2005 Paper B

Question 1

An eight-year-old boy presents with moderately severe cellulitis involving the left shin. The most appropriate empiric antibiotic treatment would be:
A. benzylpenicillin plus flucloxacillin.
B. benzylpenicillin plus gentamicin.
C. cefotaxime.
D. flucloxacillin.
E. vancomycin.

Answer 1

D. flucloxacillin.

Question 2

An eight-year-old boy with attention deficit hyperactivity disorder (ADHD) and oppositional-defiant disorder is being treated with stimulant medication, with benefits reported at both school and home. What further functional improvement might be expected from adding intensive clinic-based behavioural intervention to his stimulant medication therapy?
A. Improved compliance in the classroom.
B. Reduced hyperactivity.
C. Reduced impulsivity.
D. Reduced inattention.
E. Reduced oppositional/aggressive behaviour.

Answer 2

E. Reduced oppositional/aggressive behaviour.

Question 3

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


A. Type I.

B. Type II.

C. Type III.

D. Type IV.

E. Type V.

Answer 3

D. Type IV.

Question 4

A healthy three-year-old girl presents with a squint. On examination, visual acuity is diminished in the left eye. The magnetic resonance imaging (MRI) scan of her head is shown opposite. Which one of the following inherited conditions is she most likely to have?
A. Familial retinoblastoma.
B. Neurofibromatosis type 1.
C. Sturge-Weber syndrome.
D. Tuberous sclerosis.
E. Von Hippel-Lindau disease.

Answer 4

B. Neurofibromatosis type 1.

Question 5

A 14-year-old girl presents to the emergency department with a four-day history of headache and blurring of vision. She has previously been well. She is on no medication.
On examination she is very confused and disorientated. Her blood pressure is 230/140 mmHg. Her jugular venous pressure (JVP) is not elevated, heart sounds are normal and lung bases clear. Her reflexes are generally brisk. Fundoscopy shows bilateral haemorrhages, exudates and papilloedema.
Which of the following is the most appropriate treatment?
A. Intramuscular hydralazine.
B. Intravenous frusemide.
C. Intravenous sodium nitroprusside.
D. Oral enalapril.
E. Oral nifedipine.

Answer 5

C. Intravenous sodium nitroprusside.

Question 6

A seven-year-old girl is referred with a history of increasing daytime wetting, characterised by loss of urine control when laughing and particularly when being tickled. Her classmates are causing embarrassment by tickling her in the playground.
Her past history suggests no neurodevelopmental problems. She had a single urinary tract infection at 18 months of age, followed by a normal renal ultrasound. Physical examination is normal.
Which of the following is the most appropriate therapy?
A. Behavioural therapy.
B. Imipramine.
C. Oxybutynin.
D. Pelvic floor exercises.
E. Vasopressin spray.

Answer 6

C. Oxybutynin.

Question 7

A six-year-old boy presents with a five-week history of polyuria and polydipsia. There is no family
history of autoimmune disease. Investigations are as follows:

Which of the following tests would confirm the diagnosis?
A. Antibodies for type 1 (insulin-dependent) diabetes mellitus.
B. Magnetic resonance imaging (MRI) of brain.
C. Oral glucose tolerance test.
D. Renal ultrasound.
E. Water deprivation test.

Answer 7

E. Water deprivation test.

Question 8

An otherwise normal two-year-old girl requires surgical repair of a large secundum atrial defect. There is no other family history of congenital heart disease. Her parents are concerned about the risk that their next child will also have congenital heart disease. This risk is closest to:
A. 0.5%.
B. 2.5%.
C. 6%.
D. 12.5%.
E. 25%.

Answer 8

B. 2.5%.

Question 9

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

A Anal fissure.

B. Bacterial gastroenteritis.

C. Food protein proctocolitis.

D. Juvenile polyp.

E. Swallowed maternal blood.

Answer 9

C. Food protein proctocolitis.

Question 10

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

What would be the most appropriate next step?
A. Extubate to nasal continuous positive airways pressure (CPAP).
B. Make no ventilator changes.
C. Reduce inspiratory time to 0.3 seconds.
D. Reduce PIP by 2 cm H2O.
E. Wean rate to 20/minute.

