Q1

A 12-year-old boy presents with a one-week history of

increasing shortness of breath, cough and exercise
intolerance. On examination he is tachypnoeic and has
marked cervical adenopathy and moderate
hepatosplenomegaly. A fine needle aspirate of a cervical
node is consistent with non-Hodgkin lymphoma. The
computerised tomography (CT) scan of his chest is shown
. Which one of the following
chemotherapeutic agents is
contraindicated with these CT
findings?A. Cyclophosphamide.
B. Cytosine arabinoside.
C. Doxorubicin (adriamycin).
D. Methotrexate.
 Q2

A 12-year-old boy presents to the emergency

department with persistent productive cough and
fever despite three days of oral amoxycillin at an
appropriate dose. His pulse oximetry on room air
is 97% and he has a respiratory rate of
24/minute, heart rate of 110/minute and
temperature of 38.2C. His chest X-ray is shown
opposite.
Which of the following is the most
appropriate antibiotic regime?
A. Intravenous cefotaxime.
B. Intravenous penicillin.
C. Intravenous vancomycin.
D. Oral cefaclor.
E. Oral roxithromycin.
 Q3

In the pedigree shown above, a diagnosis of

Duchenne muscular dystrophy (DMD) is made in
a three-year-old boy (IV:1). The family history
reveals that a maternal uncle (II:I) died of DMD
aged 19, and that the probands aunt (III:4) is
currently at 30 weeks of gestation in her first
pregnancy.
What is the risk that the baby (IV:2) will be
affected by DMD?
A. Approximately 1 in 8000 (population
risk).
B. 1 in 8.
C. 1 in 4.
D. 1 in 2.
E. 2 in 3.
 Q4

The rhythm strip shown above was

obtained from an infant who was
delivered by emergency caesarean
section for fetal bradycardia. Which of
the following best describes the
rhythm demonstrated?
A. Blocked premature atrial
contractions.
B. Intermittent 2:1 block.
C. Mobitz type I.
D. Mobitz type II.
E. Profound sinus arrhythmia.
 Q5

Abnormalities in which component

of the immune system are most
responsible for the clinical picture
shown above?
A. Antibodies.
B. Complement.
C. Leucocytes.
D. Natural killer cells.
E. Neutrophils.
 Q6

A five-year-old girl presents one week

after an upper respiratory tract
infection with a lump in her neck. She
is afebrile and well. The lump is
midline, non-tender and moves
vertically with swallowing. A
photograph is shown below.
Which of the following is the most
likely diagnosis?
A. Goitre.
B. Submandibular abscess.
C. Submandibular lymphadenopathy.
D. Thyroglossal cyst.
E. Thyroid adenoma.
 Q7

A 12-year-old boy presents to the emergency

room by ambulance, having collapsed at school.
He has a past history of supraventricular
tachycardia but is receiving no regular
medication. He is semiconscious with an
intermittently palpable pulse and a blood
pressure of 60 mmHg systolic. His
electrocardiogram (ECG) is shown above. Which
of the following modalities is the most
appropriate to control his rhythm?
A. Direct Current (DC) shock.
B. Facial ice water.
C. Intravenous adenosine.
D. Intravenous amiodarone.
E. Intravenous lignocaine.
 Q8
A term male infant is admitted to hospital on day
seven of life for repair of an inguinal hernia. He is
the first child to non-consanguineous parents. His
mother is quite anxious, and reports that her son
has not been feeding particularly well over the
past two days. He is afebrile and his clinical
examination
reveals a reducible right sided inguinal hernia.
Otherwise his examination is normal. The pre-
operative chest X-ray arranged by the
anaesthetists is shown below.
The chest X-ray is most consistent
with:
A. cardiomegaly.
B. congenital neuroblastoma.
C. extra-pulmonary sequestration.
D. normal thymic shadow.
E. right upper lobe consolidation.
 Q9
A six-month-old boy presents to the emergency
department with a five day history of coryza, low
grade fever and poor oral intake. He has
developed an extensive migratory rash overnight
and is generally miserable. On examination he
has a widespread rash as shown below, with no
evidence of mucous membrane involvement. He
has been previously well and is not on any
regular medications.
 Which of the following is the most
likely diagnosis?
A. Erythema marginatum.
B. Erythema multiforme.
C. Stevens-Johnson syndrome.
D. Urticaria.
E. Viral exanthem.
 Q10

