2012 A Remembered

Question 1

In a child with a known ventricular septal defect, which of the following signs is most useful as an indicator of significant pulmonary vascular disease?

A. Early diastolic murmur at the left sternal edge

B. A harsh 4/6 pan-systolic murmur

C. Fixed splitting of the second heart sound

D. Increased intensity of the second heart sound

E. A mid diastolic murmur

Answer 1

D. Increased intensity of the second heart sound

Question 2

Which of the following inheritance patterns best describes the condition illustrated in the genogram below?

A. Autosomal dominant
B. Autosomal recessive
C. Mitochondrial
D. X-linked dominant
E. X-linked recessive

Answer 2

Ans A

AD transmission but of a gene that only effects females and may have multifactorial inheritance pattern? Eg breast/ovarian cancer

AR – unlikely, in all generations and only affects females

Mitochondrial – is being passed on by father and would affect male too

X-linked dominant – no recurrent miscarriages, ? would effect male too

Question 3

A 12 year old girl falls from a trampoline through a plate glass window. A photograph of the volar aspect of her right forearm is shown.
Which of the following structures is least likely to be affected?

A. Radial artery.


B. Tendon of extensor pollicis longus.


C. Tendon of flexor carpi ulnaris.

D. Tendon of palmaris longus.

E. Ulnar artery.

Answer 3

B. Tendon of extensor pollicis longus.

Question 4

Which cells are depleted to minimise the risk of Graft Vs Host Disease?

a. NK Cells

b. T cells

c. B cells
d. Neutrophils
e. Eosinophils

Answer 4

B. T cells

Question 5

The most important stimulus for controlling level of ventilation in resting phase is:

a. pCO2 on peripheral chemoreceptors
b. pH on central chemoreceptors

c. pH on peripheral chemoreceptors

d. pO2 on central chemoreceptors
e. pO2 on peripheral chemoreceptors

Answer 5

Answer b. pH on central chemoreceptors

CO2 – main controller at rest, hypoxia plays a major role when compromised

The breathing centre located near the rear of the brain (medulla oblongata) regulates our breathing movements.

The central chemoreceptors detect changes in the pH of the cerebro-spinal fluid and they are responsible for long-term or slow changes in breathing. Since CO2 dissolves in the blood and can penetrate through the blood-brain barrier, the main reason for pH variations in the brain are changes in CO2 concentrations.

Question 6

The luteal or secretory phase of the menstrual cycle is characterized by which of the following hormonal changes?


a. decreasing oestrogen production


b. increasing LH levels
c. increasing inhibin B levels

d. increasing FSH levels
e. increasing progesterone production

Answer 6

Ans E increasing progesterone production

• Follicular/proliferative phase – follicles grow/mature, endometrium thickens. Main control by FSH and oestradiol
• Ovulation – surge in LH causes release of an ovum
• Luteal/secretory – corpus luteum sectretes progesterone which prepares endometrium for implantation and also causes oestrogen to rise again. Progesterone then falls if no fertilisation and menstruation occurs. Otherwise embryo witll secrete HCG which preserved corpus luteum

Question 7

A 16 yr old boy wants to improve his ability playing sport and hence wants to quit smoking. He has booked an appointment to see his school nurse to discuss about available nicotine replacement therapy.
What stage of change is he in?

a. action

b. maintenance

c. contemplation
d. precontemplation
e. preparation

Answer 7

Ans E. Preparation

• Pre-contemplation (not thinking about quitting)
• Contemplation (thinking about quitting but not ready to quit)
• Preparation (getting ready to quit) - may include setting a date for quitting, and establishing what kind of help you think will support your decision, eg talking to a doctor, enrolling in a stop-smoking clinic, using NRT or acupuncture.
• Action – quitting phase
• Maintainance

Question 8

What is the recommendation for oxygen use in term newborn resuscitation?

a. 21%
b. 30%
c. 50%
d. 70%
e. 100%

Answer 8

Answer A. 21%

Air (21% oxygen) is recommended as the initial gas for all babies, with the exception of very preterm babies in whom supplemental oxygen (between 30% and 90%), guided by pulse oximetry, may be preferable until clinical trials provide firm direction.

