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

A. Early diastolic murmur at the left sternal edge

B. A harsh 4/6 pan-systolic murmur

C. Fixed splitting of the second heart sound

D. Increased intensity of the second heart sound

E. A mid diastolic murmur

D. Increased intensity of the second heart sound


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

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

Ans A

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

AR – unlikely, in all generations and only affects females

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

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


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

A. Radial artery.

B. Tendon of extensor pollicis longus.

C. Tendon of flexor carpi ulnaris.

D. Tendon of palmaris longus.

E. Ulnar artery.

B. Tendon of extensor pollicis longus.


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

a. NK Cells

b. T cells

c. B cells
d. Neutrophils
e. Eosinophils

B. T cells


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

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

c. pH on peripheral chemoreceptors

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

Answer b. pH on central chemoreceptors

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

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

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


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

a. decreasing oestrogen production

b. increasing LH levels

c. increasing inhibin B levels

d. increasing FSH levels

e. increasing progesterone production 

Ans E  increasing progesterone production 

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


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

a. action

b. maintenance

c. contemplation
d. precontemplation
e. preparation 

Ans E. Preparation


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


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

a. 21%
b. 30%
c. 50%
d. 70%
e. 100% 

Answer A. 21%

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


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

a. Ig A

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

Answer D. IgG

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


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

a. decrease common variable in randomised control trial

b. present a real life situation value rather than controlled situation

c. decrease effect of people who have change to another study

d. adjust number of people who did not comply with the treatment

e. adjust number of people who has left the study 

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

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

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


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

a. Carbohydrate
b. Protein

c. Fat

d. Vitamin A
e. Vitamin E 

a. Carbohydrate


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

Plotting her on the BMI chart she would be:

a. Obese

b. Overweight

c. Underweight

d. FTT

e. Normal 

a. Obese

BMI = 20 =>95th percentile


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

a. Antithrombin III

b. Protein C

c. Protein S

d. Thrombin

e. Factor X 

Answer E. Factor X

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

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

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

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


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

a. DNA

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

Answer C. Antigen

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

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


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

a. Left upper bronchus

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

Ans E. Right lower bronchus

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



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

a. Eosinophils

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

a. Eosinophils


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

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

d. Left optic tract


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

a. Noradrenaline

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

Answer B. Acetylcholine

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


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

a. Adrenal hypertrophy

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

d. Altered myocardial performance

e. Reduced nephron number

E. Reduced nephron number

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

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


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

a. Cytomegalovirus

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

B. Epstein-Barr Virus

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


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

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

d. AV accessary pathway
e. AV nodal arrhythmia

D. AV accessory pathway

Most likely WPW


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

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

D. Selective Noradrenaline reuptake inhibitor (SNRI)


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

a. Genital

b. Renal
c. Cardiac

d. Otological

e. Gastrological 

d. Otological


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

a. Aneuploidy

b. Microdeletion
c. Triploidy

d. Ring chromosome

e. Reciprocal translocation

e. Reciprocal translocation

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


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

a. Decreasing conversion of hypoxanthine to uric acid

b. Alkalysing the urine

c. Conversion of uric acid to allantoin

d. Promotion of diuresis

e. Increasing potassium excretion

c. Conversion of uric acid to allantoin

Urate oxidase inhibitor


What is the mechanism of action of aminoglycoside antibiotics?

a. Binding to 50S ribosomal subunit

b. Inhibition of cell wall synthesis

c. Inhibition of protein synthesis

d. Purine analogues

e. Interference with RNA synthesis

c. Inhibition of protein synthesis

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


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

The most likely primary diagnosis is:

a. generalised anxiety disorder.

b. night terrors.

c. narcolepsy.

d. Parental limit settings

e. insomnia with bedtime fears. 

e. insomnia with bedtime fears. 

or D. Parental limit setting


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

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


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

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

B. L3



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

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

a. 35%

b. 41%

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

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


Craniopharyngioma arises from

a. Arachnoid membrane

b. Hypothalamus

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

Answer E. Rathke's pouch

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