The mother of a ten-year-old with type 1

(insulin dependent) diabetes mellitus asks
for your advice
about a breakfast cereal, recommended as
"good for diabetics" by a health food shop.
The cereal Nutrition Information Panel is
shown.
 Based on this information you advise that the
cereal is not a good choice for her child because
it is:
A. high in sugar, although low in fat and high in
fibre.
B. high in sugar and high in fat, although high in
fibre.
C. high in sugar, high in fat and low in fibre.
D. low in sugar and low in fat, but also low in
fibre.
E. low in sugar, but high in fat and low in fibre.
 Q11
An 11-year-old girl has undergone a T-cell
depleted unrelated bone marrow transplant for
relapsed acute lymphoblastic leukaemia.
Recovery is complicated by slow neutrophil
engraftment, grade 3 acute graft-versus-host
disease requiring high dose methylprednisolone,
and persistent fevers. The
computerised tomography (CT) scan of her chest,
performed at day +50 post-transplantation, is
shown above.
 Which one of the following pathogens is
most likely to be responsible for the CT
scan findings?
A. Aspergillus fumigatus.
B. Candida albicans.
C. Klebsiella pneumoniae.
D. Scedosporium prolificans.
E. Staphylococcus aureus.
 Q12

A three-week-old term male infant is noticed by

his mother to be breathless during feeds. On
examination he is tachypnoeic with a respiratory
rate of 90 breaths per minute, marked subcostal
recession, and poor breath sounds on the left
side. The chest X-ray is shown below.
The most likely diagnosis is:
A. congenital cystic adenomatoid
malformation.
B. congenital lobar emphysema.
C. dextrocardia.
D. diaphragmatic hernia.
E. pneumothorax.
 Q13
A six-year-old girl presents to the emergency
department with a persistent headache and
dizziness following a minor fall one week
previously in which there was no loss of
consciousness. She has had several vomits today
and feels unwell. On examination, she is afebrile
with a respiratory rate of 24/minute, a heart rate
of 110/minute and a blood pressure of 96/55
mmHg. She is pale and quiet but able to respond
appropriately to questions and commands. There
are no focal neurological signs. Her non-contrast
computed tomography (CT) scan of the head is
shown below.
 Which of the following is the most likely
diagnosis?
A. Extradural haematoma.
B. Intracerebral haemorrhage.
C. Meningioma.
D. Subarachnoid haematoma.
E. Subdural haematoma.
 Q14

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. true hermaphrodite.
D. Turner syndrome.
E. undervirilised male.
 Q15

A seven-year-old boy presents with a three

month history of staring spells associated
with eye flickering and lip smacking
movements. His electroencephalogram
(EEG) is shown below.
 Which of the following anticonvulsants is
most likely to aggravate the underlying
seizure disorder in
this patient?
A. Carbamazepine.
B. Clonazepam.
C. Ethosuximide.
D. Sodium valproate.
E. Topiramate.
 Q16

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.
 Q17

A 13-year-old boy presents to the

emergency department after falling out of
a hammock onto grass.
He is complaining of a sore left shoulder.
On examination there is a tender lump over
the left clavicle,but the overlying skin is not
compromised. An X-ray of the area is
shown below.
 Which of the following is the best next
step in management?
A. Broadarm sling.
B. Closed reduction.
C. Figure-of-eight bandage.
D. Open reduction.
E. U-plaster.
 Q18

A five-year-old boy presents with multiple

ulcerated skin lesions (as shown) with
raised margins, which commenced as
pustular lesions associated with fever a
week prior to presentation. Pyoderma
gangrenosum is confirmed by skin biopsy.
Which of the following is most likely to be
associated with this skin lesion?
 A. Chronic granulomatous disease.
B. Human immunodeficiency virus (HIV)
infection.
C. Inflammatory bowel disease.
D. Pseudomonas septicaemia.
E. Systemic lupus erythematosis.
 Q19

