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1

Which of the following is not a typical clinical feature of severe intrauterine cytomegalovirus (CMV) infection?
A. Anaemia.
B. Cataracts.
C. Chorioretinitis.
D. Hepatosplenomegaly.
E. Intrauterine growth restriction.

B. Cataracts.

CID is characterized by intrauterine growth retardation, hepatosplenomegaly, hematological abnormalities (particularly thrombocytopenia), and various cutaneous manifestations, including petechiae and purpura (ie, blueberry muffin baby). However, the most significant manifestations of CID involve the CNS. Microcephaly, ventriculomegaly, cerebral atrophy, chorioretinitis, and sensorineural hearing loss are the most common neurological consequences of CID.

If primary maternal infection occurs during pregnancy, the average rate of transmission to the fetus is 40%; approximately 65% of these infants have cytomegalovirus disease at birth. With recurrent maternal infection (ie, cytomegalovirus infection that occurs in the context of preconceptual immunity), the risk of transmission to the fetus is lower, ranging from 0.5-1.5%

2

A previously well seven-year-old girl presents to the Emergency Department with a four day history of fever and sore throat, lethargy and two days of dyspnoea and a macular rash on her palms and soles. On examination her heart rate is 160, temperature 38.6°c, respiratory rate of 60, blood pressure of 70/55 and oxygen saturation of 92% on room air. On examination she is pale and looks unwell with cool peripheries and panting respirations. Her chest radiograph is shown below.

Which of the following is the most likely diagnosis?
A. Atypical pneumonia.
B. Mediastinal mass.
C. Myocarditis.
D. Pneumomediastinum.
E. Pneumonitis.

C. Myocarditis.

3

In the secondary prevention of rheumatic fever which of the following is the current recommended regime?
A. Intramuscular penicillin.
B. Intravenous amoxicillin with febrile illness.
C. Oral amoxicillin with febrile illness.
D. Oral erythromycin, twice daily.
E. Oral penicillin V, twice daily.

A. Intramuscular penicillin.

4

A six-year-old girl presents with enuresis. She has never been reliably dry at night. She also has problems with daytime wetting. Her underpants are often damp, and she has urgency and frequency. Examination and urinalysis are normal.

Which treatment is most likely to be effective?

A. Bladder training exercises.
B. DDAVP.
C. Laxatives.
D. Oxybutinin.
E. Pad + bell.

D. Oxybutinin.

5

A 15-year-old girl presents with a history of deterioration of night vision and peripheral vision. Her past history includes mild global developmental delay, obesity and surgery in infancy for 4-limb post-axial polydactyly. Eye examination reveals a pigmentary retinopathy.
The most likely diagnosis is:
A. autosomal recessive retinitis pigmentosa.
B. bardet-biedl syndrome.
C. choroideraemia.
D. McKusick-kaufman syndrome.
E. refsum disease.

B. bardet-biedl syndrome.

Retinitis pigmentosa -

  • progressive degeneration and dysfunction of the retina, primarily affecting photoreceptor and pigment epithelial function.
  • Night and peripheral vision are lost progressively, leading to a constricted visual field and markedly diminished vision in some patients.

Bardet-Biedl syndrome 

  • autosomal recessive
  • obesity
  • hypogenitalism in men,
  • mental retardation,
  • retinal dystrophy,
  • polydactyly,
  • renal malformations (particularly calyceal abnormalities),
  • hypertension 
  • and, over time, progressive chronic kidney disease.

Choroideremia is an x-linked recessive retinal degenerative disease.

McKusick-Kaufman

  • affects the development of the hands and feet, heart, and reproductive system.
  • characterized by a combination of three features:
  • polydactyly
  • heart defects, and
  • genital abnormalities.
     

