CANDIDATE NUMBER:..

Royal College of Paediatrics and Child

Health
MRCPCH PART I EXAMINATION
PAPER One A
Specimen Paper
1. Complete the following:

Your full name (BLOCK LETTERS)

RCPCH Number.

Signature

2. Check your surname (family name) and initials appear in the top left hand
corner of the Answer Sheet. Check your candidate number is in the top right
hand corner.

Using the pencil provided, complete your response to each item on the
Answer Sheet.

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communicate with, other candidates whilst the examination is in progress.
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Breaches of these instructions, or misbehaviour in any other way, including
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from College examinations.

4. Question papers and individual questions must not be copied or removed from
the examination room.

5. Copyright law protects examination questions and the intellectual property of

their authors. The unauthorised use of questions is a breach of copyright law.

6. Answer all the following 75 questions.

 EXTENDED MATCHING QUESTIONS

Qu 1

This is a list of diagnoses:

A Kawasaki disease

B Measles

C Meningococcal disease

D Mycoplasma infection

E Pneumococcal meningitis

F Pneumococcal pneumonia

G Scalded skin syndrome

H Scarlet fever

I TB meningitis

J Toxic Shock Syndrome

Choose the most likely diagnosis for each of the following:

SELECT ONE ANSWER ONLY FOR EACH QUESTION

Note: Each answer may be used more than once

1. A 10-month-old infant presents with a 1-day history of a confluent blanching

rash which started on his face and now covers his entire body. He is
miserable with conjunctivitis and fever of 38.5. The illness started with
runny nose and cough 5 days previously. His 3-year-old brother has
recently started nursery.

This question
question continues on the next page.
Question 1 continued

2. An 18-month-old girl presents with a 3-day history of being unwell, feverish

and off her food. She has a rash which covers her entire body and is
variable but more marked when she is febrile. Her cheeks are red and she is
pale around her mouth. Her tongue and lips are red and pus is noted on her
tonsils. Fever is recorded up to 38.5 and she has a heart rate of 150/min,
respiratory rate of 40/min and capillary refill time of 2 seconds.
Blood
9
total white blood count 15 x 10 /l
9
neutrophil counts 11 x 10 /l

3. An 18-month-old girl, recently arrived from Nigeria, presents with a 1-week

history of fever with rigors. She has a widespread erythematous rash
covering her whole body. She is irritable, has conjunctivitis, cracked lips and
swollen hands. She has red tonsils and one small cervical lymph node. Her
heart rate is 160/min, respiratory rate 30/min and capillary refill time is 2
seconds.
Blood
9
total white blood count 15 x 10 /l
9
neutrophil count 12 x 10 /l
 Qu 2

This is a list of diagnoses:

A Acute lymphoblastic leukaemia

B Congenital bone cysts

C Infectious mononucleosis

D Juvenile idiopathic arthritis (JIA)

E Langerhans cell histiocytosis

F Neuroblastoma

G Non-accidental injury

H Osteogenic sarcoma

I Osteomyelitis

J Rickets

Choose the most likely diagnosis for each of the following:

SELECT ONE ANSWER ONLY FOR EACH QUESTION

Note: Each answer may be used more than once

1. A 4-year old boy presents with fever and limping which has been ascribed to
growing pains. He is clinically anaemic with enlarged lymph nodes in the
neck. There is a swelling in the left upper quadrant of the abdomen. A blood
count shows pancytopaenia. Skeletal survey shows wide-spread
abnormalities in the long bones.

2. A 4-year old girl presents with fever and limping which had been ascribed to
growing pains. She is clinically anaemic with bilateral proptosis. There is a
swelling in the left upper quadrant of the abdomen. A blood count shows
pancytopaenia. Skeletal survey shows wide-spread abnormalities in the long
bones.

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Question 2 continued

3. A 14-month-old girl presents with sore throat and fever up to 39.40. Her
parents say that she eats poorly, preferring juice, and she often refuses to
feed. She is very fretful and is not walking or pulling up to stand. She looks
pale and her head appears large. She is found to have tender swollen
wrists. Skeletal survey shows abnormal epiphyses.
Qu 3

This is a list of investigations:

A Cranial CT scan

B Cranial MRI scan

C Electrocardiogram

D Electroencephalogram

E Electroretinogram

F Lumbar puncture

G Post-ictal serum prolactin level

H Rectal biopsy

I Visual evoked responses

J Videotelemetry

Choose the investigation which is most likely to provide a diagnosis for the
following:

SELECT ONE ANSWER ONLY FOR EACH QUESTION

Note: Each answer may be used more than once

1. An 8-year-old boy collapsed while competing during his school sports day
nd
for the 2 year in succession. He appeared to be unconscious for
approximately 1 minute and then promptly fully recovered. A similar event
which lasted only a few seconds occurred 6 months ago during a cross-
country run. His twin brother had died at 3 months of age; the death
certificate recorded the cause as Sudden Unexpected Death in Infancy
(SIDS).

2. A 14-year-old girl is making poor school progress. Her friends and family
have noticed that she sometimes hesitates in mid-sentence and looks vague
for a brief moment, several times a day.

3. A 7-year-old boy developed a squint following a tonsillectomy 3 months ago.

th
He has a right 6 nerve palsy and is mildly ataxic.
 Qu 4

This is a list of feeding choices:

A Breast feeding

B Elemental formula milk

C Expressed breast milk from a milk bank

D Expressed breast milk from mother

E Expressed breast milk with fortifier

F Follow-on formula milk

G Full term formula milk

H Lactose-free formula milk

I Low birth-weight formula milk

J Soya formula milk

Choose the best feed for the following infants

SELECT ONE ANSWER ONLY FOR EACH QUESTION

Note: Each answer may be used more than once

1. At 4-weeks of age a baby boy with known atrio-ventricular septal defect is breast
feeding but is still only at his birth weight. The parents recognise the importance
of improving the nutrition but are hesitant to introduce formula feeds.