A six-year-old girl with Down syndrome is

seen for annual review. Her parents report
she has been
well. She is adjusting to school with some
attention difficulties. Her growth charts are
shown. She
resists examination. What is the most likely
cause for her growth pattern?
 A. Coeliac disease.
B. Down syndrome.
C. Growth hormone deficiency.
D. Hypothyroidism.
E. Precocious puberty.
 Q20

The electrocardiogram (ECG) shown

above was performed on an
asymptomatic ten-year-old child
with Ebstein anomaly. The rhythm
shown is:
 A. atrial fibrillation.
B. atrial flutter.
C. complete heart block.
D. premature atrial contractions.
E. sinus arrhythmia.
 Q21

A 15-year-old girl with chronic

eczema presents with facial
lesions as shown. The most likely
infecting
organism is:
 A. Candida albicans.
B. Chlamydia trachomatis .
C. Herpes simplex virus.
D. Herpes zoster virus.
E. Neisseria gonorrhoeae .
 Q22

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.
 Q23

A 16-year-old male has a past history

of Hodgkin disease treated with
chemotherapy. He presents
with a chronic dry cough. His chest X-
ray is shown below.
 Which of the following drugs is most likely
responsible for the radiographic changes?
A. Bleomycin.
B. Busulphan.
C. Carmustine.
D. Cyclophosphamide.
E. Methotrexate.
 Q24

A two-year-old boy is admitted with

fever of 39C and refusal to walk. On
examination he looks
lethargic and unwell. His left leg is
painful and hot to touch.
Photographs of his leg and tongue are
shown below.
 The best empiric antibiotic for a child
with this clinical picture is:
A. amoxycillin-clavulanate.
B. cefotaxime.
C. flucloxacillin.
D. penicillin.
E. trimethoprim-sulphamethoxazole.
 Q25

None of the seven children of a

profoundly deaf couple has any
hearing impairment (see pedigree
below). The most likely explanation for
this is:
 A. chance.
B. one or both of the parents has an
autosomal dominant form of deafness,
which is highly
variable in its expression.
C. one or both of the parents has a non-
genetic form of deafness.
D. the father has X-linked deafness and the
mother has autosomal recessive deafness.
E. the parents have autosomal recessive
 Q26
A seven-month-old girl is referred to outpatient
clinic for assessment of a misshapen head. She
weighs 7.4 kg (50th percentile), measures 66.5
cm (50th percentile) and her head circumference
is 40
cm (5th percentile). Apart from her head shape
there are no dysmorphic features. She does not
roll,
does not reach and has slight head lag on pull to
sit.
Her head and facial appearance is shown below.
 The most likely reason for this
appearance is:
A. coronal craniosynostosis.
B. deformational plagiocephaly.
C. lambdoid craniosynostosis.
D. metopic craniosynostosis.
E. sagittal craniosynostosis.
 Q27

An infant weighing 10kg presents with

fever and a rash as shown below. His
heart rate is 150/minute and blood
pressure is 85/35 mmHg. Which of the
following is the most appropriate initial
intravenous fluid management?
 A. 20 mL/hour of 0.9% saline.
B. 40 mL/hour of 0.18% saline with 4%
glucose.
C. 40 mL/hour of 0.9% saline.
D. 200 mL bolus of 0.18% saline with 4%
glucose.
E. 200mL bolus of 0.9% saline.
 Q28

The audiogram of a six-year-old boy

who completed chemotherapy for
hepatoblastoma four weeks ago is
shown below.
The audiogram is most consistent with:
A. conductive hearing loss.
B. high-frequency sensorineural hearing loss.
C. low-frequency sensorineural hearing loss.
D. non-compliance with testing.
E. normal findings for age.
 Q29