Question 9

Which antibody is most likely found to be low in a protein losing (state/enteropathy)?


a. Ig A

b. Ig E
c. Ig M
d. Ig G
e. Ig D

Answer 9

Answer D. IgG

A deficit in the intestinal mucosa, causing continuous low grade loss of immunoglobulins. These losses may be limited in some IgG subclasses and more pronounced in others because of the different physical and chemical properties of these proteins. Testing IgG subclasses in PLE may result in different profiles of IgG subclasses with a prominent low level9 of IgG2

Question 10

The idea of Intention-to-treat in randomised controlled trials is


a. decrease common variable in randomised control trial

b. present a real life situation value rather than controlled situation
c. decrease effect of people who have change to another study

d. adjust number of people who did not comply with the treatment
e. adjust number of people who has left the study

Answer 10

Ans B. present a real life situation value rather than controlled situation

In an ITT population, none of the patients are excluded and the patients are analyzed according to the randomization scheme. In other words, for the purposes of ITT analysis, everyone who begins the treatment is considered to be part of the trial, whether he or she finishes it or not. The rationale for this approach is that, in the first instance, we want to estimate the effects of allocating an intervention in practice, not the effects in the subgroup of the participants who adhere to it.

Many clinical trials have excluded participants after the random assignment in their analysis, which is often referred to as modified intention-to-treat analysis or mITT. Trials employing mITT have been linked to industry sponsorship and conflicts of interest by the authors

Question 11

In a child with exocrine pancreatic insufficiency what would be least affected in terms of absorption/digestion?

a. Carbohydrate
b. Protein

c. Fat

d. Vitamin A
e. Vitamin E

Answer 11

a. Carbohydrate

Question 12

A 3 year old presents with wheeze, height is 100cm & weight is 20kg.

Plotting her on the BMI chart she would be:

a. Obese


b. Overweight

c. Underweight
d. FTT

e. Normal

Answer 12

a. Obese

BMI = 20 =>95th percentile

Question 13

There is a long spiel talking about heparin and LMWH. What does low molecular weight heparin act on that cannot be accurately measured using APTT:


a. Antithrombin III

b. Protein C
c. Protein S
d. Thrombin
e. Factor X

Answer 13

Answer E. Factor X

Unfractionated Heparin works by binding and activating antithrombin III, which is an inhibitor of factor 10 and thrombin.

The formation of a complex between antithrombin III, hepatin and thrombin is what inactivates the thrombin (IIa). Activity of heparin is therefore dependant on the size of this complex.

LMWH overcome this by targeting only the anti-factor 10 activity rather than antithrombin activity resulting in improved therapeutic control. Also there is less risk of thrombocytopenia and osteoporosis. APTT cannot monitor as it is not sensitive to activity of factor 10.

Measure of APTT is dependant on thrombin (or antithrombin activity – IIa)

Question 14

Rotavirus in children is often detected in stool using enzyme immunoassay (EIA), what does EIA test for?


a. DNA


b. antibody
c. antigen
d. envelope
e. RNA

Answer 14

Answer C. Antigen

Antigens from the sample are attached to a surface. Then, a further specific antibody is applied over the surface so it can bind to the antigen. This antibody is linked to an enzyme, and, in the final step, a substance containing the enzyme’s substrate is added. The subsequent reaction produces a detectable signal, most commonly a color change in the substrate.

The IVD Rotavirus Antigen Detection ELISA is an in vitro procedure for the qualitative determination of rotavirus antigen in feces. It is a double antibody (sandwich) ELISA using a polyclonal anti-rotavirus antibody to capture the antigen from the stool

Question 15

A child is at the dentist and a tooth is dislodged. If the child is sitting upright, the tooth is most likely to lodge in the:


a. Left upper bronchus


b. Left lower bronchus
c. Right upper bronchus
d. Right middle bronchus
e. Right lower bronchus

Answer 15

Ans E. Right lower bronchus

Because the right main bronchus is wider and more vertical than the left, foreign objects are more likely to be aspirated into the right main bronchus. If the child is supine it enters the RUL and if erect then the RML/RLL

Question 16

50% of babies develop erythema toxicum. If you swabbed these lesions which cells would you most likely find?


a. Eosinophils

b. Monocytes
c. Macrophages
d. Lymphocytes
e. Neutrophils

Answer 16


a. Eosinophils

Question 17

A patient has the following visual field defect:
Where is the lesion?

a. Left optic nerve
b. Right optic nerve
c. Optic chiasm
d. Left optic tract
e. Right optic tract

Answer 17

d. Left optic tract

Question 18

Detrusor smooth muscle contraction in the bladder is mediated by which neurotransmitter?


a. Noradrenaline

b. Acetylcholine
c. Dopamine
d. Serotonin
e. Adenosine

Answer 18

Answer B. Acetylcholine

PNS stimulates detrusor muscle contraction via acetylcholine. This also inhibits urethral contraction.

