2 P103 QUESTION 1 Resection of 50% of the small bowel, including terminal ileum, following neonatal necrotising enterocolitis may result in deficiency of a number of vitamins. Which of the following vitamins is least likely to be deficient? A. Vitamin A. B. Vitamin B12. C. Vitamin C. D. Vitamin E. E. Vitamin K. QUESTION 2 Which of the following techniques is most appropriate for testing visual acuity in a four-year-old child? A. Cover test. B. E test. C. Red reflex test. D. Snellen chart. E. Toy matching test. QUESTION 3 A five-year-old child is investigated with a fasting study for suspected hypoglycaemia. Which combination of plasma glucose, insulin, beta hydroxybutyrate (β-OH-butyrate), lactate and cortisol can best be described as a normal metabolic response after 18 hours of fasting in a five-year-old? The non-fasting normal range values are shown in [ ] brackets. Plasma glucose [3.5-8.0 mmol/L]
3 P103 QUESTION 4 The pedigree shown above is most consistent with which one of the following modes of inheritance? A. Autosomal dominant. B. Autosomal recessive. C. Mitochondrial. D. X-linked dominant. E. X-linked recessive. QUESTION 5 Which one of the following best describes the renal function of a 34-week pre-term infant compared with a full-term infant? A. Excessive potassium loss. B. Increased acid excretion. C. Increased bicarbonate reabsorption. D. Increased calcium reabsorption. E. Reduced glomerular filtration rate.
4 P103 QUESTION 6 In obstructive airways disease the most useful long-term measure of disease progression is: A. forced expiratory flow 25-75% (FEF25%-75%). B. forced expiratory flow 50% (FEF50%). C. forced expiratory volume in one second (FEV1). D. forced vital capacity (FVC). E. peak expiratory flow. QUESTION 7 An acutely septic child’s blood gas result, in room air, demonstrates the following: pH 7.35 [7.35-7.45] plasma bicarbonate 11 mmol/L [22-26] PCO2 21 mmHg [35-45] PO2 90 mmHg [>80] This blood gas result is most consistent with which of the following? A. Compensated metabolic acidosis. B. Compensated respiratory alkalosis. C. Mixed metabolic and respiratory acidosis. D. Uncompensated metabolic acidosis. E. Uncompensated respiratory alkalosis. QUESTION 8 Which of the following classes of immunoglobulins has the longest mean half-life? A. IgA. B. IgD. C. IgE. D. IgG. E. IgM.
5 P103 QUESTION 9 Allopurinol is most likely to precipitate methotrexate toxicity by which one of the following mechanisms? A. Displacement from protein binding sites. B. Impairment of renal excretion. C. Inhibition of dihydrotetrafolate reductase. D. Inhibition of metabolism. E. Promotion of gastrointestinal absorption. QUESTION 10 AUDIOGRAM TYMPANOMETRY
Ear Type
Right A
Left A KEY
Right Left
Air X
Bone < > A child’s audiogram is shown. Which of the following is the most likely cause of these findings? A. Cholesteatoma. B. Goldenhar syndrome. C. Homozygous Connexin 26 mutation. D. Otitis media with effusion. E. Otosclerosis.
6 P103 QUESTION 11 An infant has sustained a large cerebral infarct involving most of the left occipital lobe. The remainder of the brain is unaffected. A later neurological examination would be most likely to reveal which one of the following? A. Afferent pupillary defect. B. Bitemporal hemianopia. C. Central scotoma. D. Right amblyopia. E. Right homonymous hemianopia. QUESTION 12 In pre-renal failure secondary to acute haemorrhage, which of the following kidney changes would be most likely to occur? A. Decreased afferent and efferent arteriolar vascular tone. B. Decreased filtration fraction. C. Increased potassium and hydrogen secretion. D. Increased renal blood flow. E. Increased sodium reabsorption. QUESTION 13 Bone marrow trephine biopsy is most commonly needed in attempting to confirm the diagnosis of which one of the following conditions? A. Acute lymphoblastic leukaemia. B. Acute myeloblastic leukaemia. C. Aplastic anaemia. D. Chronic immune thrombocytopenia. E. Megaloblastic anaemia. QUESTION 14 A two-week-old baby, otherwise well, has a warm, erythematous and enlarged breast bud that is discharging pus. The infant is most likely to be infected with: A. Escherichia coli. B. Group A Streptococcus. C. Group B Streptococcus. D. Staphylococcus aureus. E. Staphylococcus epidermidis.