A three-year-old boy presents with

episodes of loss of consciousness related to
exercise and also
minor trauma. During the episodes he
becomes pale, his eyes may roll upwards
and he has had
urinary and faecal incontinence. His
electrocardiogram (ECG) is shown above.
What is the most
 A. Aortic stenosis.
B. Breath holding episodes.
C. Long Q -T syndrome.
D. Primary pulmonary hypertension.
E. Seizure disorder.
 Q30

In patients who have previously

received radiotherapy, exposure to
which one of the following
chemotherapy agents is most likely
responsible for the skin reaction as
shown?
 A. Cisplatin.
B. Cyclophosphamide.
C. Daunorubicin.
D. Etoposide.
E. Methotrexate.
 Q31

An eight-year-old boy presents

with an isolated rash on his foot as
shown above. The most
appropriate initial management is:
 A. oral griseofulvin.
B. oral prednisolone.
C. oral terbinafine.
D. topical mometasone.
E. topical terbinafine.
 Q32

A newborn infant is noted to be

tachypnoeic in the post natal ward. His
chest X-ray is shown below.
 What is the most likely diagnosis?
A. Congenital cystic adenomatoid
malformation.
B. Congenital diaphragmatic hernia.
C. Congenital lobar emphysema.
D. Intralobar sequestration.
E. Pulmonary interstitial emphysema.
 Q33

A 15-month-old infant has itchy

lesions on the scalp, neck, palms
and soles (as shown above). The
most likely diagnosis is:
The most likely diagnosis is:
A. Coxsackie A16 infection (Hand, foot
and mouth disease).
B. eczema herpeticum.
C. impetigo.
D. pompholyx (dyshidrotic eczema).
E. scabies.
 Q34

A two-year-old child is referred for assessment of

a murmur. Examination reveals a mid-diastolic
murmur without a systolic component. No systolic
murmur is audible. There is associated
hepatomegaly and distension of neck veins, but
no respiratory distress. The electrocardiogram
(ECG) is shown below.
 The most likely diagnosis is:
A. aortic valve regurgitation.
B. cortriatriatum.
C. mitral valve stenosis.
D. pulmonary valve regurgitation.
E. tricuspid valve stenosis.
 Q35

A nine-month-old child is reviewed

because of concerns about the appearance
of his face. He
suffered birth trauma related to shoulder
dystocia. A brachial plexus injury was
identified at birth.
What level of the brachial plexus has been
injured to explain the facial findings?
 A. C5.
B. C6.
C. C7.
D. C8.
E. T1.
 Q36

A nine-year-old girl with systemic lupus

erythematosus (SLE) presents with a
painless, erythematous,
blistering rash on her chest, as shown. She
is afebrile. She is currently on prednisone,
and has
recently been given pulse
cyclophosphamide.
 The most appropriate initial treatment
would be:
A. intravenous aciclovir.
B. intravenous flucloxacillin.
C. oral aciclovir.
D. oral flucloxacillin.
E. withhold immunosuppressants.
 Q37

A four-year-old boy is reviewed in clinic

because of a flare-up of his atopic eczema.
He has not
responded to his usual emollients and
topical steroids.
On examination his temperature is 37C.
He is irritable, and has extensive whole-
body eczema with
excoriation and crusting. The lesions
around his mouth are shown above.
 A. aciclovir.
B. flucloxacillin.
C. more potent topical steroid.
D. mupirocin ointment.
E. pimecrolimus cream.
 A four-year-old girl presents with a two to three day
Q38
history of increasing lethargy and pallor following a
recent febrile illness associated with cough. Parents report
her urine appeared dark that morning. On
examination she is clinically jaundiced and tachycardic
but well perfused and has mild splenomegaly.
The following investigations were obtained:
Haemoglobin (Hb) 67 g/L [110-145]
Mean corpuscular volume 90 fL [72-87]
White cell count (WCC) 11.5 x 109 /L [5-17]
Platelets 426 x 109 /L [150-400]
Reticulocytes 10%
Bilirubin 157mol/L [0-20]
Aspartate aminotransferase (AST) 141U/L [0-35]
Lactate Dehydrogenase (LDH) 11,751 U/L [500-920]
Creatinine 0.032 mmol/L [<0.062]
 A photomicrograph of the blood film is
shown above. Which is the most
appropriate next step in her
management?
A. Haemodialyse.
B. Intravenous gammaglobulin.
C. Intravenous methylprednisolone.
D. Transfuse packed red cells.
E. Warm the child.
 Q39

