particularly of pain on defaecation and has a mucopurulent anal discharge. His anal
appearance is shown below.

Which one of the following is the most likely diagnosis?

A. Candidiasis.

B. Child sexual abuse.

C. Group A streptococcal infection.

D. Pruritus ani.

E. Threadworm infestation.

Copyright © 2003 by The Royal Australasian College of Physicians


39 P200
Question 70

A general practitioner requests your advice about a six-year-old boy who has sustained a laceration which has
been heavily soiled with manure after a fall in a horse stable. His immunisation status, confirmed by his child
health records, is as follows:

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


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

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

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

B. DTP.

C. DTP and OPV.

D. DTP, tetanus immunoglobulin and OPV.

E. Tetanus toxoid and tetanus immunoglobulin.

Question 71

An eight-year-old girl presents with recurrent urinary infection causing symptoms of dysuria and frequency.
She ceased wearing nappies during the day at two and a half years and at night at three years. Her
underpants are often damp in the afternoon and evening. Her mother states that she only passes urine two or
three times per day and she does not void at school. Urgency and posturing occur infrequently. She was
constipated as an infant and the only abnormal physical finding is the presence of palpable faecal masses on
abdominal examination.

This girl is likely to have a:

A. bladder with detrusor instability.

B. large capacity highly compliant bladder.

C. normal bladder.

D. psychological non-neuropathic bladder.

E. small capacity hypertonic bladder.

Question 72

Which one of the following blood products is likely to have the highest risk of bacterial contamination?

A. Cryoprecipitate.

B. Factor VIII concentrate.

C. Fresh frozen plasma.

D. Platelet concentrate.

E. Suspended red cells.

Copyright © 2003 by The Royal Australasian College of Physicians


40 P200
Question 73

A 15-year-old boy is brought to see his paediatrician because of longstanding difficulty climbing stairs.
Examination reveals symmetric proximal muscle weakness. A photograph of his legs is shown below.

Which one of the following is the most likely diagnosis?

A. Becker muscular dystrophy.

B. Charcot-Marie-Tooth disease.

C. Duchenne muscular dystrophy.

D. Myotonic dystrophy.

E. Spinal muscular atrophy.

Question 74

The child whose photograph and electrocardiogram are shown (see following page), has a loud systolic
ejection murmur at the upper left sternal edge, radiating to the back and axillae.

Which one of the following is the most likely diagnosis?

A. Congenitally corrected transposition of the great arteries.

B. Primum atrial septal defect (ASD).

C. Pulmonary artery branch stenoses and supra-aortic stenosis.

D. Pulmonary valve stenosis.

E. Secundum ASD.

Copyright © 2003 by The Royal Australasian College of Physicians


41 P200
Question 74 (continued)

Copyright © 2003 by The Royal Australasian College of Physicians


42 P200
Question 75

An 18-month-old child is referred by his general practitioner for paediatric assessment because of concern
about his language development. According to his mother, he seems to understand about 60 words but the
only clear words he says are "mama", "up", "shoe" and "duck".

He smiled socially at seven weeks, sat at six and a half months, crawled at nine months and walked at 14
months. He has had two known episodes of acute otitis media, at age 10 months and 13 months. He is not
yet toilet trained.

He is very active during the assessment, which his mother confirms is usual for him. He is observed to point,
to tug his mother by the hand to show her some toys, and to pretend to drink from a toy cup. Physical
examination is normal.

Which one of the following is most likely to explain this pattern of language development?

A. Asperger disorder.

B. Normal variant.

C. Persistent otitis media with effusion.

D. Sensorineural hearing loss.

E. Specific language disability.

Question 76

Testicular relapse within the first two years following initial diagnosis is more likely to occur in patients who
have which one of the following?

A. Acute monoblastic leukaemia.

B. Acute myeloid leukaemia.

C. B-lineage acute lymphoblastic leukaemia.

D. Chronic myeloid leukaemia.

E. T-lineage acute lymphoblastic leukaemia.

Question 77

A 15-year-old boy presents with a long history of obsessive-compulsive disorder and episodes of depression.
He has previously consulted psychiatrists and psychologists and now, mistrustful of conventional medicine,
sees a naturopath, but without significant alleviation of his symptoms. Although previously an excellent
student, he has lost interest in his studies and sees no point in continuing at school. He denies feeling unduly
sad but admits to some difficulties getting to sleep. Upon further questioning he describes smoking marijuana
three or four times each night to assist his insomnia.

What is the most appropriate first step in his management?