Refsum Disease 

  • Peroxisomal disorder. Classic Refsum disease is characterized by the presence of four clinical abnormalities:
  • Retinitis pigmentosa
  • Peripheral polyneuropathy
  • Cerebellar ataxia
  • Elevated cerebrospinal fluid protein concentration (100 to 600 mg/dL) without an increase in cells

6

A four-week-old boy presents with persistent abdominal distension and infrequent bowel motions. He is exclusively breast-fed but is vomiting after most feeds. His weight gain is slow. On rectal examination he empties faecal fluid and air under pressure. An abdominal X-ray shows occasional small intestinal air-fluid levels and a distended colon.
Which diagnostic test will most likely reveal the correct diagnosis?
A. Barium meal.
B. Computed tomography scan.
C. Gas enema.
D. Nuclear medicine intestinal transit scan.
E. Rectal suction biopsy.

E. Rectal suction biopsy.

Features: constipation, partial obstruction (air fluid levels), dilated colon - hirschprungs therefore biopsy

7

A seven-year-old boy presents with a six month history of episodes occurring in sleep. The events occur in the early morning and wake him. During an episode, he is able to walk into his parent’s room, but is unable to speak. His parents have noticed that during an episode he has “spasms” of the right side of his face with marked salivation. He is able to describe tingling of his tongue after the event. An electroencephalogram (EEG) is performed and is shown below.

What is the most likely diagnosis?

A. Absence epilepsy.

B. Benign partial epilepsy of childhood.

C. Frontal lobe epilepsy.

D. Parasomnia.

E. Temporal lobe epilepsy.



.

B. Benign partial epilepsy of childhood.

Benign childhood epilepsy with centrotemporal spikes (BECTS) - Most common. Typically starts during childhood and is outgrown in adolescence. The child typically wakes up at night owing to a simple partial seizure causing buccal and throat tingling and tonic or clonic contractions of one side of the face, with drooling and inability to speak but with preserved consciousness and comprehension. Complex partial and secondary generalized seizures can also occur. EEG shows typical broad-based centrotemporal spikes that are markedly increased in frequency during drowsiness and sleep. MRI is normal. Patients respond very well to AEDs such as carbamazepine. In some patients who only have rare and mild seizures treatment might not be needed.

Absence Seizures
Typical absence seizures usually start at 5-8 yr of age and are often, owing to their brevity, overlooked by parents for many months even though they can occur up to hundreds of times per day. Unlike complex partial seizures they do not have an aura, usually last for only a few seconds, and are accompanied by flutter or upward rolling of the eyes but typically not by automatisms of the complex partial seizure type (absence seizures can have simple automatisms like lip-smacking or picking at clothing and the head can minimally fall forward). Absence seizures do not have a postictal period and are characterized by immediate resumption of what the patient was doing before the seizure. Hyperventilation for 3-5 min can precipitate the seizures and the accompanying 3 Hz spike–and–slow wave discharges. The presence of periorbital, lid, perioral or limb myoclonic jerks with the typical absence usually predicts difficulty in controlling the seizures with medication.

Atypical absence seizures have associated myoclonic components and tone changes of the head and body and are also usually more difficult to treat. They are precipitated by drowsiness and are usually accompanied by 1-2 Hz spike–and–slow wave discharges.

Juvenile absence seizures are similar to typical absences but occur at a later age and are accompanied by 4-6 Hz spike–and–slow wave and polyspike–and–slow wave discharges. These are usually associated with juvenile myoclonic epilepsy.

Nocturnal autosomal dominant frontal lobe epilepsy has been linked to acetylcholine-receptor gene mutations and manifests with nocturnal seizures with dystonic posturing that respond promptly to carbamazepine. Several other less-frequent familial benign epilepsy syndromes with different localizations have also been described, some of which occur exclusively or predominantly in adults.

Parasomnias are defined as episodic nocturnal behaviors that often involve cognitive disorientation and autonomic and skeletal muscle disturbance. Parasomnias may be further characterized as occurring primarily during NREM sleep (partial arousal parasomnias) or in association with REM sleep, including nightmares, hypnogogic hallucinations, and sleep paralysis; other common parasomnias include sleep-talking.