Answer 10

D. Reduce PIP by 2 cm H2O.

Question 11

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

In addition to gradually advancing her bedtime to an earlier time, bright light therapy is recommended. This is most effective if undertaken at which of the following time periods?
A. Early morning.
B. Late morning.
C. Mid afternoon.
D. Evening.
E. Prior to retiring.

Answer 11

A. Early morning.

Question 12

A nine-year-old girl with cystic fibrosis presents to clinic with a cough productive of brown sputum. Her chest X-ray is shown opposite.
The most likely diagnosis is:
A. allergic bronchopulmonary aspergillosis.
B. atypical mycobacterium infection.
C. Burkholderia cepacia infection.
D. Staphylococcus aureus infection.
E. Stenotrophomonas maltophilia infection.

Answer 12

A. allergic bronchopulmonary aspergillosis.

Question 13

An eight-year-old girl presents with ketoacidosis and is diagnosed with type 1 (insulin-dependent) diabetes mellitus.
Which of the following autoimmune comorbidities is she most at risk of developing?
A. Addison disease.
B. Hypoparathyroidism.
C. Hypothyroidism.
D. Primary ovarian failure.
E. Vitiligo.

Answer 13

C. Hypothyroidism.

Question 14

A three-year-old boy is brought to the emergency department of a small rural hospital 30 minutes after being involved in an unwitnessed explosion at his family home. On examination he has sustained facial burns with singeing of his eyebrows and eyelashes. He has a non-circumferential burn to the anterior neck and his estimated percentage of body surface area (BSA) burnt is 5%. He is alert, pink in air and in no respiratory distress. His parents feel that his voice is now ‘croaky’ and you notice a hoarse cough.
Which of the following is the first priority in caring for this patient?
A. Commence intravenous fluids at maintenance.
B. Commence intravenous morphine infusion.
C. Prepare for endotracheal intubation.
D. Urgent ambulance transfer to a tertiary level paediatric hospital.
E. Urgent medical retrieval team to come to the patient.

Answer 14

C. Prepare for endotracheal intubation.

Question 15

A seven-year-old girl is brought into the emergency department with a generalised rash. Her arm is shown above. This rash is most commonly found in association with:
A. administration of carbamazepine.
B. administration of cefaclor.
C. enterovirus infection.
D. herpes simplex virus (HSV) infection.
E. Mycoplasma pneumoniae infection.

Answer 15

D. herpes simplex virus (HSV) infection.

Question 16

A four-year-old boy presents with language impairment. His first words were at 18 months. He exhibits anger when he is not understood. His preschool teacher reports that he has difficulty following or understanding basic instructions, often responding inappropriately with talk about his dinosaurs.
His conversation is difficult to follow, with confusing replies. E.g.:
Question: “What did you do at preschool?
Answer: “Time to get in car, and drive long way all way home”
He is heard with playmates responding unclearly. E.g.:
Statement: “I’m making a green snake with playdoh”
Reply: “Greg and Anthony go up the big red car on Wiggles TV”
His language problems are most likely due to:
A. dyspraxia.
B. hearing impairment.
C. intellectual impairment.
D. phonological delay.
E. semantic pragmatic disorder.

Answer 16

E. semantic pragmatic disorder.

Question 17

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

Which of the following findings is most suggestive of a poor long-term prognosis?
A. Nadir serum creatinine > 0.1 mmol/L.
B. Persistent bladder dilatation.
C. Persistent hydronephrosis.
D. Persistent ureteric reflux.
E. Poor urinary stream.

Answer 17

A. Nadir serum creatinine > 0.1 mmol/L.

Question 18

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

Which of the following viral exanthema have been associated with this clinical scenario?
A. Coxsackie.
B. Measles.
C. Parvovirus.
D. Rubella.
E. Varicella.