A. Encourage cessation of marijuana.

B. Prescribe sertraline.

C. Prescribe temazepam for two weeks.

D. Recommend a course of hypnosis.

E. Recommend St. John’s wort (Hypericum perforatum).

Copyright © 2003 by The Royal Australasian College of Physicians


43 P200
Question 78

A 12-year-old boy with spastic quadriplegia presents with a 24-hour history of vomiting. A gastrostomy tube
was inserted 12 months ago for supplementary enteral feeding. Currently he has a balloon gastrostomy tube
in situ. Over the past 24 hours the patient has become uncomfortable with oral drinks and solids, but has
tolerated gastrostomy tube feeds. This discomfort appears to be relieved by vomiting. A barium study is
performed (shown below).

The most likely cause of the vomiting in this boy is:

A. extravasation of feeds into the peritoneal cavity.

B. gastric erosion secondary to irritation of the gastrostomy tube tip.

C. migration of the gastrostomy balloon into the stomal tract.

D. migration of gastrostomy tube into the duodenum.

E. oesophageal stricture.

Question 79

A three-week-old boy presents with a one-week history of cough. The cough is not present all the time but
comes in bouts lasting up to a minute. For two days the baby has been breathing faster and has been having
difficulty feeding. He has had no fever.

He was born by vaginal delivery at term to an 18-year-old primigravida mother. The pregnancy was normal.
He is bottle-fed. At one week of age he developed bilateral conjunctivitis which responded to chloramphenicol
eye drops.

On examination the baby is afebrile. He is in mild respiratory distress, with a respiratory rate of 52/minute,
heart rate of 140/minute and moderate intercostal recession. He is not cyanosed. He has some fine crackles
audible at both lung bases. His chest is not clinically hyperexpanded. His heart is not enlarged and heart
sounds are normal. His oxygen saturation by pulse oximetry is 94%. His chest X-ray is shown (see following
page).

Copyright © 2003 by The Royal Australasian College of Physicians


44 P200
Question 79 (continued)

Which one of the following is the most likely infecting organism?

A. Bordetella pertussis.

B. Chlamydia trachomatis.

C. Group B Streptococcus.

D. Pneumocystis carinii.

E. Respiratory syncytial virus.

Question 80

A 28-week gestation infant collapsed on day 12 with necrotising enterocolitis. At laparotomy, the distal 30 cm
of ileum was found to be necrotic and was resected. An ileostomy was performed. The ileo-caecal valve was
preserved. An additional 20 cm of the remaining ileum had extensive intramural gas but was thought to be
viable, and was not resected. Enteral feeds were withheld for 14 days and parenteral nutrition (100
kcal/kg/day) was administered. The infant recovered uneventfully after surgery, and oral feeds (Pregestimil
20 kcal/30 mL) were recommenced on day 26. There had been a weight gain of 200 g since the laparotomy.
By day 40 enteral feeds had been increased to 90 mL/kg/day (60 kcal/kg/day). The infant was also receiving
parenteral nutrition via a central venous line in a volume of 80 mL/kg/day, providing a further 60 kcal/kg/day.
Sodium, 3 mmol/kg/day, and potassium, 3 mmol/kg/day, were administered with the parenteral nutrition
throughout. Ileostomy fluid losses were 60-80 mL/kg/day after enteral feeds were resumed. No weight gain
occurred between day 26 and day 40. There were no clinical signs of dehydration.

The following laboratory investigations were obtained on day 40:

blood:
sodium 138 mmol/L [135-145]
potassium 3.1 mmol/L [3.4-5.5]
chloride 101 mmol/L [98-110]
pH 7.25
PaCO2 44 mmHg
base excess -9 mmol/L [-4-+3]
bilirubin conjugated 220 µmol/L [<15]
bilirubin unconjugated 110 µmol/L [<15]
alanine aminotransferase (ALT) 320 U/L [0-105]
gamma glutamyltransferase (GGT) 1100 U/L [9-76]

Copyright © 2003 by The Royal Australasian College of Physicians


45 P200
Question 80 (continued)

urinary:
sodium <5 mmol/L
potassium 25 mmol/L
osmolality 120 mosmol/kg

ileostomy fluid:
sodium 70 mmol/L
potassium 12 mmol/L
chloride 52 mmol/L

The most important next step in achieving adequate weight gain is to:

A. close the ileostomy.

B. increase enteral caloric intake.

C. increase parenteral caloric intake.

D. increase sodium supplements intravenously.

E. perform a barium study to exclude a stricture.

Question 81

A three-year-old girl presents with an abnormal gait but no other symptoms. Her photograph is shown below.
Apart from the abnormality shown, her examination is otherwise normal.

Which one of the following is most commonly associated with her abnormality?