A two-year-old boy presents with a history

of constipation for several months and
recent ataxia. He is
otherwise well. On examination he is ataxic
without other neurological signs. He has a
non-tender
(right) upper abdominal mass. Computed
tomography (CT) scans of his head and
abdomen are shown
below.
 Which one of the following diagnoses
is most likely?
A. Alveolar rhabdomyosarcoma.
B. Desmoplastic round cell tumour of
the abdomen.
C. Ewing sarcoma.
D. Neuroblastoma.
E. Wilms tumour.
 Q40
A six-year-old Sudanese male presents to emergency
appearing toxic with a temperature of 39.4o C.
He has a three-day history of fevers and a 24-hour history
of left elbow pain and swelling. Blood tests are o
haemoglobin 70 g/L [115-155]
white cell count 18.9 x 109 /L [4.5-14.5]
absolute neutrophil count 10500 [1500-8000]
platelets 530 x 109 /L [150-400]
reticulocytes 15.5% [<2%]
C-reactive protein (CRP) 90 mg/L [0-10]
 A photomicrograph of the blood film is
shown above. Which of the following
organisms is most likely
to cause this clinical presentation?
A. Escherichia coli.
B. Haemophilus influenzae.
C. Salmonella enteritidis.
D. Staphylococcus epidermidis.
E. Yersinia enterocolitica.
 Q41

A clinically well child with the

dysmorphic features shown in the
photograph below presents with a loud
ejection systolic murmur.
 The child undergoes cardiac catheterisation
which yields the following information:
Saturation Pressure (mmHg)
superior vena cava 64%
right atrium 62% 9/6 (mean 8)
right ventricle 62% 51/7
main pulmonary artery 62% 51/15 (mean
35)
distal left pulmonary artery 62% 12/9 (mean
11)
distal right pulmonary artery 62% 14/9 (mean
12)
 Which of the following is the most likely
diagnosis?
A. Alagille syndrome.
B. Congenital rubella syndrome.
C. Noonan syndrome.
D. Velocardiofacial syndrome.
E. Williams syndrome.
 Q42

A four-year-old girl is seen in diabetes clinic. It is

four months since she was diagnosed with type 1
(insulin-dependent) diabetes mellitus and coeliac
disease. Her parents report marked behavioural
problems and temper tantrums, associated with
diabetes treatment and dietary restrictions.
 On examination extensive hairloss is noted as
shown in the photograph above.
What is the most likely diagnosis?
A. Alopecia areata.
B. Telogen effluvium.
C. Tinea capitis.
D. Traction alopecia.
E. Trichotillomania.
 Q43
A 21-month-old girl presents, with her siblings,
with a viral upper respiratory tract infection. Her
facial features are noted to be different from her
siblings and this has been present since birth. A
photograph is shown (the patient is seated in the
middle). She has no history of feeding or
breathing difficulties as an infant. On examination
her eye movements are normal with normal
pupillary responses. Her smile is equal and
symmetrical. What is the most likely diagnosis?
 A. Bilateral facial nerve (VII) palsy.
B. Bilateral oculomotor (III) nerve
palsy.
C. Congenital myasthenia gravis.
D. Congenital ptosis.
E. Mbius syndrome.
1 D 16A. 31.E Answers
2.B 17.A 32.B
3.B 18.C 33.E
4.A 19.D 34.E
5.E 20.B 35.E
6.D 21.C 36.A
7.A 22.A 37.B
8.D 23.A 38.E
9.D 24.C 39.D
10.B 25.E 40.C
11.A 26.A 41.A
12.B 27.E 42.A
13.A 28.B 43.D
14.E 29.D
15.A 30.C