The electrocardiogram (ECG) shown above was obtained from a three-year-old girl with a systolic murmur. Which one of the following is the most likely diagnosis? A. Perimembranous ventricular septal defect. B. Persistent ductus arteriosus. C. Primum atrial septal defect. D. Pulmonary valve stenosis. E. Subaortic stenosis. QUESTION 16 Which of the following tests is most likely to detect early respiratory failure in neuromuscular disease? A. Blood gas analysis. B. Forced expiratory volume in one second (FEV1). C. Forced vital capacity (FVC). D. Maximal inspiratory/expiratory airway pressures. E. Polysomnography.
8 P103 QUESTION 17 Which of the following best describes the mechanism of resistance of Haemophilus influenzae to ampicillin? A. Altered binding proteins. B. Decreased permeability of cell wall. C. Efflux pump. D. Production of beta lactamase. E. Pus formation. QUESTION 18 The diagram below shows the relationship between the plasma concentration of a drug and the effect of that drug over time, in a single individual given one dose of the drug. The direction of change over time is shown by the arrows. The relationship is described by an anti-clockwise hysteresis loop. The numbers on the loop indicate the number of hours after the dose was given.
The best explanation of this phenomenon is that: A. the drug is active itself but has no active metabolites. B. the drug is binding irreversibly to its target receptor. C. there is a delay in the absorption of the drug from the gastrointestinal tract. D. there is a delay in the distribution of the drug from plasma to its site of action. E. there is down-regulation of the drug’s target receptor over time.
9 P103 QUESTION 19 Which of the following correlates most strongly with language abilities at age six years? A. Cumulative time with otitis media with effusion since birth. B. Intelligence quotient. C. Number of siblings. D. Socio-economic status. E. Time spent in child care. QUESTION 20 A three and a half-year-old boy presents after falling off a coffee table at home. He has sustained an injury to his right elbow and is complaining of a ‘funny feeling’ in his right thumb and forefinger. On examination he has obvious deformity of his right elbow with a strong radial pulse and normal capillary refill of his nail beds. An X-ray of his elbow is shown below.
Which of the following movements is most likely to be affected on clinical examination? A. Abduction of the fingers. B. Adduction of the fingers. C. Thumb abduction. D. Thumb adduction. E. Wrist extension.
10 P103 QUESTION 21 The incidence of type 2 (non-insulin-dependent) diabetes mellitus is increasing and presenting at a younger age. Which combination of the indicated group of markers would be most characteristic of this form of diabetes mellitus? Ketoacidosis
presentation Acanthosis nigricans
Presence of insulin autoantibodies
Elevated C peptide
A. + + - +
B. + - + -
C. - + + +
D. - + - +
E. - - + - QUESTION 22 On day 3 of life, a breastfed infant developed profuse watery diarrhoea, dehydration and acidosis. The diarrhoea ceased within 24 hours when given intravenous fluids only. When nasogastric rehydration was attempted with oral rehydration solution the diarrhoea and acidosis recurred. Which of the following is the most likely diagnosis? A. Congenital chloride diarrhoea. B. Fructose malabsorption. C. Glucose-galactose malabsorption. D. Rotavirus gastroenteritis. E. Sucrase-isomaltase deficiency. QUESTION 23 Dendritic cells are distinguished by an exceptional ability to carry out which one of the following immune functions? A. Antigen presentation. B. Chemokine secretion. C. Cytokine secretion. D. Immunoglobulin secretion. E. Phagocytosis.