Question 19

The Barker hypothesis describes the relationship between fetal and postnatal factors and the risk of cardiovascular and metabolic disease in adulthood.
The link between Intrauterine Growth Restriction and systemic hypertension in adulthood is most likely due to:

a. Adrenal hypertrophy

b. Altered arterial response to endogenous pressor
c. Altered baroreceptor sensitivity

d. Altered myocardial performance

e. Reduced nephron number

Answer 19

E. Reduced nephron number

Birth Weight has been hypothesized to adversely affect normal renal development, thereby contributing to an increased risk of acute renal failure and transient imbalance of fluid and electrolyte homeostasis soon after birth and an increased risk of developing chronic kidney disease later in life. Although the number of nephrons in the human kidney varies considerably under normal circumstances, retarded intrauterine growth has been reported to be specifically associated with a significant reduction in nephron number. In turn, low nephron number may be an independent risk factor for the development of hypertension.

There is emerging evidence from experimental and clinical studies of a link between LBW and cardiovascular disease in adulthood. Barker hypothesized that individuals who develop CHD experience slowed growth during fetal life and infancy, followed by accelerated weight gain in childhood. Hypertension and type 2 DM, disorders that predispose to the development of CHD, have been linked to similar paths of growth. Specific underlying mechanisms for CHD may include reduced number of nephrons associated with LBW, the development of insulin resistance in utero, and altered programming of the microarchitecture and function of the liver.

Question 20

Which virus is most likely to trigger Haemophagocytic Lymphohistiocytosis (HLH) in X-linked Lymphoproliferative disease


a. Cytomegalovirus

b. Epstein-Barr Virus
c. Herpes Simplex Virus
d. Human Herpes Virus 6
e. Parvovirus B19

Answer 20

B. Epstein-Barr Virus

EBV is the most frequent infection associated with HLH. EBV-associated HLH varies widely from inflammation that resolves spontaneously to unrelenting disease requiring HCT. EBV infection may trigger HLH in patients with any form of familial disease, and patients with X-linked lymphoproliferative disease (XLP) are at particularly high risk. EBV-HLH has been associated with acute infections not only in B cells, but also in T cells and NK cells.

Question 21

An ECG was given with a rate of about 80/min and normal axis and normal rhythm. The only abnormality I could see was the slurring/ notch of R waves generally.

a. Right bundle branch block
b. left bundle branch block
c. Pacemaker rhythm

d. AV accessary pathway
e. AV nodal arrhythmia

Answer 21

D. AV accessory pathway

Most likely WPW

Question 22

Atomoxetine is used as a treatment for ADHD. What is its mechanism of action?

A. Dopamine and NA reuptake inhibitor
B. Dopamine blockade
C. Noradrenaline blockade
D. Selective Noradrenaline reuptake inhibitor
E. Serotonin reuptake inhibitor

Answer 22

D. Selective Noradrenaline reuptake inhibitor (SNRI)

Question 23

Boy has a chronic cough consistent with his primary ciliary dyskinesia. What is then next most likely system to be involved in childhood?


a. Genital

b. Renal
c. Cardiac

d. Otological

e. Gastrological

Answer 23


d. Otological


Question 24

Microarray CGH is replacing karyotype for investigation of mental retardation. What does karyotype detect that would be missed on microarray?


a. Aneuploidy

b. Microdeletion
c. Triploidy

d. Ring chromosome

e. Reciprocal translocation

Answer 24

e. Reciprocal translocation

Microarray testing will not detect balanced chromosome rearrangements such as reciprocal translocations, Robertsonian translocations, inversions, and balanced insertions. These types of abnormalities may be detected by karyotyping.

Question 25

In children with tumour lysis syndrome secondary to ALL or lymphoma, Rasburicase may decrease the risk of requiring renal dialysis. Rasburicase acts by:


a. Decreasing conversion of hypoxanthine to uric acid


b. Alkalysing the urine


c. Conversion of uric acid to allantoin


d. Promotion of diuresis

e. Increasing potassium excretion

Answer 25


c. Conversion of uric acid to allantoin


Urate oxidase inhibitor

Question 26

What is the mechanism of action of aminoglycoside antibiotics?

a. Binding to 50S ribosomal subunit
b. Inhibition of cell wall synthesis
c. Inhibition of protein synthesis
d. Purine analogues

e. Interference with RNA synthesis

Answer 26

c. Inhibition of protein synthesis

Aminoglycosides inhibit translation of mRNA by binding irreversibly to the 30S subunit of the ribosomes and inhibiting the translocation of the tRNA from the A-site of the ribosome to the P-site of the ribosome. As a result of which the protein sequence does not get elongated to the full sequence, leading to incomplete protein expression. Since the protein is not fully expressed, the small peptide chains are not capable of functioning like the whole proteins, leading to faulty cellular function which eventually causes cell death of the bacteria.

