1. A 9-year-old girl with a recent diagnosis of polyarticular JIA returns for follow-up.

Six months ago, she was diagnosed and started on an NSAID. Four months ago, she
was started on subcutaneous methotrexate (1 mg/kg/week) and folic acid. In the
office today, she reports that she is improved, but still admits to 60–120 minutes of
morning stiffness daily and swelling in the small joints of her hands and wrists that
is interfering with her schoolwork. Exam confirms the presence of active synovitis in
her MCPs and PIPs bilaterally, as well as both wrists. Your next best step would be
which of the following?
a) Continue current therapy for 3 more months and evaluate
b) Change her current NSAID to different NSAID
c) Add an anti-TNF agent
d) Inject all of the affected joints with intra-articular corticosteroids
e) Increase her methotrexate
2. Alex 15-year-old girl presents with symptoms of vaginal irritation, pruritus, and
discharge. She is sexually active and uses condoms during sexual intercourse. She
denies dysuria. A urine pregnancy test is negative. Tests are sent using the patient’s
urine for Chlamydia and gonorrhea. Examination reveals a normal-appearing
cervix without motion tenderness and a nonspecific vaginal gray discharge with a
pH >4.5 that has a slight fishy odor. Sodium chloride microscopy reveals a few
PMNs but no trichomonads and possible stippling of some epithelial cells. The best
presumptive treatment for the patient’s condition would be:
a. Metronidazole 500 mg orally, twice daily, for 7 days
b. Metronidazole 2 g orally, once
c. Fluconazole 150 mg orally, once
d. Azithromycin 1 g orally, once, and ceftriaxone 250 mg IM, once
e. Tinidazole 2 g orally, once
3. An expectant mother undergoes a routine prenatal ultrasound and severe polyhydramnios
is diagnosed. The differential diagnosis of polyhydramnios includes congenital anomalies
such as esophageal atresia (EA). Of the following types of EA, which is the most
common?
4. A 4-year-old girl presented to your office with fever and dysuria 1 week ago. Her
urinalysis is positive for leukocyte esterase and nitrites. Her urine culture eventually
grew out >100,000 E. coli . You started her on a course of trimethroprim–
sulfamethoxazole. Her fever and dysuria resolved completely, but the mother
returns to the clinic today for the development of a rash. On examination, she is well
appearing, but there are multiple punctate nonblanching macular purplish spots on
her arms, legs, and trunks. You obtain a CBC that shows a white blood cell count of
1.7 × 10 9 /L, hemoglobin of 7 g/dL, and platelets of 25 × 10 9 /L. What is the most
likely cause of her laboratory findings?
a. Acute lymphoblastic leukemia
b. Drug effect
c. Viral suppression
d. Congenital bone marrow failure syndrome
e. Aplastic anemia
5. Which of the following statements regarding renal dysplasia is correct?
a. It may be discovered incidentally on antenatal ultrasound
b. Unilateral renal dysplasia is associated with oligohydramnios
c. A dysplastic kidney on ultrasound will have a loss of echogenicity
d. Renal dysplasia is not associated with urological anomalies
e. Patients with unilateral renal dysplasia usually present with renal failure
6. In your practice you have been following a child with a subarterial type of
ventricular septal defect. On past visits the murmur has been a blowing holosystolic
murmur. However, today you appreciate a descrescendo diastolic murmur. What is
the most likely cause for this new murmur?
a. Aortic regurgitation due to prolapse of the aortic valve cusp into the defect
b. Relative mitral stenosis due to increase flow across the valve
c. Flow across an atrial septal defect due to increased flow in the left atrium
d. Pulmonary regurgitation due to stretching of the pulmonary annulus from pulmonary
hypertension
e. Endocarditis of the tricuspid valve related to turbulence near the VSD has caused a left
ventricle to right atrium shunt
7. You are evaluating a recently adopted 2-year-old from overseas. His new parents
were told that he has a murmur. They noticed he loves to run around the house, but
he often takes breaks squats down and breathes heavily. He has dark skin, but they
wonder if he looks dusky when he runs. On examination, he has room air
saturations of 80%, a right ventricular heave, and a harsh systolic ejection murmur
at the LUSB that radiates to the lung fields. There is no hepatomegaly. Pulses are
equal in all extremities. His upper and lower extremity blood pressures are normal
for age. Which congenital cardiac lesion do you suspect?