A. Craniopharyngioma.

B. Ewing sarcoma.

C. Osteosarcoma.

D. Retinoblastoma.

E. Wilms tumour.

Copyright © 2003 by The Royal Australasian College of Physicians


46 P200
Question 82

A six-year-old girl has a three-month history of pubic hair development, body odour and acne. On
examination, she has Tanner stage 1 breasts, stage 3 pubic hair and axillary hair. Her height and weight are
on the 75th percentile.

Investigations reveal:
age-specific
normal ranges
17-hydroxyprogesterone 1.6 nmol/L [0-6.0]
dehydroepiandrosterone sulphate (DHEAS) 1.5 µmol/L [0.5-1.5]
androstenedione 1.2 nmol/L [0.7-1.7]
testosterone 0.2 nmol/L [<1.0]
oestradiol 32 pmol/L [<50]
bone age six years
pelvic ultrasound normal for age

Based on these investigations, the most likely diagnosis is:

A. adrenal tumour.

B. benign premature adrenarche.

C. congenital adrenal hyperplasia.

D. idiopathic precocious puberty.

E. polycystic ovary syndrome.

Question 83

The following results are obtained from a two-day-old male infant.

IgG 6.53 g/L [5.34-16.94]


IgA <0.10 g/L [0-0.07]
IgM <0.09 g/L [0-0.18]
IgE <5 kU/L [<25]
Haemoglobin 189 g/L [145-225]
Red cell count 5.06 x 1012/L [4.00-6.60]
Platelet count 326 x 109/L [150-400]
White cell count 11.5 x 109/L [5.0-21.0]
Differential:
band forms 0.68 x 109/L (6%)
neutrophils 9.01 x 109/L (78%)
lymphocytes 0.10 x 109/L (1%)
monocytes 1.37 x 109/L (12%)
eosinophils 0.34 x 109/L (3%)

These findings are most consistent with which one of the following?

A. IgA deficiency.

B. Kostmann syndrome.

C. Normal results.

D. Severe combined immune deficiency.

E. X-linked agammaglobulinaemia.

Copyright © 2003 by The Royal Australasian College of Physicians


47 P200
Question 84

A 10-day-old baby with Down syndrome, born after a high forceps delivery, develops poor feeding, hypothermia
and lethargy. A magnetic resonance imaging (MRI) scan with contrast of her brain was performed and is shown
below.

The MRI is most suggestive of:

A. a cerebral abscess.

B. an infarct involving the right internal capsule.

C. an intracerebral haematoma.

D. intracerebral calcification.

E. ring artefact.

Question 85

An 11-year-old girl presents with a 10-month history of episodic abdominal pain, which clusters over a two to
three-day period. The pain is described as constant, lasting for 40 minutes to one hour and localised to the
mid-abdomen. There is no clear relationship of the pain to meals, specific foods, activity or stool pattern. She
has no associated vomiting, weight loss, or joint pain.

On examination she is a well looking pre-pubertal girl, weight 35 kg (50th percentile) and height 140 cm (25th
percentile). Her abdomen is soft with mild diffuse tenderness noted throughout on deep palpation. There is
no rebound tenderness elicited. There is no organomegaly or masses felt. The remainder of the examination
is normal.

Which one of the following would most suggest an organic cause for this girl’s pain?

A. Failure to respond to analgesia.

B. Frequent school absenteeism.

C. Frequent waking from sleep due to pain.

D. Nausea occurring at the time of pain.

E. Positive family history of similar pain.

Copyright © 2003 by The Royal Australasian College of Physicians


48 P200
Question 86

A seven-year-old boy wakes one morning with severe leg pain, predominantly in the calf muscles after an upper
respiratory tract infection four days previously. He is unable to walk but is otherwise well. The casualty officer
thinks that there is weakness distally and has difficulty obtaining reflexes. The boy experiences a lot of calf pain
on examination. His serum creatine kinase is 2,000 U/L [40-240].

Which one of the following is the most likely diagnosis?

A. Dermatomyositis.

B. Guillain-Barré syndrome.

C. Reactive arthritis.

D. Rhabdomyolysis.

E. Viral myositis.

Question 87

A male infant was born at 35 weeks gestation following premature rupture of membranes. Hypothermia and
unconjugated hyperbilirubinaemia were problems during the newborn period.

He presents at six months with myoclonic seizures and is found to be globally developmentally delayed. He is
not rolling, does not reach for objects (although he is reported to have done so previously) and does not
vocalise normally. There is generalised mild hypotonia but no focal neurological signs. He has hair which
breaks easily, leaving generally short hair with a stubbly feel to his scalp. His photograph is shown below.
His mother is said to have had similar hair as a child. A maternal uncle had seizures and developmental delay
and died at age three years.

