You are on page 1of 13

Q1. 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.

Q2. 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%.

Q3. 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.

Q4. 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.
In addition to further counselling, which one of the following medications is most appropriate?
A. Amitriptyline.
B. Clomipramine.
C. Oxazepam.
D. Paroxetine.
E. Thioridazine.

Q5. 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.

Q6. 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.

Q7. 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).

Q8. 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.

Q9. 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.
Q10. 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.

Q11. 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 10 /L [4.00-6.60]
Platelet count 326 x 10 /L [150-400]
White cell count 11.5 x 10 /L [5.0-21.0]
band forms 0.68 x 10 /L (6%)
neutrophils 9.01 x 10 /L (78%)
lymphocytes 0.10 x 10 /L (1%)
monocytes 1.37 x 10 /L (12%)
eosinophils 0.34 x 10 /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.

Q12. 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:
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.

Q13. 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:
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]
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.

Q14. 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).

Q15. 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.

Q16. 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.

Q17. 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.

Q18. 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.

Q19. 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.
C. DTP and OPV.
D. DTP, tetanus immunoglobulin and OPV.
E. Tetanus toxoid and tetanus immunoglobulin.

Q20. 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
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.

Q21. 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.

Q22. 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.

Q23. 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]
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.
Q24. 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.

Q25. 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.

Q26. 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
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.

Q27. 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.

Q28. 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.

Q29. Which one of the following sets of urinary electrolytes is most likely to be found in established pyloric

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

Q30. A 2-year-old female child presents with VT, severe ventricular dysfunction,
hypotension, and metabolic acidosis. The patient is cardioverted into ventricular
fibrillation, which degenerates into asystole. What is the most appropriate indication for
using intravenous epinephrine in this patient?
a) Ventricular ectopy
b) Asystole
c) Severe refractory metabolic acidosis and/or hyperkalemia
d) Bradycardia
e) Supraventricular tachycardia

Q31) A 16-year-old female patient presents with short stature and no secondary sexual
characteristics. What diagnosis must be considered?
a) Turner syndrome
b) Isolated growth hormone deficiency
c) Cushing disease
d) Familial short stature
e) Addison disease

Q32) Galactosemia, a disorder of carbohydrate metabolism, is inherited in an autosomal
recessive fashion. What is the risk of galactosemia in a child whose parents are both
carriers for the disorder?
a) 100%
b) 75%
c) 50%
d) 25%
e) 0%

Q33) Which of the following statements is true regarding children with sickle cell disease?
a) Vaccinations are not required because they receive penicillin prophylaxis
b) Gallstones typically develop before the age of 3 years
c) Episodes of dactylitis should be treated with antibiotics
d) Hydroxyurea maintenance therapy decreases the number and severity of vasoocclusive
e) Acute chest syndrome requires only supportive care

Q34) A mother brings her 5-year-old son to your office in New Mexico for his regular health
maintenance visit. A quick review of the patient's chart reveals that he and his family are
strict vegans. Their house is very small, so all the children spend a good deal of time
outside. The mother states that her son eats plenty of dark green vegetables and ironfortified
grains. She does not believe in providing supplemental vitamins and minerals.
This child is most at risk for nutritional deficiency involving which of the following?
a) Vitamin B12
b) Vitamin B6
c) Niacin
d) Riboflavin
e) Vitamin D

Q35) A 6-year-old boy presents with a newly appreciated heart murmur. He is
asymptomatic, with normal growth and development and normal exercise tolerance. On
examination S1 and S2 are normal; a II/VI low-frequency midsystolic murmur is heard at
the left lower sternal border. His pulses are normal. The most likely diagnosis is:
a) Bicuspid aortic valve
b) Still's murmur
c) Ventricular septal defect
d) Atrial septal defect
e) Coarctation of the aorta

Q36) You are called to the delivery room for a routine birth. The infant cries when the cord
is cut. You examine the child under the warmer and notice that when he stops crying, his
chest heaves, and he turns blue. You are unable to pass the NG tube through the nose for
suctioning. Which condition is most likely causing this infant's respiratory distress?
a) Choanal atresia or stenosis
b) Vocal cord paralysis
c) Subglottic stenosis
d) Recurrent laryngeal nerve damage
e) Laryngeal web