11 P103 QUESTION 24 Female carriers of an X-linked recessive mutation may manifest features of the disorder. Which of the following is the most common cause? A. Dominant negative mutation. B. Maternal uniparental disomy. C. Selection for the mutant allele. D. Skewed X-inactivation (Lyonisation). E. Turner syndrome. QUESTION 25 A key feature of anorexia nervosa is a body mass index (BMI) of less than 17.5. This index is also valuable for diagnosing and monitoring those with obesity. The index is calculated with which one of the following formulae (in kilograms and metres)? A. weight/height. B. 2 x weight/height. C. weight/2 x height. D. weight/height2. E. weight2/height. QUESTION 26 A one-month-old infant presents with stridor, which is worse when crying. A barium swallow demonstrates an anterior indentation of the oesophagus, while bronchoscopy demonstrates a pulsation of the posterior wall of the lower trachea and also tracheomalacia. Which of the following is the most likely cause of these findings? A. Aberrant left pulmonary artery. B. Aberrant right subclavian artery. C. Anomalous innominate artery. D. Anomalous left carotid artery. E. Double aortic arch. QUESTION 27 The predominant cause of anaemia in chronic renal failure is: A. decreased production of erythropoietin. B. inhibition of erythropoiesis by uraemic toxins. C. increased levels of parathyroid hormone. D. iron deficiency. E. reduced red cell life span.
In the diagrammatic representation of the cardiac cycle shown above, the aortic trace is represented by ‘Ao’ and the left ventricular trace by ‘V’. Which one of the periods represented at the bottom of the diagram best corresponds to the period of isovolumetric contraction? A. Period A. B. Period B. C. Period C. D. Period D. E. Period E. QUESTION 29 A randomised controlled clinical trial of a new antibiotic for otitis media shows that children treated with the new antibiotic have a 50% reduction in ear pain within 24 hours. Approximately 10% of children in the control group had pain at 24 hours compared to only 5% of children treated with the new antibiotic. The number of children who need to be treated with the new antibiotic in order to prevent one child from having ear pain at 24 hours is: A. 2. B. 5. C. 10. D. 20. E. 50.
13 P103 QUESTION 30 Which of the following infectious agents is most commonly associated with erythema multiforme? A. Epstein Barr virus. B. Group A Streptococcus. C. Herpes simplex virus. D. Mycoplasma pneumoniae. E. Parvovirus B19. QUESTION 31 Growth hormone is secreted from the anterior pituitary gland. Which of the following is least likely to stimulate growth hormone release? A. Exercise. B. High carbohydrate intake. C. High protein intake. D. Hypoglycaemia. E. Sleep. QUESTION 32 A mother brings her nine-month-old daughter to see you with concerns about her child’s hearing. Which of the following would be the most appropriate to determine the child’s hearing acuity? A. Auditory brainstem response (ABR) testing. B. Automated auditory brainstem response (A-ABR) testing. C. Kendall toy test. D. Tympanometry. E. Visual reinforcement audiometry.
14 P103 QUESTION 33 A 14-year-old girl is hiking on a school camp. She has been carrying a heavy backpack for about four hours during the day. She wakes the next morning with pain across her right shoulder and upper arm. The pain persists for about a day and she then develops arm weakness. Examination shows weakness of abduction at the shoulder and of flexion at the elbow. She has a depressed biceps deep tendon reflex and sensory loss on the lateral aspect of her arm at the insertion of the deltoid muscle. The most likely site of injury is to the: A. accessory nerve. B. axillary nerve. C. brachial plexus. D. C7/C8 spinal roots. E. radial nerve. QUESTION 34 The parents of a 13-year-old boy, an only child, are concerned about his recent behaviour. His mother reports that he will not take books home from the library for fear of catching germs and frequently washes his hands. The boy shakes his head while his mother is speaking, but doesn’t respond when you ask him about this. The father reports that the boy’s problems often follow arguments with his mother. His mother disagrees vigorously and emphasizes how she has needed to look after him, especially over the past week as he has been home from school with a severe sore throat. The boy denies any problems at school but agrees that there have been arguments about him washing his hands at home. Which of the following is the most appropriate initial treatment? A. Family therapy. B. Individual cognitive-behavioural therapy. C. Parental counselling. D. Penicillin. E. Sertraline. QUESTION 35 During intermittent positive pressure ventilation, increasing which of the following (in isolation) would be least likely to improve carbon dioxide removal? A. Delivered tidal volume. B. Inspiratory time. C. Peak inspiratory pressure. D. Positive end-expiratory pressure. E. Ventilator rate.