2. An infant born at 26-weeks gestation reaches 6-weeks of age and has chromic
lung disease. Necrotising enterocolitis was treated conservatively between day 5
and 15 and the baby subsequently built up to full feeds with expressed breast milk.
The weight has been static for 2 weeks.

3. A mother knows that she is HIV positive. Her other child has asthma so she says
she would prefer to breast-feed her baby.
Qu 5

T his is a list of treatments:

A Demonstration and education in the use of emollients

B Explanatory leaflet about topical treatment

C Hypoallergenic diet

D Intravenous aciclovir

E Intravenous antibiotics

F Oral aciclovir

G Oral antibiotics

H Oral antihistamines

I Topical tacrolimus ointment

J Wet wraps

Choose the best treatment for each of these children who have recently arrived in
the UK.

SELECT ONE ANSWER ONLY FOR EACH QUESTION

Note: Each answer may be used more than once

1. A 6-month-old boy presents with a severe exacerbation of eczema. His skin is

markedly inflamed all over. He has been breast-fed from birth. He developed
mild facial eczema at the age of four months and up till now has been treated
with emollients. His mother has a sore on her lip. His temperature is 37.8 C

2. A 6-month-old boy has been breast-fed from birth. His skin became dry and
itchy at the age of four months and he has become distressed and is sleeping
poorly. The skin is very dry and excoriated. His temperature is 37 C. His
mother is unwilling to use steroids under any circumstances.

3. A 6-month-old boy presents with a severe exacerbation of eczema. His skin is

markedly inflamed all over. Some of the lesions have yellow crusting. He has
been breast-fed from birth. He developed mild facial eczema at the age of four
months and up till now has been treated with emollients. He is feeding poorly
and has a temperature of 39 C.
 Qu 6

This is a list of diagnoses:

A Accidental head injury

B Diabetic ketoacidosis

C Ingestion of alcohol

D Ingestion of aspirin

E Ingestion of iron tablets

F Insulin overdose

G Non-accidental head injury

H Overdose of metformin

I Paracetamol overdose

J Post convulsive state

Choose the most likely diagnosis for each of the following

SELECT ONE ANSWER ONLY FOR EACH QUESTION

Note: Each answer may be used more than once

1. A boisterous 4-year-old boy had been staying at his elderly grandparents

house to give his pregnant mother a rest. He had been playing on the
climbing frame in their garden. His mother collected him in the evening and
found he was more sleepy than usual. The next morning he was found
unrousable in bed.
On arrival at the Emergency department his Glasgow coma scale is 4/15.
He is apyrexial, with a patent airway and his respirations are shallow and
irregular.
Capillary blood glucose 4.2 mmol/l.
Urine dipstick trace of protein

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Question 6 continued

2. A thin 14-year-old boy has been treated for diabetes since the age of 3
years. At his last clinic visit his HbA1C level was 10% and his insulin dose
was increased. He comes home later than expected after football with
abdominal pain and headache. He shouts at his mother, goes to his room
and does not come down to tea. His mother, who is pregnant, finds him
sweating and semiconscious with slurred speech.
Capillary blood glucose 2.0 mmol/l.
Urine dipstick trace of ketones

3. A boisterous 4-year-old boy had been staying at his elderly grandparents

house to give his pregnant mother a rest. He had been playing on the
climbing frame in their garden. His mother arrived to collect him in the
evening and found him asleep but difficult to rouse.
On arrival at the Emergency department his Glasgow coma scale is 9/15.
He is apyrexial, with a patent airway and his respirations are shallow and
shallow.
Capillary blood glucose 4.2 mmol/l.
Urine dipstick protein 1+, ketones 1+
Qu 7

This is a list of diagnoses:

A Allergic rhinitis

B Asthma

C Bilateral vocal cord paralysis

D Epiglottitis

E Laryngotracheomalacia

F Mycoplasma pneumonia infection

G Subglottic haemangioma

H Subglottic stenosis

I Vascular ring

J Viral croup

Choose the most likely diagnosis for each of the following

SELECT ONE ANSWER ONLY FOR EACH QUESTION

Note: Each answer may be used more than once

1. A 5-week-old girl was born at 32 weeks gestation and was ventilated for 2
days. She had been well since apart from a strawberry naevus on her
forehead. She presents with a 2-week history of increasing stridor.

2. A 1-month-old boy has intermittent stridor which has been present since 2
weeks of age. It increases during feeding and crying but disappears during
rest and sleep.

3. A 3-year-old girl presents with short history of respiratory distress and

stridor associated with cough and blocked nose. She had been well in the
past apart from an episode of fever and rash at the age of 11 months
following which her parents had declined MMR immunisation because they
believed she had egg allergy.
 Question 8

This is a list of maternal infections:

A Cytomegalovirus

B Group B streptococcus

C Hepatitis B

D Herpes simplex virus

E Human immunodeficiency virus

F Listeria monocytogenes

G Rubella

H Salmonella typhimurium

I Toxoplasma gondii

J Treponema pallidum

Choose the infection which applies most closely to the following:

SELECT ONE ANSWER ONLY FOR EACH QUESTION

Note: Each answer may be used more than once

1. If the mother is infected with this organism during late pregnancy, the baby
is at increased risk of deafness

2. If the mother is infected with this organism during pregnancy the baby is
likely to be born prematurely and to have diarrhoea.