a. Coarctation of the aorta
b. Patent ductus arteriosus
c. Tetralogy of fallot
d. Atrial septal defect
 e. Ventricular septal defect
8. A 13-year-old girl with a history of asthma presents for her annual well-child visit.
She has mild, intermittent asthma. She has recently been seen by an allergist who
has confirmed that she is sensitive to house dust mite allergen. House dust mite
allergen seems to be a trigger for her asthma exacerbations. Which of the following
allergen avoidance strategies would be inappropriate for this patient?
a. Removal of wall-to-wall carpeting in the bedroom
b. Weekly washing all the sheets and bedding in hot
water at a temperature greater than 130°F
c. Use of encasings for the child’s bedroom mattresses
d. Use of encasings for the child’s bedroom pillows
e. Use of a warm mist humidifier at night in the child’s bedroom
9. A 4-year-old previously healthy boy presents with fever to 102.5°F, sore throat,
irritability, and refusal to eat or drink. Symptoms began that morning and have
progressed over the past few hours. You note the child to be ill appearing, leaning
forward, and drooling. There are no ill contacts and the child has received all
immunizations. You keep the child comfortable with his mother and immediately
contact anesthesia and otolaryngology to assist with further management. If neck
films were ordered, the most likely finding would be:
a. Thumbprint sign
b. No acute abnormality
c. Steeple sign
d. Reverse spine sign
e. Irregularity of the tracheal air column
10. Which of the following statements is true regarding premature thelarche?
a. Small for gestational age is a risk factor
b. Gonadotropin levels are in pubertal ranges
c. Most cases are self-limited and benign
d. Patients are at an increased risk for polycystic ovarian syndrome in adulthood
e. Most case occur after the age of 4 years
11. An 11-year-old boy presents to clinic for concerns about short stature. He has been
consistently growing at the 3 rd percentile for the last 10 years. On exam, his
weight is at the 75 th percentile. He has a round face with a flattened nasal bridge.
Brachydactyly and small cutaneous nodules are felt beneath the skin of his finger
tips. Which of the following laboratory results are the most representative of this
child’s diagnosis?
a. Low PTH, low calcium, low phosphorous
b. Elevated PTH, elevated calcium, elevated phosphorous
c. Elevated PTH, low calcium, elevated phosphorous
d. Low PTH, elevated calcium, elevated phosphorous
e. Elevated PTH, elevated calcium, low phosphorous
12. What percentage of children with new-onset epilepsy will eventually be able to
discontinue medication and remain seizure-free?
a. 10%
b. 30%
c. 50%
d. 70%
e. 90%
13. A 7-year-old girl, has had abdominal pain for the last 6 months. On several
occasions it has been sufficiently severe for her to be sent home early from school.
The pain happens once or twice a week in the afternoon or early evening. It is
periumbilical in nature. It does not wake her at night. She has not had vomiting or
diarrhoea. She is growing well. Her examination is normal. Her urine is clear on
dipstick testing. What is the most likely cause for her pain?
A. Functional abdominal pain
B. Gastritis
C. Hepatitis A
D. Irritable bowel syndrome
E. Meckel diverticulum
14. Ellie is a 4-year-old girl who has been complaining of pain in her tummy for a
month. It is worse when she goes to the toilet; her stools are firm and she opens her
bowels only every 2–3 days. She has not had any vomiting. For the last 2 weeks her
stools have become loose. On examination she has a mass in the left
iliac fossa. What is the most likely diagnosis?