Question 27

A six-year-old boy is referred for problems with sleeping. He goes to bed at 9 p.m., but is frequently awake for two hours before finally falling asleep. Once asleep, he sleeps through the night. He gets up reluctantly at 8 a.m. on weekdays. He goes to sleep at 10.30 pm on Saturday and fall asleep straight away and wakes up spontaneously at 10 a.m without any problems. He is not noticeably sleepy during the day, but sometimes falls asleep in the car. During the day he is a confident boy, with many friends and no difficulties

The most likely primary diagnosis is:

a. generalised anxiety disorder.

b. night terrors.

c. narcolepsy.
d. Parental limit settings


e. insomnia with bedtime fears.

Answer 27


e. insomnia with bedtime fears.

or D. Parental limit setting

If pt is afraid while in bed, calling out to parents for something under bed/in cupboard etc, this is insomnia with bedtime fears.

If he is just calling out for water and stalling, to which the parents give in, this is a problem with parental limit setting.

Question 28

A 17 year old obese boy presents with numbness over his lateral thigh after a night out in very tight jeans. Which dermatome is primarily affected? (picture of boy with patch of affected area over the lateral aspect of his R anterior thigh below the pelvic crease extending around 1/3 of the way to his knee)

a. L1
b. L3
c. L5
d. S1
e. S3

Answer 28

B. L3

Question 29

Below is a Forest plot showing the effect of an antibiotic compared to placebo in preventing urinary tract infections.

In the PREVENT (= Craig 2009) trial, antibiotic therapy reduces rate of UTI by

a. 35%

b. 41%

c. 44%
d. 65%
e. 96%

Answer 29

?Ans A
?risk ratio is same as hazard ratio?
So the risk of UTI is 0.65 so reduced by 35%??

Question 30

Craniopharyngioma arises from

a. Arachnoid membrane

b. Hypothalamus

c. Pars intermedia of pituitary
d. Pineal gland
e. Rathke’s pouch

Answer 30

Answer E. Rathke’s pouch

Craniopharyngioma is a rare, usually suprasellar neoplasm, which may be cystic, that develops from rests of epithelium derived from Rathke’s pouch. Rathke’s pouch is an embryonic precursor of the anterior pituitary.

Question 31

12 year old girl thought to have myocarditis has the ECG below
What is the most likely cause of this pattern?
a. Complete heart block

b. Mobitz I

c. Mobitz II
d. 1st degree heart block

Answer 31

A. complete heart block

• complete heart block – no relationship between PW and QRS
• Mobitz 1(Wenkebach) – lengthening of PR then dropped beat
• Mobitz 2 – some PWs not followed by QRS
• 1st degree – prolonged PR

Question 32

A 15 year old girl presents to the Emergency Department after five days of a flu- like illness. She is hypotensive and a chest xray shows an enlarged heart.

(actual ECG had a P rate of ~100bpm and an R rate of ~40bpm. No PR association, marching through)
What rhythm best describes this ECG

A. First degree heart block
B. Second degree heart block type 1
C. Second degree heart block type 2
D. Sinoatrial escape block
E. Third degree heart block

Answer 32

E. Third degree heart block

Question 33

The Infant mortality rate (IMR) is the number of deaths of babies under one year of age


a. per 1,000 live births

b. per 1,000 births
c. per 100 live births
d. per 100 births

Answer 33

A. Per 1,000 live births

Infant mortality rate (IMR) is the number of deaths of children less than one year of age per 1000 live births.
Perinatal mortality occurs in the late fetal period, which typically occurs after 28 weeks gestation and the first week postpartum.