Answer 18

E. Varicella.

Question 19

A term male infant with a birth weight of 2800 g is born at a level 2 rural hospital. He is noted to have a large cleft palate and significant micrognathia. At two hours of age he is noted to be in severe respiratory distress with marked subcostal and sternal recession. On auscultation, very poor breath sounds are audible bilaterally. His condition is improved in the prone position, however he becomes intermittently cyanosed and severe respiratory distress is punctuated by brief apnoeic episodes.
The most appropriate course of action would be:
A. administer head box oxygen.
B. administer oxygen via nasal prongs.
C. insert an endotracheal tube.
D. insert a nasopharyngeal tube.
E. insert an oral airway.

Answer 19

D. insert a nasopharyngeal tube.

Question 20

A three-year-old girl is admitted to hospital with a two-day history of purpuric rash on the buttocks. Over the last day, she has also developed a painful, swollen left ankle.
On examination she has a temperature of 38°C, palpable purpura on her buttocks and calves, and a warm, swollen left ankle. Her hands and feet are slightly swollen.
Over the next two days she develops intermittent, severe, colicky central abdominal pain. She has non-bilious vomiting and passes blood per rectum. In between bouts of pain her abdomen is soft, nondistended and generally tender with no guarding. There are no masses palpable.
The most appropriate next investigation is:
A. abdominal ultrasound.
B. air enema.
C. barium enema.
D. diagnostic laparoscopy.
E. stool culture.

Answer 20

A. abdominal ultrasound.

Question 21

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

His blood film is shown above. The most appropriate next investigation to confirm the diagnosis is:
A. direct antiglobulin test.
B. haemoglobin electrophoresis.
C. osmotic fragility test.
D. parvovirus B19 IgM.
E. serum haptoglobin.

Answer 21

A. direct antiglobulin test.

Question 22

A three-year-old girl presents with a two-month history of two lumps on the left side of her neck and jaw as shown above. Which of the following is the most appropriate initial management?
A. Excision of the lesions.
B. Intravenous flucloxacillin.
C. Needle biopsy of one of the lesions.
D. Oral cephalexin.
E. Oral clarithromycin.

Answer 22

A. Excision of the lesions.

Question 23

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

A. High-arched palate.

B. Long face.

C. Macro-orchidism.

D. Motor tics.

E. Poor eye contact.

Answer 23

E. Poor eye contact.

Question 24

An eight-month-old girl presents with a history of cough and recurrent chest infections. A clinical photograph and chest X-ray of the patient are shown opposite.
Which one of the following is the most likely cause of this infant’s clinical presentation?
A. Lymphoma.
B. Neuroblastoma.
C. Retinoblastoma.
D. Sarcoidosis.
E. Thymoma.

Answer 24

B. Neuroblastoma.

Question 25

A nine-year-old boy is brought in by his mother, with a story of increasingly difficult behaviour at home, and especially at school. He is in grade three. He is disruptive, calls out, distracts other children, and consistently fails to complete written work. He has been lashing out at peers and the teacher, and spends most of his lunchbreaks in class to catch up on work. His mother reports that his behaviour in preschool and grade one presented few problems.
He shows strengths in maths and science, but struggles with reading and written work. He is left handed, and his handwriting is particularly messy. When made to repeat work, he becomes angry and has occasionally abused his teacher.
At home, there are constant battles to get him to sit down in the evening to do his homework with his sister. He constantly interrupts his sister, and intentionally destroys her work.
The most likely primary diagnosis is:
A. attention deficit disorder (without hyperactivity).
B. autismspectrumdisorder.
C. intellectual impairment.
D. oppositional defiant disorder.
E. specific learning disorder.

Answer 25

E. specific learning disorder.

Question 26

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

Which of the following conclusions is most justifiable based upon the available data?
A. The ECG is consistent with the echocardiogram and the VSD is large.
B. The ECG is consistent with the echocardiogram and the VSD is small.
C. The ECG is not consistent with the echocardiogram and there may be unrecognised left heart obstruction.
D. The ECG is not consistent with the echocardiogram and there may be unrecognised right heart obstruction.
E. The ECG should be repeated as the limb leads are crossed.