3. If the mother is infected with this organism during pregnancy the baby is
likely to have a retinopathy which is amenable to treatment.
Qu 9

This is a list of diagnoses:

A Acute lymphoblastic leukaemia

B Aplastic anaemia

C Haemophilia A

D Henoch-Schnlein purpura

E Idiopathic juvenile arthritis

F Immune thrombocytopenic purpura

G Meningococcal septicaemia

H Non-accidental injury

I Sickle cell disease

J Von Willebrands disease

Choose the most likely diagnosis for each of these children presenting with
bruising:

SELECT ONE ANSWER ONLY FOR EACH QUESTION

Note: Each answer may be used more than once

1. A 5-year-old boy of Afro-Caribbean origin, born in London, is brought to the

Emergency department with a painful left leg after playing football on a cold
day. He is distressed with a tender right thigh and is noted to be clinically
anaemic and mildly jaundiced.

2. A 5-year-old boy of Afro-Caribbean origin, born in London, is brought to the

Emergency department with pain in his legs for 3 weeks. His parents say that
he has just developed bruising on his trunk and limbs. He looks unwell with a
temperature of 38.8C. He is noted to be clinically anaemic and has bruises on
his back, thighs and abdomen, and petechiae on the palate.

3. A 5-year-old boy of Afro-Caribbean origin, born in London, is brought to the

Emergency department with a swollen left knee after playing football. His
mother says that he always bruises easily. Examination confirms the swollen
knee together with bruising extending down the shin.
Qu 10

This is a list of diagnoses:

A Acrodermatitis enteropathica

B Coeliac disease

C Cows milk protein intolerance

D Crohns disease

E Cystic fibrosis

F Giardiasis

G Primary lactose intolerance

H Primary sucrose intolerance

I Rotavirus gastroenteritis

J Toddler diarrhoea

Choose the most likely diagnosis for each of the following clinical situations:

SELECT ONE ANSWER ONLY FOR EACH QUESTION

Note: Each answer may be used more than once

1. A 2-year-old boy has a 6-month history of 3 to 4 loose bowel actions per day,
with stools that contain recognisable food particles. Of normal weight and
height, he is otherwise well.

2. A 2-month-old boy was initially breast fed. At 5 weeks of age he was

diagnosed with colic by his health visitor and his mother changed him to
formula milk after pressure from her family. He continued with screaming
episodes and loose stools. He has persistent nappy rash, his scalp is red and
scaly and his cheeks are inflamed.

3. A 2-year-old boy was born in Eastern Europe. He is referred because his

th nd
weight has fallen from the 25 to below the 0.2 centile. His parents have
been concerned that his stools have always been loose and look paler than
those of his sister at the same age. His liver is firm and palpable 2 cm below
the right costal margin.
Qu 11

This is a list of ages:

A 8 years

B 10 years

C 11 years

D 12 years

E 13 years

F 14 years

G 16 years

H 17 years

I 18 years

J 21 years

Choose the age which most closely applies to the following:

SELECT ONE ANSWER ONLY FOR EACH QUESTION

Note: Each answer may be used more than once

1. The age at which a young person can legally consent to medical or dental
treatment.

2. The age at which a young person can legally refuse life sustaining treatment.

3. The age at which a young person can legally purchase cigarettes.

Qu 12

This is a list of diagnoses:

A Attention deficit hyperactivity disorder

B Autistic spectrum disorder

C Conduct disorder

D Depression

E Dyslexia

F Dyspraxia

G Food allergy

H Global developmental delay

I Specific language disorder

J Within normal limits

Select the most likely diagnosis for each of the following clinical situations

SELECT ONE ANSWER ONLY FOR EACH QUESTION

Note: Each answer may be used more than once

1. A 5-year-old boy had been slow to talk and is having speech therapy but is
not responding very well. He weighed 3.2kg at term and his motor
milestones are normal. At school entry he does not talk to other children.
He becomes restless during group activities and has temper tantrums when
other children want to share toys with him. He can read and has an
aptitude for number work.

2. A boy had been slow to talk and had speech therapy but is now
communicating well. At the age of 7 years he has difficulty writing and
copying. He does not like to join in games. He is unable to dress himself
and is a messy eater.

This question continues on the next page.

 Question 12 continued

3. An 8-year-old boy is distressed that he has not been selected for school
sports team. He weighed 2.2kg at 37 weeks gestation. He walked at 14
months. He had been slow to talk but was discharged by the speech
therapist on review at the age of 4 years. At school entry he tried to make
friends but other children found him irritating. He becomes restless and
distractible during group activities and has temper tantrums when asked to
complete his schoolwork. His mother confirms that his behaviour at home is
similar.
 MULTIPLE TRUE/FALSE QUESTIONS

Qu 13

A symmetrical red rash on the face is seen characteristically in

A. herpes zoster

B. neurofibromatosis

C. Sturge-Weber syndrome

D. systemic lupus erythematosis

E. tuberous sclerosis

Qu 14
nd
A 1-year-old child whose weight is below the 2 centile

A. is failing to thrive

B. is probably malnourished

C. is within 2 standard deviations of the mean

D. requires a family assessment by a social worker

E. requires referral to a paediatrician

Qu 15

An umbilical hernia

A. if still present at 6 months requires surgical repair

B. is a cause of recurrent abdominal pain in childhood

C. is a feature of babies with untreated congenital hypothyroidism

D. is more commonly found in Caucasian than Afro-Caribbean babies

E. poses a significant risk of intestinal obstruction

Qu 16

Causes of haematuria in a 2-year-old child include

A. fabricated illness by carers

B. hypercalciuria

C. minimal change nephrotic syndrome

D. neuroblastoma

E. sickle-cell disease

Qu 17

It is true of deliberate self harm that

A. boys are more likely than girls to complete suicide in adolescence

B. in teenage girls it is generally indicative of physical or sexual abuse

C. in the teenage years it occurs with equal frequency in males and females

D. it can result in an improvement in family functioning

E. young people who attempt suicide commonly kill themselves later in life in the
absence of therapeutic intervention

Qu 18

A 10-month-old boy is a bottom shuffler. The following would be expected:

A. A family history in a first degree relative

B. Absent downward parachute reflex

C. Dislike of the prone position

D. Increased muscle tone in the legs

E. Normal speech development

Qu 19

In Kawasaki disease

A. conjunctivitis is usually purulent

B. erythema nodosum is seen

C. peeling of the fingers is a presenting feature

D. the peak age is 5-9 years

E. thrombcytopaenia is one of the diagnostic features

Qu 20

Plagiocephaly in a 12-week-old infant

A. is associated with craniosynostosis in the majority of cases

B. is associated with epilepsy

C. is associated with sternomastoid tumour

D. is often progressive without treatment

E. occurs in babies who tend to lie on one side

Qu 21

Recurrent periumbilical pain in an otherwise healthy 8-year-old girl

A. has an organic cause in more than 20% of cases

B. if functional, characteristically wakes the child at night

C. is commonly associated with headaches

D. is frequently due to Helicobacter pylori infection

E. is likely to be organic in origin if associated with poor school attendance

Qu 22

An 8-year old boy is brought by his parents with a sore throat of 2 days duration.
He has a red throat and coryza with cough.

Best management includes

A. advice not to attend school for 2 days

B. prescription of decongestant drops

C. prescription of penicillin syrup

D. prescription of soluble aspirin

E. reassurance that the illness is self-limiting

Qu 23

At 12-months of age a healthy boy born at term should

A. be dry by day

B. cruise along the furniture

C. feed himself with a spoon

D. play peek-a boo

E. use 2-word phrases

Qu 24

It is true of fragile X syndrome that

A. it is associated with autistic spectrum disorder

B. it is associated with low birth weight

C. it is the commonest cause of learning disability in boys

D. low-set ears are a characteristic feature

E. there is a characteristic karyotype

Qu 25

The following are true of children with nocturnal enuresis:

A. An enuresis alarm is the treatment of choice at the age of 5 years

B. Fluid restriction is an effective method of management

C. If present in a 9-year-old there is probably a psychiatric disorder

D. It is a presenting feature of diabetes mellitus

E. The urinary tract is expected to be structurally normal

Qu 26

The following are true of urinary tract infection in childhood:

A. It is commoner boys than girls at the age of 1 month

B. Progressive renal scarring is uncommon after the age of 8 years

C. The presence of pyuria is necessary for diagnosis

D. Vesico ureteric reflux characteristically improves spontaneously

E. When diagnosed in an infant an immediate radioisotope (DMSA) scan is

indicated

Qu 27

Attenuated live organisms are used to immunise against

A. haemophilus influenzae type b

B. measles

C. polio

D. tuberculosis

E. whooping cough
 BEST OF FIVE QUESTIONS

Qu 28

A 2-day-old baby girl is found to be clinically cyanosed. Her colour does not improve
with supplemental 100% oxygen in a headbox.

What is the most likely diagnosis?

SELECT ONE ANSWER ONLY

A. Coarctation of the aorta

B. Fallots tetralogy

C. Pulmonary stenosis

D. Transposition of the great arteries

E. Ventricular septal defect

Qu 29

Recent studies have shown a fall in the incidence of Sudden Unexpected Death in
Infancy (SIDS).

What is the most important reason for this fall?

SELECT ONE ANSWER ONLY

A. Advice to avoid overheating

B. Health promotion campaigns to reduce maternal smoking

C. Intensive support by Health Visitors to vulnerable families

D. Midwifery support for breast feeding

E. Putting babies to sleep on their backs

Qu 30

A 15-month-old girl is admitted with increasing breathlessness over the last 2 weeks.
In spite of a good appetite, weight gain has been poor with weight crossing from the
th nd
9 to the 2 centile. Birth and neonatal history are unremarkable. Her parents are
second cousins and a sibling has severe eczema. She is passing 3-4 stools per day.
She is pale and snuffly. She has a respiratory rate of 70/minute, is unable to sit up and
is using accessory muscles of respiration. There are scattered crackles heard
bilaterally. Her abdomen is distended with a palpable liver. Oxygen saturation is 89% in
air.
What is the most likely diagnosis?

SELECT ONE ANSWER ONLY

A. Asthma

B. Atypical pneumonia

C. Cystic fibrosis

D. Immunodeficiency syndrome

E. Mucopolysaccharidosis

Qu 31

A 7-month-old girl presents with fever, evolving purpura and poor peripheral
perfusion. The fontanelle is flat.
Intravenous access is obtained with difficulty and a bolus of normal saline is given.

What is the best action to be taken next in the Emergency department?

SELECT ONE ANSWER ONLY

A. Notify the Public Health department

B. Perform a lumbar puncture

C. Prescribe chemoprophylaxis for the staff who have been in contact with him.

D. Start intravenous antibiotics

E. Take a swab from a purpuric lesion

Qu 32

A 14-year-old girl complains of recurrent abdominal pain for the last 6 months. She is
also suffering from mouth ulcers, swollen knees and poor appetite. She says she feels
weak. Two friends have overtaken her in height in the last year. She goes to school
every day.

She is clinically anaemic, thin and prepubertal. Examination is otherwise

unremarkable.

What is the most probable diagnosis?

SELECT ONE ANSWER ONLY

A. Anorexia nervosa

B. Coeliac disease

C. Crohns disease

D. Juvenile idiopathic arthritis

E. Turners syndrome

Qu 33

A 13-year-old girl with a 5-year history of insulin-dependent diabetes mellitus has had
several admissions over 6 months with diabetic ketoacidosis but makes a rapid
recovery and is well by the next day.