Question 34

Drug X is metabolised by liver (40%) and cleared by kidney (60%). Usual dose is 100mg.What will be the dose if renal clearance is decreased by 50%?


a. 30mg

b. 40mg
c. 50mg
d. 70mg
e. 80mg

Answer 34

D. 70mg

60/2 + 40 = 70

Question 35

In neonatal allo-immune thrombocytopenia, what is the most common human platelet antigen (HPA) sensitisation in the Caucasian population?


a. 1a


b. 2
c. 3a
d. 4
e. 5b

Answer 35


a. 1a


Question 36

Risperidone is used in autism for behavioural management. In males it can cause gynaecomastia, and in females it can cause amenorrhoea and galactorrheoa through increasing serum levels of prolactin. This is because Risperdone acts as

a. Anticholinergic agent
b. Dopamine agonist

c. Dopamine antagonist

d. Serotonin agonist

e. Nicotinic cholinergic agonist

Answer 36

c. Dopamine antagonist

Dopamine antagonist possessing antiserotonergic, antiadrenergic and antihistaminergic properties.

Prolactin secretion is suppressed by dopamine so blocking this will reduce inhibition of prolactin eg risperidone, domperidone, metachlopramide, haloperidol

Question 37

Test X is compared against the gold standard. It is tested on 100 people. The results are shown:
The sensitivity is

a. 12/17

b. 12/15

c. 80/85
d. 80/83
e. 12/100

Answer 37


b. 12/15

Sn = a/a+c

Question 38

In which renal segment is the majority of filtered bicarbonate reabsorbed?

a. Proximal convoluted tubule

b. Descending loop of henle

c. Ascending loop of henle
d. Distal convoluted tubule
e. Collecting duct

Answer 38

a. Proximal convoluted tubule


80-90% in proximal tubule

Question 39

A 6 year old boy presents with a history of intermittent unilateral left-sided clear nasal discharge. He has a history of being kicked in the face by a horse at age 3.
 A CT scan of his facial bones shows a defect in the base of his skull.
(the exam question did not have a caption or arrow pointing to the fracture, but the stem tells you what the scan shows).

Presence of which of the following will indicate that the discharge is CSF?


a. Albumin

b. B2-transferrin
c. Glucose

d. Galactose

e. Glutamate

Answer 39

b. B2-transferrin

The presence of clear fluid in the nasal cavity may indicate a cerebrospinal fluid (CSF) leak as the result of an associated skull fracture, usually through the cribriform plate. Fluid should be tested for beta-2 transferrin, which is present only in CSF, perilymph, and aqueous humor.

Question 40

What is the mortality rate of those with anorexia nervosa compared with that of the general population?


a. 2

b. 10
c. 15
d. 20
e. 40

Answer 40

B. 10

The risk of premature death for women with Anorexia Nervosa is 6-12 times higher than the general population

The risk of premature death for women with Anorexia Nervosa is ‘much higher’ than other psychiatric disorders

For females with Anorexia Nervosa and diabetes, there is a 15.7-fold increase in mortality rates when compared with females with diabetes alone

1 in 5 individuals with Anorexia Nervosa who died prematurely had committed suicide

Question 41

A medication is being trialled to relieve the symptoms associated with allergic rhinitis. Patients were enrolled into either the medication or placebo group and their symptoms were assessed at different time points. The results are shown below.

Given the information above, which of the following comments can be made regarding these results?

a. The difference between the treatment and placebo groups is too large
b. There are inappropriate time interval measurements

c. Too many endpoints/outcomes increases the likelihood of false positive results

d. Rhinorrhoea does not relate to eye symptoms

e. Cannot assess p-value in absence of confidence intervals

Answer 41

c. Too many endpoints/outcomes increases the likelihood of false positive results

Question 42

Which of the following anticonvulsants requires serial measurements of serum levels because of a narrow therapeutic index?

a. Carbamazepine
b. Lamotrigine

c. Levetiracetum
d. Phenytoin
e. Sodium Valproate

Answer 42

d. Phenytoin

Question 43

What is the primary mechanism leading to oedema in patients with nephrotic syndrome?


a. Decreased capillary oncotic pressure

b. Decreased interstitial fluid hydrostatic pressure
c. Decreased interstitial fluid oncotic pressure
d. Increased capillary hydrostatic pressure

e. Increased vascular permeability

Answer 43

e. Increased vascular permeability

Massive proteinuria ⇒hypoalbuminaemia.

The oncotic pressure in the blood goes down, and fluid leaks out of the vasculature into the surrounding tissue

Although a low plasma oncotic pressure is widely cited for the edema of nephrotic syndrome, most physicians note that the edema may occur before there is any significant protein in the urine (proteinuria) or fall in plasma protein level. Fortunately there is another explanation available. Most forms of nephrotic syndrome are due to biochemical and structural changes in the basement membrane of capillaries in the kidney glomeruli, and these changes occur, if to a lesser degree, in the vessels of most other tissues of the body. Thus the resulting increase in permeability that leads to protein in the urine can explain the edema if all other vessels are more permeable as well.