A. Appendix mass
B. Constipation
C. Gastroenteritis
D. Inguinal hernia
E. Wilms tumour
15. A 8-month-old infant who presents to his general practitioner following a bout of
diarrhoea and vomiting, associated with fever for 3 days. This was managed at home
with oral rehydration solution. The vomiting had settled but the diarrhoea has
continued for three weeks. The stool microscopy and culture were negative. He has
no other medical problems and is not on any other medication. On examination he is
not dehydrated. He has a soft, mildly distended abdomen. What is the most likely
cause of his prolonged
diarrhoea?
A. Coeliac disease
B. Giardiasis
C. IgE mediated cow’s milk protein allergy
D. Non-allergic food hypersensitivity
 E. Non-IgE mediated cow’s milk protein allergy

16. A 4-month-old black African infant, who

has recently moved to the UK from Swaziland
with his mother is seen in the Paediatric
Assessment Unit. He is feeding poorly and is
breathless. He has had loose stools for the last
4weeks and has not put on any weight since then.
On examination he appears pale and has marked
intercostal recession. His oxygen saturation in air
is 82%. His chest X-ray is shown in Fig. LEFT.
What is the most likely cause of his respiratory
failure?
A. Influenza virus
B. Pneumocystis jiroveci (carinii) pneumonia
C. Respiratory syncytial virus
D. Rhinovirus
E. Staphylococcal pneumonia

17. A 10-year-old Caucasian boy has had recurrent

chest infections requiring admission to hospital
for intravenous antibiotics. He is smaller than his
classmates: his weight is on the 2nd centile and
height on the 25th centile. His chest X-ray is
shown LEFT mostly likely diagnosis is?
a) Bronchopulmonary dysplasia (BPD)
b) Chronic asthma
c) Cystic fibrosis
d) Inhaled foreign body
e) Laryngotracheobronchitis (croup)
18. A 5-month-old infant from Poland, is admitted to hospital with breathing problems
and poor feeding. On examination he has a respiratory rate of 50 breaths/min. On
auscultation of the chest he has widespread crackles. He has moderate intercostal
recession, and oxygen saturation of 92% in air. He was born at term with a
birthweight of 3.6 kg (50th centile). His weight is now 5.2 kg (<0.4th centile). This is
his first admission to hospital but he ‘is always chesty’. You suspect Boris has cystic
fibrosis. When he is stabilized which would be the most appropriate investigation to
perform?
A. Genetic screening for cystic fibrosis
B. Heel prick for immunoreactive trypsin
C. Measurement of faecal elastase
D. Measurement of serum bilirubin
E. Sweat test
19. Tariq, who is 6 weeks old, is admitted directly from the cardiology clinic with heart
failure. He has a large ventricular septal defect. The cardiologist has recommended
treatment with furosemide and spironolactone. His mother wants to know why he
has only now started to have problems. Which of the following statements provides
the best explanation?
A. At birth and for the first few weeks the ductus arteriosus remained patent and this
balanced the flow across the septal defect
B. Pulmonary vascular resistance is increasing and blood is now flowing from right to
left
C. The left ventricle is now failing due to its progressive dilatation
D. The pulmonary vascular resistance falls after birth and now flow from left to right
across the septal defect is much greater
E. Volume overload results in decreased return to the left ventricle and a reduction in
cardiac output related to a reduced end-diastolic filling pressure
20. John, who is 6 years old, presents to the Emergency Department feeling sick and
dizzy. He was brought to hospital by a paramedic crew who were called after he
became unwell at school. His heart rate was noted to be very quick, at 260 beats/min
and supraventricular tachycardia is diagnosed. He says he can feel his heart beating
quickly and looks pale. He is crying, saying he wants his mother. Which of the
following should be undertaken by the attending team?
A. Adenosine via a large bore intravenous line
B. Bilateral carotid sinus massage
C. Direct current cardioversion
D. Reassure that it will resolve spontaneously
E. Vagal stimulation manoeuvre
21. Jane is a 5-year-old girl who presents to her general practice with bed-wetting. She
has been wetting for 4 months and wets on average three nights per week. Her
mother is upset as she had been dry during the day and night for almost a year. She
recently started school and has had two episodes of wetting at school. She has no
other medical problems and is not on any medication. She has always liked to drink
water from a bottle she carries. Which of the following would you do first?