What is the most explanation for these episodes?

SELECT ONE ANSWER ONLY

A. Failure to monitor blood sugar during illness

B. Frequent viral infections

C. Missed insulin

D. Overdose of insulin

E. Recurrent bouts of binge eating

Qu 34

A 4-year-old boy presents to the emergency department with a 2-day history of

increasing redness of his face. He had been playing in the garden the previous day and
was distressed by the number of insects flying about. His mother describes a pea-
sized area of redness on his nose yesterday, which has enlarged rapidly since then. He
has suffered from eczema in the past.
His temperature is 37.8C There is marked redness and swelling of his left eyelid and
cheek. Eye movements are full, vision is normal and there are no other abnormalities
on examination.

What is the most likely diagnosis?

SELECT ONE ANSWER ONLY

A. Haemophilus influenza Group B (HiB) infection

B. Infected insect bite

C. Neuroblastoma

D. Orbital cellulitis

E. Peri-orbital cellulitis

Qu 35

A 10-month-old boy is bought to the emergency department unconscious. The only

other abnormality on clinical examination is that fundoscopy reveals retinal
haemorrhages. Mother says that she found him unrousable in his cot. There is no
relevant past medical history and his parent-held child record shows that he had
routine child health surveillance checks at age 6 weeks and 8 months but has only
received the first dose of his primary immunisation schedule.

What is the most likely diagnosis?

SELECT ONE ANSWER ONLY

A. Apparent life threatening event (near-miss cot death)

B. Child abuse

C. Haemophilia A

D. Inherited metabolic disease

E. Viral encephalitis
Qu 36

A 3-year-old boy presents with ear-ache and fever. On examination he has bilateral
red bulging tympanic membranes. He is treated with antibiotics. His pain and fever
settle but residual middle ear effusions are found.

What is the most important issue to discuss with his parents now?

SELECT ONE ANSWER ONLY

A. That he will have a long-term hearing loss

B. That he will have a short-term hearing loss

C. The immediate risk of mastoiditis

D. The long-term risk of cholesteatoma

E. The need for adenoidectomy

Qu 37

A first-born baby girl has an atraumatic normal delivery at 35-weeks gestation.

Routine antenatal care identified no problem or need for intervention. At 18hours of
age she is well but jaundiced.

What is the most likely cause of the jaundice?

SELECT ONE
ON E ANSWER ONLY

A. ABO incompatibility

B. Congenital hypothyroidism

C. Prematurity

D. Rhesus incompatibility

E. Urinary tract infection

Qu 38

A 7-year-old boy presents with a 2-day history of sore throat and wide-spread
maculopapular rash. He had been mildly unwell for 1 week.
His temperature is 37.9C, his tonsils are inflamed, there are petechiae on the palate
and he has cervical lymphadenopathy. His spleen is palpable 4cm below the costal
margin.
Blood
haemoglobin 11.9 g/dl
9
total white cell count 18.9 x 10 /l
9
lymphocyte count 14.8 x 10 /l
9
platelet count 320 x 10 /l

Which investigation is most likely to provide a diagnosis?

SELECT ONE ANSWER ONLY

A. Abdominal ultrasound

B. Antistreptolysin O titre (ASOT)

C. Bone marrow examination

D. CMV serology

E. Monospot test
Qu 39

A 4-year-old boy has developed marked swelling of the face, legs and abdomen over
the last 4 days. He has no abdominal pain, and is still fairly active. His blood pressure
is 100/70 mmHg and pulse rate is 90/min. He cannot open his eyes as a result of the
facial oedema and there is clinical evidence of ascites.
Blood
urea 4.2 mmol/l
creatinine 50 Rmol/l

Urine protein +++

Blood nil

Which is the most appropriate first stage of management?

SELECT ONE ANSWER ONLY

A. Admit for bed rest and observation

B. Albumin infusion

C. Intravenous frusemide (furosemide)

D. Refer to dietician for low sodium diet

E. Treatment with oral prednisolone

Qu 40

A 6-year-old girl is brought to the emergency department with a 5-hour history of

difficulty in breathing. She is not known to have asthma and has had no treatment. She
is unable to speak, is agitated and looks pale.
She has a respiratory rate of 50/min and auscultation reveals very quiet breath sounds
with no added sounds.

What is the most appropriate initial treatment?

SELECT ONE ANSWER ONLY

A. Inhaled salbutamol 5 puffs via a spacer device

B. Intravenous hydrocortisone 100mg

C. Nebulised salbutamol 5 mg

D. Nebulised terbutaline 2.5 mg

E. Oral prednisolone 40 mg

Qu 41

Recently a 12-month-old girl was given her first spoon of scrambled egg. Within 5
minutes her face was red with a bumpy rash and she had swelling of her eyes and lips.
She vomited. The symptoms subsided over the next hour and she was then back to
normal without any treatment. She is otherwise a healthy girl with no medical
concerns.

What is the best advice to give to the parents regarding MMR immunisation ?

SELECT ONE ANSWER ONLY

A. Postpone her 13-month MMR vaccine till she has been investigated for egg allergy

B. Postpone her MMR vaccine until she is 3-years-old by when there is a good
chance she will have outgrown her egg allergy

C. She can have her MMR vaccine next month as normal in the community

D. She should have single antigen Mumps and Rubella vaccines next month and the
Measles vaccine can be given later.

E. She will be referred to the local hospital to have her MMR vaccine
Qu 42

A 2-year-old girl is brought to the emergency department with seizures and is found
to have tachycardia. Her parents believe she took some of her grandfathers
medication prescribed for asthma.