Answer 26

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

Question 27

Middle ear effusion is an essential criterion for the diagnosis of both acute otitis media and otitis media with effusion. Compared to myringotomy as the gold standard, which diagnostic technique is most accurate (i.e. has the highest sensitivity and specificity)?
A. Acoustic reflectometry.
B. Audiometry.
C. Otoscopy.
D. Pneumatic otoscopy.
E. Tympanometry.

Answer 27

D. Pneumatic otoscopy.

Question 28

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

Her electroencephalogram (EEG) is shown below.

A diagnosis of juvenile myoclonic epilepsy is made.
Which of the following anticonvulsants should not be prescribed?
A. Carbamazepine.
B. Clobazam.
C. Clonazepam.
D. Lamotrigine.
E. Topiramate.

Answer 28

A. Carbamazepine.

Question 29

A four-week-old infant presents with persistent diarrhoea. On examination the infant displays swollen
upper eyelids and ascites.
Faecal microscopy:
fat globules
fatty acid crystals white blood cells
Full blood count:
haemoglobin white cell count neutrophils lymphocytes
His investigations are shown below.

Which of the following is the most likely diagnosis?
A. Alpha-1-antitrypsin deficiency.
B. Coeliac disease.
C. Cystic fibrosis.
Which of the following is the most likely diagnosis?
A. Alpha-1-antitrypsin deficiency.
B. Coeliac disease.
C. Cystic fibrosis.
D. Intestinal lymphangiectasia.
E. Nephrotic syndrome.
E. Nephrotic syndrome.

Answer 29

D. Intestinal lymphangiectasia.

Question 30

A 16-year-old girl is brought to the emergency department by her mother following the ingestion of an unknown quantity of paracetamol. Four hours post-ingestion her paracetamol serum levels are non- toxic. She is poorly communicative but states that she does not feel life is worth living anymore and that she had hoped she would be able to ‘end it all’. Her mother states that the girl has attempted suicide previously and that she is currently under the care of a private psychiatrist with whom she has an appointment in one week. The mother feels the girl is overly histrionic and attention seeking. The girl is attempting to leave the department.
Which of the following is the most appropriate next step in management?
A. Detain under the mental health act.
B. Discharge home in care of her mother.
C. Refer back to private psychiatrist as planned.
D. Refer on to community mental health team semi-urgently.
E. Urgent psychiatric review in the emergency department.

Answer 30

A. Detain under the mental health act.

Question 31

A five-year-old boy is seen in the emergency department with a red, swollen left eye as shown above. He has a fever and is moderately unwell. He has mild proptosis and restriction of eye movements. The most important investigation to perform is:
A. blood cultures.
B. computerised tomography (CT) scan of the left orbit.
C. conjunctivalswab.
D. lumbar puncture.
E. sinus X-rays.

Answer 31

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

Question 32

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

A. Central venous lines.
B. Long-termantibiotics.
C. Prolonged severe neutropenia.
D. Use of monoclonal antibodies.
E. Use of steroids.

Answer 32

C. Prolonged severe neutropenia.

Question 33

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

Investigations show the following:

What is the most likely diagnosis?

A. Familial juvenile nephronophthisis.

B. Medullary cystic disease.

C. Polycystic kidney disease.

D. Reflux nephropathy.

E. Renal Fanconi syndrome.

Answer 33

A. Familial juvenile nephronophthisis.

Question 34

A newborn baby of Pacific Islander descent is found to have indeterminate gender. Birth weight was 3200 g and the baby is healthy. The phallus is short and with chordee. A urethra is visible at the base of the phallic structure. There is a mass in each inguinal canal the size of a testis. The genitalia are shown above.
The most likely diagnosis is:
A. female with congenital adrenal hyperplasia.
B. male with congenital adrenal hyperplasia.
C. truehermaphrodite.
D. Turner syndrome.
E. undervirilised male.

Answer 34

E. undervirilised male.