Temporal Lobe Epilepsy - Activation of temporal discharges in sleep can lead to loss of speech and verbal auditory agnosia (Landau-Kleffner epileptic aphasia syndrome). 

8

A test has a sensitivity of 95% and a specificity of 90%. It is used to screen the general population for a condition that has a prevalence of 1 in 100,000.
What will the positive predictive value be nearest to?
A. 0.01%.
B. 0.05%.
C. 0.1%.
D. 0.5%.
E. 1%.

A. 0.01%.

9

A four-year-old boy is referred because of the development of pubic hair. On examination he has Tanner stage 3 pubic hair. His testes are 2 ml in volume bilaterally. Investigations are as follows:

  • Testosterone level: 7.8 nmol/l [< 1.8 mmol/l]
  • Bone age: 7 years

Which of the following is the most likely diagnosis?

A. Central precocious puberty.
B. Congenital adrenal hyperplasia.
C. Craniopharyngioma.
D. Cushing syndrome.
E. Premature adrenarche.

B. Congenital adrenal hyperplasia.

Can’t be central as testes aren’t stimulated to produce testostérone therefore needs to be exogenous source ie CAH producing testosterone

Central precocious puberty is early breast or testicular development (testes not developed in this case)

CAH :
Girls will usually have normal female reproductive organs (ovaries, uterus, and fallopian tubes). They may also have the following changes:

  • Abnormal menstrual periods
  • Deep voice
  • Early appearance of pubic and armpit hair
  • Excessive hair growth and facial hair
  • Failure to menstruate
  • Genitals that look both male and female (ambiguous genitalia), often appearing more male than female

Boys won't have any obvious problems at birth. However, they may appear to enter puberty as early as 2 - 3 years of age. Changes may include:

  • Deep voice
  • Early appearance of pubic and armpit hair
  • Early development of male characteristics
  • Enlarged penis
  • Small testes
  • Well-developed muscles

Craniopharyngioma – multiple deficiencies

10

A full-term neonate is born following a pregnancy complicated by polyhydramnios. The baby was hydropic, and died at six hours of age.
Which one of the following is least likely to have caused this?
A. Alpha-thalassaemia.
B. Beta-thalassaemia.
C. Blackfan-Diamond anaemia.
D. Fetal parvovirus B19 infection.
E. Rh disease of the newborn.

B. Beta-thalassaemia.

Thalassaemias: prenatally, fetus with α-thalassaemia may become symptomatic because HbF requires sufficiency α-globin gene production, whereas postnatally infants with β-thalassaemia become symptomatic because HbA requires adequate production of β-globin genes
Blackfan-Diamond: haematopoesis usually adequate in fetal life but some are pale at birth, hydrops fetalis occurs but is rare

11

A seven-year-old boy is presented with a slowly evolving history of frequent and excessive checking of locks around the house at night, lining up his toys and books in his bedroom and hoarding paper and string. These new symptoms are distressing for him and may preoccupy him for one to two hours every day.
The most likely diagnosis is:

A. asperger syndrome.
B. depressive disorder.
C. generalised anxiety disorder.
D. obsessive compulsive disorder.
E. schizophrenia.

D. obsessive compulsive disorder.

12

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.

C. Inflammatory bowel disease.

13

You attend the delivery of a term female infant born to an intravenous drug user. The mother’s antenatal screening revealed that she was positive for hepatitis C and hepatitis B surface antigen. She was HIV negative. The management of this infant should include:
A. administration of hepatitis B vaccination.
B. administration of both hepatitis B vaccination and hepatitis B immunoglobulin.
C. check liver function tests and serology of the infant within 24 hours.
D. withhold hepatitis B vaccination and screen the infant for seroconversion in 12 months time after disappearance of maternal antibody.
E. exclusion of breast milk from the diet.