Which of the following drugs is most likely to have caused the problem?

SELECT ONE ANSWER

ANSWE R ONLY

A. Monteleukast

B. Prednisolone

C. Salbutamol

D. Salmeterol

E. Theophylline

Qu 43

A 4-year-old boy complains of pain in the groin and has been walking with a limp for 2
days. He lies on the examination couch with his hip flexed and externally rotated. His
o
temperature is 37 and his pharynx red and injected.

What is the best next action?

SELECT ONE ANSWER ONLY

A. Admit for hip traction

B. Advise strict bed rest for 10 days

C. Prescribe simple analgesia and observe him

D. Request emergency joint aspiration

E. Warn the parents that he is likely to develop Perthes disease.

Qu 44

A 7-year-old boy is the tallest in his class and requires 10-year-old sized clothes.

What is the most helpful initial information?

SELECT ONE ANSWER ONLY

A. Bone age

B. Height to weight ratio

C. Karyotype

D. Mid-parental height

E. Span to height measurement

Qu 45

A 12-year-old boy presents with a limp. He has not been to school for 3 weeks and
complains of pain in the left knee. You note that he is overweight (69kg) and his
mother thinks he is possibly being bullied about this. The knee is normal on
examination.

What is the most likely diagnosis?

SELECT ONE ANSWER ONLY

A. Ischaemic necrosis of tibial tubercle (Osgood-Schlatter disease)

B. Juvenile idiopathic arthritis

C. Perthes disease

D. School refusal

E. Slipped upper femoral epiphysis

Qu 46

The parents of a 19-month-old girl consult you because she appears to have breast
development. On examination you confirm that there is symmetrical swelling of both
breasts with what feels like breast buds.

Which is the most important additional clinical feature suggesting a referral for
endocrine investigation?

SELECT ONE ANSWER ONLY

A. A history of recent onset of masturbation

B. Fused labia minora

C. Presence of an umbilical hernia

D. Presence of pubic hair

th
E. Tall stature with height and weight above the 90 centile

Qu 47

An 8-year-old boy with Henoch Schnlein purpura (HSP) presents with acute scrotal
pain and swelling on one side of the scrotum.

Which is the most important condition to exclude?

SELECT
SELECT ONE ANSWER ONLY

A. Epididymo-orchitis

B. Idiopathic scrotal oedema

C. Inguino-scrotal hernia

D. Torsion of the Hydatid of Morgagni

E. Torsion of the testis

Qu 48

A 7-year-old girl is admitted with high fever and painful cough productive of purulent
sputum. There is dullness at the left base. Chest X-ray shows left lower lobe
consolidation.
Though previously well in general, she had a similar illness while on holiday abroad 9
months ago and made a complete recovery. She is fully immunised immunisation.

She is prescribed a course of antibiotics but remains febrile.

Which investigation is the most useful to guide further management?

SELECT ONE ANSWER ONLY

A. Bronchoscopy

B. CT scan of chest

C. Mantoux test

D. Serum immunoglobulins

E. Ultrasound scan of chest

Qu 49

A healthy 3-year-old boy was found to have a hernia and was referred for surgery. He
was noted to have a systolic murmur but no other abnormalities. A diagnosis of
ventricular septal defect was confirmed by echocardiography. His mother asks the
general practitioner for advice.

What is the most useful advice for the mother?

SELECT ONE ANSWER ONLY

A. The anaesthetist will advise about antibiotic cover

B. The boy needs surgical closure of the VSD before the hernia operation

C. The boy will have routine surgery for the hernia and the VSD will close
spontaneously

D. The boy will have routine surgery for the hernia then he will need surgical
correction of the VSD

E. The GP will prescribe oral penicillin to start the day before surgery for the hernia
Qu 50

A 5-year-old boy has normal first and second heart sounds with a loud pansystolic
murmur at the left lower sternal border but no thrill is palpable. He has no cardiac
symptoms.

What is the most likely diagnosis?

SELECT ONE ANSWER ONLY

A. Coarctation of aorta

B. Functional murmur

C. Mitral valve prolapse

D. Patent ductus arteriosus

E. Ventricular septal defect

Qu 51

A 10-year-old boy is seen in the outpatient clinic because of recurrent headaches. A

diagnosis is made of simple tension headaches. This is explained at length in an
attempt at reassurance. Parents are unhappy with the diagnosis of tension headaches
and request a brain scan.

Which is the best next step to take?

SELECT ONE ANSWER ONLY

A. Agree to ordering a CT scan of head for reassurance

B. Explore in more detail the parents' concerns

C. Offer a second opinion from a colleague

D. Repeat your explanation carefully in more detail

E. Suggest referral to child psychologist

Qu 52

A 4-year-old Caucasian boy has developed bruises on the body overnight. He had
been treated with cephalexin for an upper respiratory tract infection 2 weeks
previously.
His temperature is 37.6C and he is otherwise well. He has bruises on the limbs and
trunk, together with purpura on the forearms and palate. Multiple small lymph nodes
are palpable in the posterior triangle of the neck. The liver and spleen are not
palpable.
Blood
haemoglobin 11.8 g/dl
9
white cell count 6.7 x 10 /l
9
platelet count 18 x 10 /l

Which is the best choice of management?

SELECT ONE ANSWER ONLY

A. Assure parents that no immediate treatment is needed

B. Commence oral prednisolone immediately

C. Give intravenous immunoglobulin infusion immediately

D. Observe for a week and commence prednisolone if the problem continues

E. Request a bone marrow examination

Qu 53

A 6-year-old girl has hereditary spherocytosis. Splenectomy has been advised. Her
parents are particularly concerned about risks to her health in adult life.

Which of the following represents her greatest risk in adult life?