Which one of the following investigations is most likely to yield a diagnosis?

A. Cranial computed tomography (CT) scan with contrast.

B. Nerve conduction studies.

C. Serum copper levels.

D. Serum zinc levels.

E. Urine metabolic screen.

Copyright © 2003 by The Royal Australasian College of Physicians


49 P200
Question 88

The child pictured below is noted to have a grade 4/6 systolic murmur.

Which one of the following is the most likely diagnosis?

A. Atrioventricular septal (A-V canal) defect.

B. Hypertrophic cardiomyopathy.

C. Pulmonary valve stenosis.

D. Supravalvular aortic stenosis.

E. Ventricular septal defect.

Question 89

You are called to see a four-year-old girl with seal-like barking cough, severe inspiratory stridor, marked wheeze
and agitation. Her oxygen saturation is 89% in room air.

Which one of the following would be the most appropriate immediate therapy in addition to oxygen?

A. Nebulised adrenalin.

B. Nebulised ipratropium.

C. Nebulised salbutamol.

D. Nebulised steroids.

E. Oral steroids.

Copyright © 2003 by The Royal Australasian College of Physicians


50 P200
Question 90

A five-year-old child presents with fever, vomiting, neck stiffness and a petechial rash. All of the following are
contraindications to immediate lumbar puncture except:

A. hypertension.

B. hypotension.

C. intractable fitting.

D. mild weakness of left arm.

E. moderate drowsiness (Glasgow coma score of 10).

Question 91

A four and a half-year-old girl is referred for investigation of short stature. Her birthweight was 2650 g and length
48 cm at term. Her mid parental height is 164 cm (50th percentile). At age two, her length was on the 10th
percentile. Her health is good except for recurrent otitis media.

Physical examination reveals no dysmorphic features but she has thickened tympanic membranes with fluid
behind the drums. Her current height is 95 cm (1st percentile) and weight is 14 kg (10th percentile).

Which one of the following investigations is most likely to establish a diagnosis?

A. Bone age.

B. Endomysial antibody.

C. Insulin-like growth factor 1.

D. Karyotype.

E. Thyroid-stimulating hormone.

Question 92

Copyright © 2003 by The Royal Australasian College of Physicians


51 P200
Question 92 (continued)

A newborn infant delivered vaginally after a pregnancy complicated by polyhydramnios, presents with
intermittent respiratory distress. The radiograph shown (see previous page) was taken.

Which one of the following is the most likely cause of her respiratory difficulties?

A. Congenital myotonic dystrophy.

B. Duodenal atresia.

C. H-shaped tracheo-oesophageal fistula.

D. Meconium aspiration syndrome.

E. Oesophageal atresia.

Question 93

A six-month-old girl presents with a 14-day history of diarrhoea. The illness initially began with fever, vomiting and
diarrhoea. Her vomiting and fever resolved after 36 hours, however, her stools have remained watery and loose.
She has recommenced on her usual cow’s milk based formula and solids including pureed fruit and vegetables.
On examination she is a tired but not unwell looking girl. Her weight is on the 25th percentile for age and height is
on the 50th percentile for age. She is not dehydrated or clinically pale. She has no rashes. Her abdominal
examination reveals a soft non-tender abdomen with no masses or hepatosplenomegaly. The following blood
tests were performed:

sodium 138 mmol/L [135-145]


potassium 4.2 mmol/L [3.5-5.1]
chloride 107 mmol/L [98-110]
urea 2.5 mmol/L [1.3-6.6]
creatinine 0.05 mmol/L [0.01-0.05]

Examination of the stool is most likely to reveal:

A. pH 3.

B. reducing substance negative.

C. rotavirus antigen.

D. sodium 110 mmol/L.

E. white blood cells.

Question 94

A 15-year-old girl lives in a rural town where you consult once per month. She presents with a 12-month
history of anxiety-based symptoms, which have prevented her from attending school.

She describes a sense of dread if she is away from home, associated with palpitations, sweating and a heavy
feeling in her chest. She finds it difficult to fall asleep and has numerous nightmares. She worries about
germs and frequently washes her hands. She also describes magical thoughts in that she dreads something
bad will happen if she tapes over her old videos. She believes that these thoughts are silly.

Prior to the onset of her symptoms, she functioned well at school and had many friends. She was not aware
of any pressures at the time.

She lives with her father and a 20-year-old sister, her mother having died from a cerebral haemorrhage eight
years ago. There is no family history of psychiatric illness. She refuses to see a psychiatrist but is willing to
continue to see you.