B. administration of both hepatitis B vaccination and hepatitis B immunoglobulin.

14

A cystic lung lesion is diagnosed antenatally on routine ultrasound. After birth a CXR was performed and was normal.
The most appropriate next step is:
A. bronchoscopy.
B. chest X-ray.
C. CT angiography.
D. high resolution CT of chest.
E. ventilation/Perfusion scan.

D. high resolution CT of chest.

15

A well eight-week-old infant girl is referred because an antenatal ultrasound scan at 34 weeks gestation showed that the right kidney contained several cysts. The left kidney was normal. A postnatal scan confirmed that the left kidney is large but normal whereas the right kidney contains multiple cysts without normal intervening parenchyma.
The most likely long term outcome of multicystic dysplastic kidney is:
A well eight-week-old infant girl is referred because an antenatal ultrasound scan at 34 weeks gestation showed that the right kidney contained several cysts. The left kidney was normal. A postnatal scan confirmed that the left kidney is large but normal whereas the right kidney contains multiple cysts without normal intervening parenchyma.
The most likely long term outcome of multicystic dysplastic kidney is:
A. normal renal function.
B. recurrent haematuria.
C. recurrent urine infections.
D. systemic hypertension.
E. Wilms tumour in the cystic kidney.
 

A. normal renal function.

16

A six-year-old boy presents to the Emergency Department with acute urinary retention requiring urgent catheterisation. He has been previously well, but his parents state that he has complained of leg and lower abdominal pain for the last three days and has been walking 'a bit funny'. On examination he is alert and cooperative with normal upper limb power, reflexes and light touch sensation. He has a broad based gait and is unable to arise from a squatting position without assistance. His lower limb reflexes are difficult to elicit and sensation is reduced in a patchy fashion in both lower limbs.
Which of the following is the most likely diagnosis?
A. Conversion disorder.
B. Guillain-Barré syndrome.
C. Multiple sclerosis.
D. Poliomyelitis.
E. Transverse myelitis.

E. Transverse myelitis.

Transverse Myelitis - Rapid development of both motor and sensory deficits. It has multiple causes and tends to occur in 2 distinct contexts. Small children, 3 yr of age and younger, develop spinal cord dysfunction over hours to a few days. They have a history of an infectious disease, usually of viral origin, or of an immunization within the few weeks preceding the 1st development of their neurologic difficulties. The clinical loss of function is often severe and may seem complete. Although a slow recovery is common in these cases, it is likely to be incomplete. The likelihood of independent ambulation in these small children is about 40%. The pathologic findings of perivascular infiltration with mononuclear cells imply an infectious or inflammatory basis. Overt necrosis of spinal cord can be seen.

In older children, the syndrome is somewhat different. Although the onset is also rapid with a nadir in neurologic function occurring between 2 days and 2 wk, recovery is more rapid and more likely to be complete. Pathologic or imaging examination shows acute demyelination.

Guillain-Barre - The paralysis usually follows a nonspecific viral infection by about 10 days. Weakness usually begins in the lower extremities and progressively involves the trunk, the upper limbs, and finally the bulbar muscles, a pattern known as Landry ascending paralysis. Proximal and distal muscles are involved relatively symmetrically, but asymmetry is found in 9% of patients. The onset is gradual and progresses over days or weeks. Particularly in cases with an abrupt onset, tenderness on palpation and pain in muscles is common in the initial stages. Affected children are irritable. Weakness can progress to inability or refusal to walk and later to flaccid tetraplegia. Paresthesias occur in some cases.

Multiple Sclerosis - Multiple sclerosis (MS) is a chronic demyelinating disorder of the brain, spinal cord and optic nerves characterized by a relapsing-remitting course of neurologic episodes separated in time and space. Presenting symptoms in pediatric MS include hemiparesis or paraparesis, unilateral or bilateral optic neuritis, focal sensory loss, ataxia, diplopia, dysarthria, or bowel/bladder dysfunction.