Q37) A 3-year-old girl is diagnosed with new-onset insulin-dependent diabetes mellitus.
Which of the following laboratory findings is consistent with diabetic ketoacidosis?
a) Hypoglycemia
b) Hypercarbia
c) Ketones in urine
d) Increased venous blood pH
e) Decreased BUN

Q38) During a male newborn examination, the testes are not palpable in the scrotal sacs.
One testis is palpable high in the right inguinal canal and cannot be gently manipulated
into the anatomically correct position. The left testis is not palpable but is discovered in
the abdomen after consultation with a pediatric urologist and an abdominal ultrasound. In
counseling the parents, which one of these statements regarding cryptorchidism is true
a) More than 99% of males have bilateral descended testes at age 1 year
b) Impaired sperm production is not a concern if neither testis descends
c) Malignant degeneration is not a risk factor for testes, which do not descend as
long as they are placed within the scrotal sac through surgery by 1 year of age
d) This infant is no more likely than his peers to manifest an inguinal hernia
e) Microphallus is a common associated condition

Q39) A 5-year-old boy presents with a waddling limp and has had a stiff right hip for the
last 2 months. He has minimal complaints of pain. The most likely diagnosis is:
a) Legg-Calve-Perthes disease
b) Slipped capital femoral epiphysis
c) Toddler's fracture
d) Septic arthritis
e) Juvenile idiopathic arthritis

Q40) A 17-year-old young girl on oral contraceptive therapy for regulation of her
menstrual periods presents with a 1-week history of left leg pain and swelling. Evaluation
with a Doppler ultrasound reveals absence of flow in the left femoral and popliteal veins.
The clot extends proximally to the left external iliac vein. The most important potential
complication that one should be cautious about in this girl is:
a) Venous insufficiency
b) Limb overgrowth
c) Pulmonary embolism
d) Edema
e) Gangrene
Q41) A woman with a seizure disorder under medical management wants to conceive a
child. Her risk of having a child with a neural tube defect is greatest if her current
medical regimen includes which of the following?
a) Phenobarbital
b) Phenytoin
c) Ethosuximide
d) Carbamazepine
e) Primidone

Q42) A 2-month-old infant presents to your emergency department with a heart rate of 220
beats/minute, pulses, and adequate perfusion. After giving the infant oxygen, you note
abnormal P waves and a narrow QRS (!0.08 sec) on the cardiac monitor. Which of the
following is the best course of action?
a) Administer IV/IO epinephrine
b) Administer IV adenosine by rapid bolus
c) Administer IV calcium chloride
d) Administer IV atropine by rapid bolus
e) Administer IV sodium bicarbonate
Q43) A 3-month-old infant presents with a history of abnormal movements that his parents
think might be seizures. You observe an episode of recurrent rhythmic flexor-extensor
spasms that repeat about 30 times before subsiding. The EEG shows hypsarrhythmia, and
a Wood lamp exam is positive for several flat, hypopigmented macules scattered over the
skin surface. This child's infantile spasms are most likely a result of which of the
following underlying disorders?
a) Von Recklinghausen disease
b) Tuberous sclerosis
c) Von Hippel-Lindau disease
d) Sturge-Weber disease
e) Bilateral acoustic neurofibromatosis

Q44) A 21-month-old girl arrives at clinic in May with a vaccination record that indicates
that she has received 3 DTaP doses, 3 Hib doses, 3 IPV doses, 3 pneumococcal conjugate
vaccine doses, 2 hepatitis A vaccine doses, and 3 hepatitis B vaccine doses. Which of the
following should be administered at this visit?
a) DTaP, Hib, IPV, varicella
b) DTaP, Hib, pneumococcal conjugate vaccine, MMR, and varicella
c) DTaP, hepatitis A, IPV, pneumococcal conjugate vaccine
d) DTaP, hepatitis B, MMR, and varicella
e) DTaP, hepatitis A, IPV, MMR, and varicella