Question 44

By which one of the following mechanisms does Staphylococcus aureus superantigens exacerbate atopic eczema dermatitis?


a. Eosiniphil activation

b. IgE production
c. Mast cell activation

d. Neutrophil activation
e. T-cell stimulation

Answer 44

E. T-cell stimulation

Staphylococcus aureus infection plays an important role in atopic eczema (AE) because of its ability to produce virulence factors such as superantigens. Epicutaneous application of superantigens induces eczema. Super- antigens also induce corticosteroid resistance, and subvert T-regulatory cell activity, thereby increasing AE severity.

Increased binding of S. aureus to skin is driven by underlying AE skin inflammation. This is supported by studies demonstrating that treatment with topical corticosteroids reduces S. aureus counts on atopic skin. AE has also been found to be deficient in antimicrobial peptides needed for host defence against bacteria. The reduced production of antimicrobial peptides in AE appear to be an acquired defect resulting from increased T-helper type 2 cell (Th2) cytokine production. A vicious cycle of skin barrier dysfunction, skin infection and Th2 cell immune activation therefore occurs in AE. Effective strategies for controlling AE require combination therapy that reduces skin inflammation and controls S. aureus colonization and infection.

Question 45

A primagrada mother gave birth to a term baby after history of prolapsed cord. Baby was flat and floppy at birth requiring resuscitation. Apgars were 0, 0, 3, 7 and 1, 5, 10 and 15minutes respectively. Heart rate was 120bpm afterwards and baby required ongoing ventilatory support. Which is the closest temperature to nurse baby at?

a. 31.5ºC
b. 33.5 ºC
c. 35.5ºC
d. 37.5 ºC
e 38.5 ºC

Answer 45

b. 33.5 ºC

cooling - Whole body hypothermia to 33 -34OC for 72 hours

Normal axilla temperature of range 36.7 - 37.3°C

Question 46

With methaemaglobinaemia you get cyanosis and brown coloured blood. This can be secondary to toxins or genetic causes. In haemoglobin with methaemaglobinaemia, what is the largest abnormality that occurs?


a. Carboxylated

b. Crystallised
c. Methylated
d. Oxidised

e. Reduced

Answer 46

D. Oxidised

Presence of a higher than normal level of methemoglobin (ferric [Fe3+-] rather than ferrous [Fe2+] haemoglobin) in the blood.

Methemoglobin is an oxidized form of hemoglobin that has an increased affinity for oxygen and also results in an increased affinity of oxygen to the three other heme sites (that are still ferrous) within the same tetrameric hemoglobin unit.

This leads to an overall reduced ability of the red blood cell to release oxygen to tissues, with the associated oxygen–hemoglobin dissociation curve therefore shifted to the left. When methemoglobin concentration is elevated in red blood cells, tissue hypoxia can occur.

Question 47

Bruising in toddlers is common. Which of the following sites would you be most suspicious for NAI?

a. Forehead
b. Ear

c. Chest

d. Nose
e. Shin

Answer 47

B. ear

• Bruising in a child <9 months of age or nonmobile child
• Bruising away from bony prominences
• Bruising to the ears, face, abdomen, arms, back, buttocks and hands
• Multiple bruises in clusters
• Multiple bruises of uniform shape (eg. opposing arc from a bite)
• Bruising that has the shape of an object or a ligature (eg. tram track from a rod shaped object)

Question 48

In which of the following is PCR least likely to detect?

a. Insertion/deletion of a single base pair

b. Missense mutation

c. Deletion of an entire exon

d. Deletion resulting in an altered stop codon
e. Splice site mutation

Answer 48

a. Insertion/deletion of a single base pair


Question 49

Which of the following, commonly taken by atopic individuals, should be ceased prior to skin prick testing?

a. Loratidine

b. Montelukast

c. Prednisolone

d. Topical hydrocortisone
e. Topical Pimecrolimus

Answer 49

A. Loratidine

Question 50

A colleague of yours reads a study which shows 5/50 individuals on a new IV treatment, compared to 15/50 on standard treatment experienced asthma symptoms at 2hrs. She reports this to her collegues as a 20% improvement with the new treatment. She is referring to

a. Number needed to treat
b. Odds ratio

c. Relative risk

d. Relative risk reduction
e. Risk difference

Answer 50

E. Risk difference

Risk difference is the absolute risk reduction
30% - 10% = 20%

Question 51

In a 10 year old boy with moderate-severe Crohn’s disease affecting the terminal ileum, which of the following is the LEAST appropriate long term maintenance therapy?

a) Azathioprine
b) Corticosteroids
c) Infliximab

d) Methotrexate
e) polymeric diet

Answer 51

b) Corticosteroids

Question 52

Interaction between troponin and myosin complex is triggered by which of the following in the myocardium?