Poliomyelitis - Virus attacks anterior spinal cord so only motor affected. Weakness may vary from one muscle or group of muscles, to quadriplegia, and respiratory failure. Tone is reduced, nearly always in an asymmetric manner. Proximal muscles usually are affected more than distal muscles, and legs more commonly than arms. Reflexes are decreased or absent. The sensory examination is almost always normal.

Weakness typically worsens over two to three days, although sometimes worsening can progress for up to a week. Bulbar involvement occurs in 5 to 35 percent of patients, producing dysphagia, dysarthria, and difficulty handling secretions. There may be encephalitis, usually in infancy. Respiratory insufficiency may occur.

Brown-Sequard Syndrome (for interest)
The Brown-Séquard syndrome is characterized by ipsilateral loss of motor function, vibration, and proprioception below the level of the lesion with contralateral loss of pain and temperature sensation beginning approximately two levels below the lesion. This pattern of deficits occurs because the spinothalamic tract travels on the ipsilateral side of the cord before crossing over to the contralateral side. In addition, ipsilateral loss of pain and temperature sensation may occur at one or two levels below the lesion.

17

A 27-week-female infant develops abdominal distension and increasing ventilatory requirements at four days of age. Abdominal x-rays are taken and shown below.

he most likely cause is:
A. duodenal atresia.
B. hirshsprungs disease.
C. ileal perforation.
D. meconium ileus.
E. volvulus.

C. ileal perforation.

18

An eight-year-old male presents to the emergency room with severe leg pain, predominantly in the calf muscles after an upper respiratory tract infection three days previously.

On examination, he is unable to walk but is otherwise well. He complains of pain during the examination.
Investigations show a creatine kinase of 2000 iu/l [40-240 iu/l]. Which of the following is the most likely diagnosis?

A. Dermatomyositis
B. Guillain-Barré syndrome.
C. McArdle disease.
D. Myositis.
E. Rhabdomyolysis.

D. Myositis.

Typical story for benign acute childhood myositis → URTI symptoms followed by calf pain, otherwise normal examination, markedly raised CK, improves by a week

  • The onset of pain tended to occur after a period of rest— that is, on awakening
  • The vast majority of children tested had a raised CK
    • In many cases this was massively elevated, however none of the children tested had evidence of rhabdomyolysis—that is, myoglobin in urine.
  • Other less consistent laboratory findings are leucopenia,  thrombocytopenia, and elevated serum glutamic oxaloacetic transaminase (SGOT).
  • Neurology is reported as normal and it has been suggested that mild calf weakness is due to muscle pain rather than true inability of muscle to generate power.
  • Muscle studies have been performed relatively infre- quently in view of the short duration of symptoms and the benign prognosis. When electromyograms have been recorded they have either been normal or suggested patchy myopathic changes.The few muscles biopsies taken have been reported as normal, or said to demonstrate myositis, segmental rhabdomyolysis, or moderate muscle necrosis with interstitial inflammation.

19

A 12-year-old boy presents with a two day history of severe right iliac fossa pain. The illness started with vomiting, as well as high fevers and diarrhoea. On examination, he is tender in the right iliac fossa, with the remainder of the physical examination unremarkable.
Which of the following organisms is most likely to cause this clinical picture?
A. Aeromononas hydrophila.
B. Campylobacter jejuni.
C. Enterococcus faecalis.
D. Salmonella typhi.
E. Yersinia enterocolitica.

E. Yersinia enterocolitica.

20

A 2 1⁄2 -year-old boy presents for developmental assessment. He has only a few single words, but babbles extensively and uses some jargon. His parents feel he can follow some directions; however he is unable to point to body parts. He takes his parents by the hand and leads them to things he wants. He has no pretend play, and does not interact with other children. He is very active. He can run, jump, climb and take off his clothes. He is easily frustrated, and screams, hits and bites when upset.
What is the most likely diagnosis?
A. Autism.
B. Autistic disorder.
C. Developmental language disorder
D. Intellectual disability
E. Sensorineural hearing impairment

D. Intellectual disability

21

An eight-year-old boy is referred for evaluation of wheezing which had been present on a monthly basis over the previous year. Physical examination was normal as was his chest X-ray.
His spirometry results were as follows:

  • Forced Vital Capacity (FVC ) 70% of predicted
  • Forced Vital Capacity in 1 second (FVC) 79% of predicted
  • Forced Expiratory Flow 25%-75% (FEF25%-75% ) 74% of predicted.