SELECT ONE ANSWER ONLY

A. Gall stones

B. Haemochromatosis

C. Lymphoma

D. Meningococcal septicaemia

E. Pneumococcal septicaemia
Qu 54

A 3-year-old boy has been sleeping poorly since the arrival of a new baby sister. He
has been having temper tantrums at nursery during the day and regularly gets up at
night to climb into his parents bed. In the morning his parents are exhausted but he is
full of energy.
What is the best first-line management of the sleep problem?

SELECT ONE ANSWER ONLY

A. Behavioural management techniques

B. Exclude artificial additives from his diet

C. Keeping him awake all day

D. Prescribe him oral night time sedation

E. Talk to his nursery school teacher

Qu 55

A month ago a 3-year-old girl tripped over onto her face, running into the house for
lunch. She remained on the ground, went very pale and was unresponsive few
moments before recovering completely. She has had 2 similar episodes since then.

What is the most likely diagnosis?

SELECT ONE ANSWER ONLY

A. Absence seizures (petit mal epilepsy)

B. Concussion

C. Hypoglycaemia

D. Reflex anoxic seizures

E. Vasovagal attacks
Qu 56

A 2-year-old girl presents with drooling since returning from the child-minder. She is
refusing drinks. Her mother finds that a favourite small toy is missing and suspects
that she could have swallowed it.
She is afebrile and alert. Examination is normal. A chest X-ray is normal.

What is the best management at this stage?

SELECT ONE ANSWER ONLY

A. Intravenous antibiotics

B. Intravenous dexamethasone

C. Intravenous fluids

D. Referral for endoscopy

E. Request ultrasound of chest

Qu 57

A 6-year-old boy presents with a 2-week history of chest infection and lethargy. He
has been on treatment with 2 different antibiotics. Over the last 48 hours he has
developed a widespread rash on his limbs associated with joint pains and abdominal
discomfort.
He has a temperature of 38.5 C and is generally unwell. The rash appears to consist
of circular lesions and is not itchy. He has aphthous ulcers on the buccal mucosa, and
his tongue looks erythematous.

Which is the most likely diagnosis?

SELECT
SELECT ONE ANSWER ONLY

A. Dermatitis herpetiformis

B. Erythema multiforme

C. Henoch- Schnlein purpura

D. Kawasaki disease

E. Penicillin allergy
Qu 58

A 13-year-old boy is concerned that he is not developing like his friend at school. He
has normal prepubertal external genitalia.

Your advice is that the first sign of puberty will be:

SELECT ONE ANSWER ONLY

A. Accelerated increase in height

B. Enlargement of the penis

C. Enlargement of the testes

D. Growth of axillary hair

E. Growth of pubic hair

Qu 59

A baby boy was born at term by Ventouse extraction to a mother who was known to
have gestational diabetes. His birth weight was 3.9 Kg. He had subconjunctival
haemorrhages and there were petechiae on his face. He breast-fed well and his
capillary blood glucose levels were satifactory. At 24 hours of age he has developed a
large left-sided cephalhaematoma.

What is the one most important aspect of management now?

SELECT ONE ANSWER ONLY

A. Give a second dose of Vitamin K

B. Give prophylactic oral phenobarbitone

C. Monitor haemoglobin levels

D. Monitor serum bilirubin levels

E. Perform ultrasound of the head

Qu 60

The mother of a 10-day-old baby presents with fever, backache and a large tender,
red, non-fluctuant mass in her right breast. The right nipple is sore and has been
bleeding intermittently. Her baby, who was born at 39 weeks of gestation, is unsettled
and now weighs 200 grams less than his birth weight of 3400g. Mother is started on
flucloxacillin.

What is the most important advice to give now?

SELECT ONE ANSWER ONLY

A. Mother to express breast milk to feed the baby

B. Recommend ibuprofen for mother

C. Replace breast feeding with formula milk

D. Start the baby on oral flucloxacillin and continue breast feeding

E. Stop breastfeeding until the results of milk cultures are known

Qu 61

A 7-year-old boy is referred to outpatients because his mother reports that his
behaviour has deteriorated over the last year. He is overactive, does not sleep well
and is disobedient. He concentrates poorly on given tasks but enjoys watching his
favourite video for over an hour without interruption. His mother is insisting that
something must be done about this. Neurological examination reveals mild
clumsiness.

What is the most appropriate action to take at his first outpatient visit?

SELECT ONE ANSWER ONLY

A. Ask for a report from school

B. Discuss a trial of methylphenidate

C. Prescribe a short term trial of nocturnal sedation to break his poor sleeping pattern

D. Refer to an educational psychologist for assessment of special educational

needs

E. Refer to Social Services for assistance as a possible Child in Need (Section 17

Children Act)
Qu 62

A 5-year-old boy has had 4 episodes of a localised blotchy raised rash of variable
distribution in the last 4 months. The rash was itchy, usually red but occasionally white
and lasted about 12 hours. By the next day the skin is normal again. He has mild
asthma and had infantile eczema in his first year of life. He has a pet cat and hamster.

Which of the following statements best summarises the advice you should give to the
parents at this stage?

SELECT ONE ANSWER ONLY

A. An identifiable cause for the rash is unlikely to be found

B. It would be helpful to investigate for food allergy

C. On future occasions he should be excluded from school while the rash is present

D. The family cat should be treated for fleas

E. This is a common manifestation of parvovirus infection and is self-limiting.

Qu 63

A 3-year-old girl diagnosed at birth as having Down syndrome, has been followed up
regularly in the paediatric outpatient department. After a 6-month interval between
appointments it is noted that she is now falling away from her previous height centile
on a Down syndrome growth chart.

Which of the following actions is most appropriate?