15 P103 QUESTION 36 Captopril is an angiotensin converting enzyme inhibitor. Its clinical benefit in congestive cardiac failure derives mostly from: A. decreased pulmonary vascular resistance. B. decreased renal reabsorption of water. C. decreased systemic vascular resistance. D. increased renal absorption of sodium. E. positive inotropic effect. QUESTION 37 Which one of the following capsular polysaccharides of Neisseria meningitidis is least immunogenic? A. A. B. B. C. C. D. W-135. E. Y. QUESTION 38 Which one of the following is the most potent inhibitor of aldosterone secretion in a healthy individual? A. Dietary sodium restriction. B. Elevated adrenocorticotrophic hormone. C. Elevated plasma angiotensin II. D. Elevated plasma atrial natriuretic peptide. E. Elevated plasma potassium.
A 10-year-old boy presents with a history of recurrent palpitations, precipitated by strenuous exercise, over the last 12 months. On the day of presentation he had the sudden onset of a rapid heart rate while playing cricket at school. On arrival at triage he has a pulse rate of 240/minute, a respiratory rate of 29/minute and a blood pressure of 80/50 mmHg. He is pale but alert and after a large vomit at triage his rapid heart rate spontaneously resolves. His 12-lead electrocardiogram (ECG) is shown above. An echocardiogram is most likely to show which of the following? A. Dilated cardiomyopathy. B. Ebstein anomaly. C. l-Transposition of the great arteries (corrected transposition). D. Mitral valve prolapse. E. Normal cardiac anatomy. QUESTION 40 In a research study, bias is best avoided by: A. achieving a high response rate. B. assessing outcomes ‘double blind’. C. conducting a prospective study. D. ensuring an adequate sample size. E. randomising participants.
17 P103 QUESTION 41 In which of the following disorders have the beneficial effects of human immune globulin not been established in controlled clinical trials? A. Chronic fatigue syndrome. B. Dermatomyositis. C. Guillain-Barré syndrome. D. Idiopathic thrombocytopenic purpura. E. Kawasaki disease. QUESTION 42 In a patient presenting with a severe acute exacerbation of asthma, arterial blood gases on breathing room air show: PaCO2 31 mmHg [36-44] PaO2 59 mmHg [80-100] pH 7.47 [7.36-7.44] The hypoxaemia worsens with the administration of an intravenous beta-2 agonist bronchodilator. The PaCO2 is unchanged. Which one of the following mechanisms best explains the worsening of this patient’s hypoxaemia? A. Increase in cardiac output. B. Increase in oxygen consumption by skeletal muscle. C. Peripheral systemic arterial dilatation. D. Pulmonary arterial dilatation in low ventilation-perfusion ratio (V/Q) units. E. Pulmonary vasoconstriction. QUESTION 43 Which of the following organisms is the most efficient at breaking down urea? A. Campylobacter jejuni. B. Cryptosporidium parvum. C. Escherichia coli. D. Helicobacter pylori. E. Rotavirus.