A. Release of calcium from sarcoplasmic reticulum
B. Intracellular uptake of calcium

C. Release of intracellular chloride

D. Intracellular uptake of sodium
E. Release of intracellular sodium

Answer 52

A. Release of stored calcium for sarcoplasmic reticulum

Calcium released from the SR allows myosin heads to bind to actin filaments and pull them by a process called a power stroke. That is how action potential causes the individual muscle cells to contract.

Question 53

Which factor will affect the Vitamin D level most in a 6 week old infant?

a. Birth Weight

b. Breast Feeding

c. Sunlight
d. Maternal 25 Hydroxy Vitamin D
e. Skin Pigmentation

Answer 53

d. Maternal 25 Hydroxy Vitamin D

If a mother is vitamin D replete, her infant has an 8–12 week store of vitamin D. Breast milk only has 25iu/L.

Question 54

Which of the following antibiotics promotes biliary sludge formation?

a. Ceftriaxone

b. Clindamycin

c. Erythromycin
d. Metronidazole
e. Cotrimoxazole

Answer 54

a. Ceftriaxone


Question 55

Which of the following antibiotics is not active against Pseudomonas?

a. Ceftazidime

b. Clindamycin

c. Ciprofloxacin

d. Meropenem

e. Tobramycin

Answer 55

B. Clindamycin

Most aerobic Gram-negative bacteria (such as Pseudomonas, Legionella, Haemophilus influenzae and Moraxella) are resistant to clindamycin.

Being Gram-negative bacteria, most Pseudomonas spp. are naturally resistant to penicillin and the majority of related beta-lactam antibiotics, but a number are sensitive to piperacillin, imipenem, ticarcillin, tobramycin, or ciprofloxacin.

Ceftazidime - Unlike most third-generation agents, it is active against Pseudomonas aeruginosa, however it has weaker activity against Gram-positive microorganisms and is not used for such infections.

Question 56

Phenytoin causes increased MCV. What is the mechanism?

a. Decreased B12 absorption

b. Decreased Folate absorption

c. Decreased Intrinsic Factor secretion
d. Haemolysis

e. Transcobalamin II binding

Answer 56

B. Folate absorption

Phenytoin causes a reduction in folic acid levels, predisposing patients to megaloblastic anemia. Folic acid is presented in foods as polyglutamate, which is then converted into monoglutamates by intestinal conjugase. Phenytoin acts by inhibiting this enzyme, thereby causing folate deficiency

Question 57

A 6 year old boy presents to ED after sustaining a laceration to the flexor surface of his wrist. His peripheral nerves were examined completely by the treating doctor. Which nerve is being tested in the photographs below (showing finger adduction against resistance)?

a. Radial nerve

b. Anterior interosseous nerve
c. Median nerve

d. Posterior interosseous nerve
e. Ulnar nerve

Answer 57

e. Ulnar nerve

Radial nerve - extensors of forearm

Median nerve - flexors of forearm

Ulnar nerve - lumbricals

Question 58

In beta-thalassemia (β-thalassemia) is a group inherited blood disorders. Homozygous B (superscript 0) is caused by mutation of 2 B chains. It is characterized by

a) Absence of B Globin Gene

b) Absence of B Subunit of hemoglobin
c) Increase of B subunit of hemoglobin
d) Decrease of B unit of hemoglobin

e) Structurally abnormal B globulin

Answer 58

b) Absence of B Subunit of hemoglobin

Question 59

Infliximab is a monoclonal antibody used in Crohn’s disease management. It is an antibody against:

a. interleukin 1

b. interleukin 4

c. interleukin 6

d. interferon- alpha
e. TNF-alpha

Answer 59

e. TNF-alpha

Question 60

Cyclophosphamide is a chemotherapeutic agent that functions by

a. alkylating agent

b. inhibits DNA synthesis

c. inhibits tyrosine kinase complex
d. inhibits purine synthesis

e. inhibits mitotic spindle synthesis

Answer 60

A. Alkylating agent

Alkylating agent – prodrug, metabolised in liver. Active compound phosphoramide cross links with DNA and inhibits cell replication and causes cell death.