This spirometric pattern is most suggestive of which of the following?

A. Lower airway obstruction.
B. Poor technique.
C. Respiratory muscle weakness.
D. Restrictive pattern.
E. Upper airway obstruction.

B. Poor technique.

22

A two-year-old girl returns from child care after an apparently ordinary day. When her mother undresses her for her bath she notices blood in the girl’s underwear. The mother examines the girl’s genital region and notices the findings in the photograph.

What is most likely the cause of the girl’s genital bleeding?

A.  Accidental “fall astride” injury.


B. Congenital haemangioma of the labia


C. Lichen sclerosis et atrophicus.


D. Sexual abuse.

E. Traumatic separation of labial adhesions.
 

A.  Accidental “fall astride” injury.

23

A three-year-old boy is brought to the Emergency Department by ambulance with sudden onset of stridor, barking cough and hoarse voice. His oxygen saturation in the ambulance was 88% in air. On arrival he is sitting on his mother's lap looking anxious, pale and sweaty. He has a loud stridor at rest with marked tracheal tug, intercostal recession and subcostal indrawing.
Which of the following is the most appropriate next step in management?
A. Intramuscular Adrenaline.
B. Intravenous Dexamethasone.
C. Nebulised Adrenaline.
D. Nebulised Budesonide.
E. Oral Dexamethasone.

C. Nebulised Adrenaline.

Croup
Mild – single dose oral dex, home
Moderate – oral dex, observe
Severe – adrenaline nebulised 1% solution 0.05mL/kg made to 4mL with N/saline and give with O2, single dose oral steroids, consider IV dexamethasone 0.6mg/kg

24

A two-year-old boy is found to have severe bilateral sensorineural deafness. There is no family history of note. On examination, he has partial heterochromia iridis, white eyelashes, a broad nasal bridge with telecanthus, and several depigmented patches on his trunk and limbs.

What is the most likely diagnosis?

A.  Branchio-oto-renal syndrome. 


B. Oculo-cutaneous albinism.


C. Pendred syndrome. 

D. Tuberous sclerosis. 

E. Waardenburg syndrome.

 

E. Waardenburg syndrome.

Waardenburg syndrome is a group of genetic conditions that can cause hearing loss and changes in coloring (pigmentation) of the hair, skin, and eyes. Although most people with Waardenburg syndrome have normal hearing, moderate to profound hearing loss can occur in one or both ears. People with this condition often have very pale blue eyes or different colored eyes, such as one blue eye and one brown eye. Sometimes one eye has segments of two different colors. Distinctive hair coloring (such as a patch of white hair or hair that prematurely turns gray) is another common sign of the condition. 

Branchio-oto-renal syndrome (BOR), also known as branciootorenal syndrome or BOR syndrome, is an autosomal dominant genetic disorder involving the kidneys, ears, and neck.
Individiduals with BOR may have underdeveloped (hypoplastic) or absent kidneys with resultant renal insufficiency or renal failure.
Ear anomalies include extra openings in front of the ears (preauricular pits), extra pieces of skin in front of the ears (preauricular tags), or further malformation or absence of the outer ear (pinna). Malformation or absence of the middle ear is also possible. Individuals can have mild to profound hearing loss, which can either be sensorineural, conductive, or mixed. People with BOR may also have cysts or fistulae along the sides of their neck corresponding to the location of the embryologic branchial clefts.