18 P103 QUESTION 44 A 38-week gestation male infant is delivered by caesarean section because of concerns regarding foetal growth. The baby weighs 1850 g at birth but is otherwise normal. He is at increased risk of developing the following in adult life except: A. hypertension. B. inflammatory bowel disease. C. ischaemic heart disease. D. short stature. E. type 2 (non-insulin-dependent) diabetes mellitus. QUESTION 45 Parathyroid hormone (PTH) acutely increases serum calcium predominantly by: A. decreasing calcitonin synthesis. B. decreasing renal losses of calcium. C. increasing small intestinal absorption of calcium. D. inhibiting the production of 1,25-dihydroxycholecalciferol. E. stimulating release of calcium from bone. QUESTION 46 Which one of the following types of mutation is most likely to lead to the introduction of a premature stop codon? A. 1 base pair insertion in an exon. B. 1 base pair insertion in the promoter. C. 2 base pair duplication in an intron. D. 3 base pair deletion in an exon. E. 3 base pair inversion in an exon. QUESTION 47 Which one of the following cells of the immune system is most reliant on its release of mediators into the extracellular fluid surrounding the organism, in order to carry out its role in eradication of foreign organisms? A. Cytotoxic T lymphocytes. B. Eosinophils. C. Macrophages. D. Natural killer cells. E. Neutrophils.
19 P103 QUESTION 48 The risk of externalising (antisocial or under-controlled behaviour) among school-aged girls is highest in families with which one of the following demographic characteristics? A. Divorced parents. B. Low income. C. Parents together, both unemployed. D. Rural abode. E. Unemployed single parent. QUESTION 49 Warfarin is predominantly cleared by hepatic metabolism, with a low hepatic extraction ratio and therefore a low hepatic first pass effect and high bioavailability after oral administration. Which one of the following best describes the most likely effect on warfarin pharmacokinetics of concomitant administration of an inhibitor of warfarin metabolism, such as erythromycin? Key to symbols: ↔ = little or no change ↑ = significant increase ↓ = significant decrease
Effect on Bioavailability Effect on Clearance
A. ↔ ↓
B. ↔ ↔
C. ↑ ↓
D. ↑ ↔
E. ↓ ↔
QUESTION 50 If blood is taken 72 hours following a significant paracetamol overdose, which one of the following tests will allow the best prediction of death or need for liver transplantation? A. Blood ammonia. B. Prothrombin time-international normalised ratio (PT-INR). C. Serum alanine aminotransferase (ALT). D. Serum albumin. E. Serum bilirubin.
20 P103 QUESTION 51 Over a 24-hour period, an average two-year-old child could be expected to sleep: A. less than 6 hours. B. 7 hours. C. 9 hours. D. 11 hours. E. more than 12 hours. QUESTION 52 A five-year-old boy with a diagnosis of intractable epilepsy is prescribed a new anticonvulsant. About one month later, he presents with a 24-hour history of abdominal pain, vomiting and low-grade fever. The pain worsens over the subsequent 24 hours and he develops intractable vomiting. On examination he is dehydrated, mildly jaundiced and febrile. He has tenderness in the epigastric area. A serum amylase is elevated. He is diagnosed with pancreatitis. Which of the following anticonvulsants is most likely to be associated with this clinical scenario? A. Carbamazepine. B. Lamotrigine. C. Phenytoin. D. Sodium valproate. E. Topiramate. QUESTION 53 What is the greatest strength of the case-control study design? A. Controls for bias. B. Controls for confounding. C. Feasible with small or moderate numbers. D. Multiple endpoints can be assessed. E. Multiple risk factors can be assessed.
21 P103 QUESTION 54 Which of the following is the most appropriate antibiotic to treat a child with pneumococcal meningitis caused by a strain of Streptococcus pneumoniae with intermediate resistance to penicillin (minimum inhibitory concentration (MIC) 1 mg/L)? A. Ceftriaxone. B. Cotrimoxazole. C. Erythromycin. D. Penicillin G. E. Vancomycin. QUESTION 55 The use of high frequency oscillation compared with conventional mechanical ventilation has been demonstrated to be of most benefit in reducing the incidence of: A. chronic lung disease. B. intraventricular haemorrhage. C. mortality. D. pneumothorax. E. retinopathy of prematurity. QUESTION 56 In the process of cellular transcription, messenger RNA (mRNA) is derived from which one of the following components of the gene? A. Enhancer sequences. B. Exon sequences. C. Intron sequences. D. Promoter sequences. E. Termination sequences. QUESTION 57 Which of the following factors is the most consistently identified in cases that result in litigation against a doctor? A. Dosing errors. B. Incorrect medication. C. Insufficient knowledge. D. Negligence of duty. E. Poor communication.