Question 61

A 3 year old child is in out-of-home care (foster care). His community case worker brings him to a general paediatrican for assessment.
He is most likely to have:

a) behavioural/ emotional problems
b) incomplete immunisations

c) language delay

d) skin infections
e) underweight

Answer 61

a) behavioural/ emotional problems

Question 62

Confounders are variables which are related to both the exposure and the outcome and can account for some of the relationship between the two. There are various ways to create a study or analyze the results to minimize the effect of confounders. Which of these best accounts for confounders.

a. Patient match with confounding variables

b. Perform a multivarient analysis

c. Randomization

d. Include only confounders of interest in the study
e. Perform a post analysis of cofounders of interest

Answer 62

c. Randomization

Question 63

Which of the following will cause a rise in ADH secretion?

a. Hyponatremia

b. Hyposmolar serum
c. Caffeine

d. Pain

e. Hypertension

Answer 63

d. Pain


Main stimulants are Hypotension (pressure receptors in the veins/atria/carotid) and hyperosmolality (osmoreceptors in hypothalamus). Sodium itself is not a stimulus – in SIAHD Na content is normal but there is dilutional effect

Ang II stimulates secretion

Ethanol and caffeine reduce vasopressin secretion

AVP is also released in response to stressful stimuli, such as pain or anxiety, and by various drugs.

Question 64

A primum ASD is most likely to be associated with:

a. Muscular VSD

b. Cleft mitral valve

c. Bicuspid aortic valve

d. Coarctation of the Aorta
e. Ebsteins anomaly

Answer 64

B. Cleft mitral valve

Ostium primum (AVSD)– lower portion of atrial septum, overlies mitral and tricuspid valves, cleft in anterior leaflet of left/mitral valve (which leaks), tricuspid valve normal

Question 65

Which of the following drugs is most commonly associated with DRESS (Drug Reaction with Eosinophilia and Systemic Symptoms)?

A. ACE Inhibitors
B. TCAs

C. Carbamazepine
D. B-lactams
E. Aminoglycosides

Answer 65

C. Carbamazepine

Syndrome caused by exposure to certain medications, that may cause a rash, fever, inflammation of internal organs, lymphadenopathy, and characteristic hematologic abnormalities such as eosinophilia, thrombocytopenia, and atypical lymphocytosis. The syndrome carries about a 10% mortality.

Drugs - phenobarbital, carbamazepine, phenytoin, lamotrigine, minocycline, sulfonamides, allopurinol, modafinil and dapsone. It has been associated with HHV6.

Tx - supportive, steroids

Question 66

With normal puberty, growth of pubic hair is associated with an increase with which hormone?

a. FSH

b. 17-hydroxypregesterone
c. Dehydroepiandrosterone
d. Leutinizing Hormone

e. Testosterone

Answer 66

c. Dehydroepiandrosterone

Question 67

A young boy with William’s syndrome presents to ED with his mother. He has a bead stuck up his nose and you are preparing to sedate him with Ketamine. Whilst trying to restrain him, he turns pale and becomes unresponsive. On examination he has no pulse and ECG tracing reveals Ventricular Fibrillation. According to current guidelines, which is the most appropriate course of action:

a. Adrenaline IV → Shock 4J/kg → CPR 2 min
b. CPR 2 min → Shock 4J/kg→ adrenaline

c. CPR 2min → Shock 4J/kg→ CPR 2min

d. Shock 4J/kg → CPR 2min → Shock 4 J/kg
e. Shock 4J/kg → Shock 4J/kg → Shock 4J/kg

Answer 67

e. Shock 4J/kg → Shock 4J/kg → Shock 4J/kg

In hospital arrest with witnessed VF current guidelines (2013) indicated 3 x 4 J/kg is appropriate.

Other cardiac arrest you would commence 2 mins CPR before shock 4 J/kg followed by another 2 mins CPR

Question 68

Which of the following does NOT increase risk of invasive pneumococcal?

A. CSF leak

B. Nephrotic syndrome
C. Asplenia

D. Protein losing enteropathy
E. Complement deficiency

Answer 68

D. Protein Losing Enteropathy

• Decreased immune function
• Asplenia (functional or anatomic)
• Chronic heart, pulmonary, liver or renal disease
• Cigarette smoking
• Cerebrospinal fluid (CSF) leak

(All options increase the risk, but protein losing enteropathy least so)

Question 69

Which of the following increases oxygen affinity in Hb?

A. Carbon monoxide

B. Increase temperature

C. Increased carbon dioxide
D. Increased 2,3 DPG

E. Acidosis

Answer 69

A. Carbon monoxide