Q45) The mother of a 30-month-old boy is concerned that the child's speech is “garbled.”
The child uses “ma-ma” and “da-da” appropriately. He uses about 30 other words, but
most of them are mispronounced (for instance, “boo” instead of “blue”). The boy's aunt,
uncle, and cousins came to visit for a weekend and were unable to understand more than
half of what he said. Examination of the ears reveals normal canals with translucent,
mobile tympanic membranes, and visible landmarks. Which of the following evaluations
for speech delay should be performed first?
a) Receptive language testing
b) Phonetic testing
c) Dysfluency evaluation
d) Tympanogram testing
e) Audiologic (hearing) assessment

Q46) A 13-year-old girl presents with recurrent abdominal pain over the last 3 months. She
has missed a total of 8 days of school. There is no associated fever, weight loss,
gastrointestinal bleeding, and the pain does not occur in relation to meals or awaken her
from sleep. There is diffuse abdominal tenderness but no other abnormal findings on
examination. Which approach is likely to help in the diagnosis and management of her
a) Abdominal CT scan with contrast
b) Upper and lower endoscopy and biopsies
c) Explaining the likely etiology of her symptoms using a biopsychosocial model
and symptomatic therapy
d) A diet history and a diet elimination trial
e) Referral to a psychiatrist

Q47) A newborn male child has a flat facial profile, upslanted palpebral fissures, epicanthal
folds, a small mouth with a protruding tongue, small genitalia, and simian creases on his
hands. What of the following chromosomal disorders is most likely in this child?
a) Trisomy 21
b) Trisomy 18
c) Trisomy 13
d) Klinefelter syndrome
e) Turner syndrome

Q48) At a 2-year well-child visit, you collect information that your patient lives in a very
old rental home with peeling paint. Both the capillary (screening) and venous blood lead
measurements are 50 "g/dL. The patient has a history of constipation but is otherwise
asymptomatic. Which of the following courses of action is most appropriate?
a) Initiate chelation therapy in a lead-free environment within 48 hours
b) Redraw the blood lead level in 1 week and test all siblings; treat if #50 "g/dL
c) Optimize calcium and iron intake and repeat the blood lead level in 1 month;
treat if #50 "g/dL
d) Refer the family to a lead-removal company; repeat the blood lead level 1
month after decontamination of the home, and treat if #50 "g/dL
e) Refer the case to child protective services for parental neglect

49) A young couple is in your office for their prenatal visit, and you are discussing infant
feeding. The father states that he prefers that the mother breastfeed the baby. The mother
is hesitant to commit to breastfeeding because she plans on returning to full-time
employment 6 weeks after the child is born. Neither her mother nor her sisters chose to
breastfeed. She is concerned that human breast milk may not provide all the nutrients that
the child needs, and she believes formula is a more complete nutritional source for
infants. She is willing to consider exclusive breastfeeding based on the American
Academy of Pediatrics recommendation. If her baby is exclusively breastfed, when
should the child begin receiving oral vitamin D supplementation?
a) Never
b) Within the first month of life
c) Age 2 months
d) Age 4 months
e) Age 6 months

Q50) A 12-year-old female patient presents with fever, night sweats, weight loss, fatigue,
anorexia, and painless, rubbery, cervical lymphadenopathy. What is the most common
presentation of Hodgkin disease?
a) Fever, night sweats, and/or weight loss of >10% in the preceding 6 months
b) Mediastinal lymphadenopathy
c) Painless, rubbery, cervical lymphadenopathy
d) Pruritus
e) Extreme fatigue and anorexia
Answer Key:
1. D
2. B
3. C
4. D
5. A
6. D
7. E
8. A
9. E
10. C
11. D
12. B
13. D
14. A
15. E
16. B
17. D
18. B
19. D
20. E
21. D
22. C
23. B
24. D
25. A
26. A
27. D
28. B
29. A
30. B
31. A
32. D
33. D
34. A
35. B
36. A
37. C
38. A
39. A
40. C
41. D
42. B
43. B
44. B
45. E
46. C
47. A
48. A
49. B
50. C