22 P103 QUESTION 58 The chronic administration of a thiazide diuretic is associated with all of the following except: A. hypercalciuria. B. hyperglycaemia. C. hyperuricaemia. D. hypochloraemic alkalosis. E. normal serum magnesium. QUESTION 59 In a patient with a ventricular septal defect (VSD), which of the following clinical signs best correlates with a pulmonary to systemic blood flow ratio (Qp/Qs) of greater than 2:1? A. Apical mid-diastolic murmur. B. Loud ejection systolic murmur. C. Loud pulmonary component of the second heart sound. D. Prominent systolic thrill. E. Reversed splitting of the second heart sound. QUESTION 60 Which of the following is the most common long-term complication of cranial irradiation? A. Delayed puberty. B. Diabetes insipidus. C. Growth hormone deficiency. D. Hypothyroidism. E. Thyroid malignancy. QUESTION 61 Which immunological mechanism is the major cause of the destruction of the small intestinal villous architecture in coeliac disease? A. Activation of B lymphocytes. B. Activation of T lymphocytes. C. Secretion of anti-endomysial antibodies. D. Secretion of antigliadin antibodies. E. Secretion of tissue transglutaminase antibodies.
23 P103 QUESTION 62 The polymerase chain reaction (PCR) requires the use of a DNA polymerase. The action of the DNA polymerase is best described as: A. allowing primers to affix to the single strands. B. causing double-stranded DNA to become singled-stranded. C. extending the primers once they are affixed to the single strands. D. inducing fluorescence of DNA. E. splitting the single strand and the extended primer. QUESTION 63 Specific lung compliance is best standardised by measuring lung compliance at which of the following lung volumes? A. Expiratory reserve volume. B. Functional residual capacity. C. Inspiratory reserve volume. D. Residual volume. E. Total lung capacity. QUESTION 64 A couple wants to start a family. There is a vague history of thalassaemia in both families. Which one of the following combinations would be of least concern?
The woman is a carrier for: The man is a carrier for:
A. β-thalassaemia β-thalassaemia
B. αo-thalassaemia αo-thalassaemia
C. α+-thalassaemia αo-thalassaemia
D. haemoglobin E β-thalassaemia
E. αo-thalassaemia β-thalassaemia
Legend: β = beta αo = absent alpha chain production α+ = decreased alpha chain production
24 P103 QUESTION 65 A six-year-old child has a syncopal episode in association with an airway infection. An electrocardiogram (ECG) shows a QTc of 500 milliseconds. Which of the following medications is least likely to exacerbate the prolonged QT interval? A. Cisapride. B. Dexamphetamine. C. Erythromycin. D. Imipramine. E. Ketoconazole. QUESTION 66 The patient shown in the photograph below is pushing with arms extended against a fixed object.
Which one of the following nerves is affected? A. Accessory. B. Long thoracic. C. Pectoral. D. Subclavian. E. Suprascapular.
25 P103 QUESTION 67 During an acute infection with a virus, which of the following is the most important antigen-specific immune response that eradicates viruses from the body? A. Cytotoxic T lymphocytes. B. IgG antibody. C. IgM antibody. D. Interferon. E. Secretory antibody. QUESTION 68 A 10-month-old boy has a longstanding history of failure to thrive, vomiting and recurrent dehydration. Which one of the following is most consistent with a diagnosis of distal renal tubular acidosis?
Serum sodium Serum potassium Urinary calcium
A. high high normal
B. high low low
C. low high low
D. normal high normal
E. normal low high QUESTION 69 The need for informed consent before enrolling a patient in a clinical trial investigating a novel treatment is primarily based on the principle of: A. autonomy. B. beneficence. C. justice. D. nonmaleficence. E. risk management. QUESTION 70 Which of the following chromosomal abnormalities is most likely to not be detected on routine karyotyping? A. Balanced reciprocal translocation. B. Microdeletion. C. Monosomy. D. Robertsonian translocation. E. Trisomy.