Oculocutaneous albinism is a group of conditions that affect coloring (pigmentation) of the skin, hair, and eyes. Affected individuals typically have very fair skin and white or light-colored hair. Long-term sun exposure greatly increases the risk of skin damage and skin cancers, including an aggressive form of skin cancer called melanoma, in people with this condition. Oculocutaneous albinism also reduces pigmentation of the colored part of the eye (the iris) and the light-sensitive tissue at the back of the eye (the retina). People with this condition usually have vision problems such as reduced sharpness; rapid, involuntary eye movements (nystagmus); and increased sensitivity to light (photophobia). 4 types.

Pendred syndrome is a disorder typically associated with hearing loss and a goiter. 

 

25

A three-month-old male boy presents with a four week history of persistent crying and frequent vomiting after most feeds. The infant is predominantly breast-fed. Occasional supplemental cow milk formula feeds were commenced from eight weeks of age because his mother returned to part-time work. The infant is generally well and passes four soft bowel motions per day, with increased mucus but no visible blood. Over the past two months his weight has fallen from the 50th to the 25th weight- for-age percentile.
Which one of the following is the most likely diagnosis?
A. Cow milk protein intolerance.
B. Gastro-oesophageal reflux.
C. Infantile colic.
D. Lactose intolerance.
E. Pyloric stenosis.

A. Cow milk protein intolerance.

26

Which of the following observations regarding a rare disorder would provide the best evidence of autosomal dominant inheritance?
A. Father and son affected.
B. Father and daughter affected.
C. Mother and son affected.
D. Mother and daughter affected.
E. Male and female cousins affected.

A. Father and son affected.

27

An otherwise healthy four-year-old without drug allergies is admitted with the chest X-ray shown below.

Empiric treatment is initiated with Benzylpenicillin. By the second hospital day the patient is improving and the microbiology laboratory reports that a blood culture is growing Streptococcus pneumoniae with a penicillin MIC = 0.2 μg/mL (intermediate) and resistant to erythromycin.
Which one of the following antibiotics is the most appropriate to continue therapy?
A. Amoxicillin-clavulinic acid.
B. Azithromycin.
C. Cefotaxime.
D. Penicillin.
E. Trimethoprim-sulfamethoxazole.

D. Penicillin.

28

An immediate generalised reaction to which of the following drugs is most likely to be mediated by IgE (immunoglobulin E)?
A. Aspirin.
B. Cephalothin.
C. Dextran.
D. Radiographic contrast media.
E. Vancomycin.

B. Cephalothin.

29

A 15-year-old girl with known anorexia nervosa is brought to the Emergency Department following a collapse at school. On examination she is alert and orientated but feels faint when standing. She is clinically dehydrated with dry mucous membranes, reduced tissue turgor and reduced urine output. Her heart rate is 45, respiratory rate 30, temperature of 35.5 and blood pressure of 90/65. Her blood chemistry is shown below.

Which of the following would be the electrocardiogram?
A. Elevation ST segment.
B. Peaked T-waves.
C. Reduced PR interval.
D. Shortened QT interval.
E. U-waves.

E. U-waves.

Hypokalaemia: flattened or inverted T waves, a U wave, ST depression and a wide PR interval.

Hyperkalaemia: reduction of the size of the P wave and development of peaked T waves. Severe hyperkalemia results in a widening of the QRS complex, and ECG complex can evolve to a sinusoidal shape. Faster repolarization of the cardiac action potential causes the tenting of the T waves, and the inactivation of sodium channels causes a sluggish conduction of the electrical wave around the heart, which leads to smaller P waves and widening of the QRS complex

30

A neonate, born at 36-weeks to a Sudanese mother presents on day eight of life with apnoea and seizures. The baby had a birth weight of 2.4kg and has been fully breastfed. Investigations done at the time of a seizure are as follows:

Which of the following is the most likely cause of the seizures?

A. Excessive phosphate in milk.
B. Maternal diabetes.
C. Maternal hyperparathyroidism.
D. Maternal Vitamin D deficiency.
E. Prematurity.

D. Maternal Vitamin D deficiency.