Copyright © 2003 by The Royal Australasian College of Physicians


52 P200
Question 94 (continued)

In addition to further counselling, which one of the following medications is most appropriate?

A. Amitriptyline.

B. Clomipramine.

C. Oxazepam.

D. Paroxetine.

E. Thioridazine.

Question 95

A 14-year-old boy presents with a history of recurrent chest infections, often with wheeze, since five years of
age. He lives with his family on a sheep farm.

Over the last two years he coughs about half a cup of green or yellow sputum into the sink each morning
when he wakes. He does not complain of breathlessness and copes normally with school sports.

He looks well and has no finger clubbing. He is on the 25th percentile for height and weight. His chest is not
hyperexpanded and respiratory examination reveals only coarse crackles at the left base. The rest of the
physical examination is normal. His chest X-ray is shown below.

Which one of the following is the most likely diagnosis?

A. Bronchiectasis.

B. Cystadenomatoid malformation.

C. Diaphragmatic hernia.

D. Hydatid disease.

E. Staphylococcal pneumatoceles.

Copyright © 2003 by The Royal Australasian College of Physicians


53 P200
Question 96

Which one of the following conditions is most likely to be responsive to treatment with interferon alpha?

A. Arterio-venous malformation.

B. Hepatoblastoma.

C. Large capillary haemangioma.

D. Neuroblastoma.

E. Wilms tumour.

Question 97

An 18-month-old boy was referred by his general practitioner to a paediatrician for advice about febrile
seizures.

The child has had three previous episodes of febrile convulsions, the first at 13 months of age. On each
occasion, two seizures have occurred in a 24-hour period. Each seizure was brief (less than five minutes) in
the setting of a high fever (greater than 39°C). The child is developing normally and his neurological
examination is unremarkable. The child’s father has a history of febrile seizures.

The risk of epilepsy in this child is approximately:

A. 0.5%.

B. 2%.

C. 5%.

D. 10%.

E. 15%.

Question 98

A two and a half-year-old girl is referred for developmental assessment. Her parents report that she has 10 to 15
single words in her vocabulary and one recognisable two word phrase. Her pronunciation of words is not always
clear. She seems to understand most things said to her. Audiological testing is normal. She is physically very
active and finds it difficult to settle to task. However, she can sit and watch television for up to five minutes. She
plays with toy cars by pushing them up and down repeatedly and making engine noises. She also enjoys playing
with dolls and will kiss, hug, scold, pretend to feed them, and push them around in a toy pram. However, she
does not play cooperatively or interactively with other children, and is somewhat self-absorbed. She runs, climbs
a playground slide, scribbles with a crayon and can feed herself with a spoon. She can also drink from a cup and
take off some of her clothes. She tantrums if things do not go her way and screams on separation from her
mother. She becomes highly agitated and cries when the vacuum cleaner is turned on. She is also frightened of
the neighbour's dog.

What is the one best explanation for this child?

A. Anxiety disorder.

B. Autistic spectrum disorder.

C. Intellectual disability.

D. Isolated speech delay.

E. Normal variation.

Copyright © 2003 by The Royal Australasian College of Physicians


54 P200
Question 99

The clinical photograph shown above was taken soon after birth. The infant was delivered vaginally at 34
weeks gestation after premature onset of labour. Birth weight was 2800 g (>90th percentile).

The lesion was covered with a polythene film, and intravenous 10% dextrose was commenced shortly after
delivery. At one hour of age the infant’s core temperature was 35.8°C and the plasma glucose was 0.8
mmol/L.

Which one of the following is the most likely cause for the plasma glucose reading?

A. Abnormal insulin secretion.

B. Cold stress.

C. Defect in fatty acid oxidation.

D. Delayed serum cortisol response.

E. Impaired glycogenesis.

Copyright © 2003 by The Royal Australasian College of Physicians


55 P200
Question 100

A 14-year-old boy presents with a three-week history of dyspnoea and a dry, hacking cough. On examination
there are diffuse crackles throughout his chest and an enlarged liver. His immunoglobulins are elevated and
he has eosinophilia. He has had recurrent parotid swelling and a transient facial nerve lesion. His chest X-ray
is shown below.

Which one of the following is the most likely diagnosis?

A. Churg-Strauss syndrome.

B. Lymphocytic interstitial pneumonitis.

C. Mycoplasma infection.

D. Sarcoidosis.

E. Sjögren’s syndrome.

Copyright © 2003 by The Royal Australasian College of Physicians


56 P200

2000 FRACP Written Examination

Paediatrics & Child Health

Paper 2 – Clinical Applications

Answers

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

Copyright © 2003 by The Royal Australasian College of Physicians