SELECT ONE ANSWER ONLY

A. Check full blood count and film

B. Measure anti-human-tissue transglutaminase antibodies

C. Measure growth hormone level

D. Measure serum T4 and TSH levels

E. Take a detailed dietary history

Qu 64

A 2-year-old boy is brought to the emergency department with a 12-hour history of

vomiting. He is alert but miserable and has bruising behind both ears and over his
trunk.
Blood
haemoglobin 12.4 g/dl
9
white cell count 10 x10 /l
9
platelet counts 220 x10 /l
coagulation screen normal.

Which is the most urgent next investigation?

SELECT
SELECT ONE ANSWER ONLY

A. Abdominal ultrasound scan

B. CT Brain

C. Opthalmology examination

D. Skeletal Survey

E. Skull X-ray

Qu 65

A 5-year-old boy is seen in the emergency department. He is unwell with stridor and
pallor following a bee-sting approximately 1 hour previously.

What is the best first-line management?

SELECT ONE ANSWER ONLY

A. Inhaled salbutamol

B. Intramuscular adrenaline

C. Oral antihistamine

D. Oral prednisolone

E. Sub-cutaneous adrenaline
Qu 66

A 3-year-old boy comes to the clinic. His mother reports that he does not speak,
attempt to dress himself or obey any instructions. His mothers brother has learning
difficulties. He wanders aimlessly round the clinic room. Physical examination is
normal.

What is the most likely diagnosis?

SELECT ONE ANSWER ONLY

A. Aspergers syndrome

B. Attention deficit hyperactivity disorder (ADHD)

C. Developmental dyspraxia

D. Fragile-X syndrome

E. Glue ear (otitis media with effusion)

Qu 67

A 4-year-old boys mother reports that he snores excessively at night. He suffers from
recurrent upper respiratory tract infections.
Which of the following is the most useful additional item of information to include in
the referral letter to an oto-rhino-laryngologist (ENT surgeon) to prompt an urgent
clinic appointment?

SELECT ONE ANSWER ONLY

A. He has glue ear and is due to start school next term

B. He has persistent cervical lymphadenopathy

C. His mother says he is always difficult to wake in the morning

D. His tonsils meet in the midline

E. The nursery report that his speech is difficult to understand

Qu 68

A thriving 2-year-old boy is referred because of long-standing excessive drinking. His

maternal aunt has Type 1 diabetes mellitus.

What is the most appropriate next step?

SELECT ONE ANSWER ONLY

A. Check osmolarity of early morning urine

B. Keep a diary of fluid intake

C. Measure fasting blood sugar

D. Measure random plasma osmolarity

E. Perform a water deprivation test

Qu 69

A 9-year-old girl who is the youngest of 7 children attends a school for moderate
learning difficulties. Her teacher has described blank episodes several times a day
over the past 3 months. Each of them lasts 1-2 minutes but she appears to respond
when spoken to. Her mother has not noticed any such episodes at home.

What is the most likely diagnosis?

SELECT ONE ANSWER ONLY

A. Classical generalized childhood absence

B. Complex partial seizures

C. Daydreaming

D. Juvenile absence epilepsy

E. Lennox Gastaut epilepsy

Qu 70

A 5-year-old boy has episodes of screaming and perspiration during sleep. He does
not respond to his parents and appears to talk to an imagined person in the room.
The episode settles after around 15 minutes and the child goes back to sleep. He has
no recall of the episode on waking.

What is the most likely cause of the attacks?

SELECT ONE ANSWER ONLY

A. Fear of the dark

B. Hypnogogic state

C. Night terrors

D. Nightmares

E. Nocturnal complex partial seizures

Qu 71

A 5-year-old girl presents with a 3-day history of pain in her ankles. She is afebrile,
blood pressure 105/60 and she has a non-blanching rash on her lower limbs, arms and
buttocks. She has been well in the past and there is no significant family history.
Which is the most important investigation?

SELECT ONE ANSWER ONLY

A. Blood culture

B. C-reactive protein

C. Full blood count with clotting screen

D. Urine dipstick

E. X-ray of ankles
Qu 72

A 3-week-old baby boy is fully breast-fed and thriving. He is referred because the
Health Visitor notices some jaundice His parents say he is irritable and has pale stools.

What is the most probable diagnosis?

SELECT ONE ANSWER ONLY

A. Alpha-1-antitrypsin deficiency

B. Biliary atresia

C. Breast milk jaundice

D. Congenital hypothyroidism

E. Hereditary spherocytosis

Qu 73

At birth a male infant was found to have both testes in the scrotum. At 4 months of
age his mother thinks the scrotum looks empty. The doctor cannot locate either
testis.

What is the most likely explanation?

SELECT ONE ANSWER ONLY

A. He has partially descended testes

B. He has retractile testes

C. He has testicular atrophy

D. The doctor has cold hands

E. The first examination was incorrect

Qu 74

A 3-week old girl, birth weight 3.4kg, is referred with persistent vomiting. She has
been bottle fed since birth. She takes her bottle well and has put on 450g since birth.
She looks well and is afebrile.

What is the most likely cause for the vomiting?

SELECT ONE ANSWER ONLY

A. Cows milk protein intolerance

B. Gastro-oesophageal reflux

C. Over-feeding

D. Pyloric stenosis

E. Urinary tract infection

Qu 75

An otherwise well 7-year-old boy of Caucasian origin is noted to be slightly jaundiced.

His spleen is palpable 3cm below the left costal margin. His Hb is 9.2 g/dl.

What is the most likely diagnosis?

SELECT ONE ANSWER ONLY

A. Acute lymphoblastic leukaemia

B. Glandular fever

C. Hepatitis B infection

D. Hereditary spherocytosis

E. Pyruvate kinase deficiency