A. Blood glucose
B. Ultrasound of the abdomen
C. Urinary dipstick
D. Urinary microscopy and culture
E. Water deprivation test
22. Hamza, a 14-year-old Indian boy, has chronic kidney disease secondary to renal
dysplasia. His mother wants him to take more responsibility for his medication and
would like you to talk to him about the different medicines he takes. Which of the
following dietary changes or medications is Hamza likely to be taking to prevent
renal osteodystrophy?
A. Bicarbonate supplements
B. Calcium restriction
 C. Phosphate supplements
D. Sodium supplements
E. Vitamin D supplements
23. Essa is a 2-year-old boy whose parents have noticed his two eyes look different. He
has no other medical history and is not currently on any medication. On
examination, the movement of the eyes is normal and the pupils are equal and
reactive to light. On checking his pupillary reflex you observe his left pupil looks red
but the right looks white. His systemic examination is normal. What is the likely
cause of this?
A. Congenital cataract
B. Glaucoma
C. Retinoblastoma
D. Allergic conjunctivitis
E. VI nerve palsy
24. Many rashes in childhood are itchy and can cause a lot of discomfort for the child.
Which of the following rashes is least likely to be itchy?
A. Atopic eczema
B. Chicken pox
C. Infantile seborrhoeic dermatitis
D. Pityriasis rosea
E. Scabies
25. You see William, a 10-month-old baby boy who has been diagnosed with atopic
eczema. His parents are struggling to control it with herbal remedies. He is
scratching himself all day and at night, and he appears in discomfort. Which of the
following is the most useful advice?
A. Apply emollients once a day
B. Bandages can only be used in children over 1 year of age
C. Regularly wash the baby with soap to avoid infection
D. Using nylon instead of cotton clothes
E. Use ointments instead of creams when the skin is dry
26. A baby is born with a disorder of sexual differentiation. Congenital adrenal
hyperplasia is suspected. What blood result would confirm the diagnosis?
A. A low testosterone
B. A markedly lowered plasma 17 α–hydroxyprogesterone
C. A markedly raised cortisol level
D. A markedly raised plasma 17α-hydroxyprogesterone
E. A raised blood glucose
27. A 4-month-old male infant, presents with a history of vomiting and diarrhoea. On
examination he has a heart rate of 160 beats/min; his capillary refill time is 2–3
seconds and he is lethargic. A bedside blood test showed that he is hypoglycaemic. A
diagnosis of Addison disease is considered. Which of the following combination of
biochemical results would be most likely with Addison’s disease?
A. Hypernatraemia and hyperkalaemia with low cortisol
 B. Hypernatraemia and hypokalaemia with high cortisol
C. Hyponatraemia and hyperkalaemia with high cortisol
D. Hyponatraemia and hypokalaemia with low cortisol
E. Hyponatraemia and hyperkalaemia with low cortisol
28. A 14-year-old boy who presents to the Emergency Department. He is a good
footballer, and after training today he complained of pain in his left knee. He has
had the pain for a while and it gets worse when he exercises. On examination there
is swelling over the left tibial tuberosity. He is afebrile. There is no night pain or
pain on waking. What is the most likely diagnosis?
A. Osteomyelitis
B. Osgood–Schlatter disease
C. Perthes disease
D. Septic arthritis
E. Slipped capital femoral epiphysis
29. Dominika is a 3-year-old girl. She presents with an acute onset limp which was not
present on the previous day. Her mother reports that she was unwell 2 weeks ago
with a coryzal illness. The pain is in her right leg and is present only on walking. On
examination she has a temperature of 37° C. The hip and leg look normal but on
passive movement of her right hip, there is decreased external rotation.
What is the most likely diagnosis from the list below?
A. Bone tumour
B. Perthes disease
C. Reactive arthritis (transient synovitis)
D. Septic arthritis
E. Slipped capital femoral epiphysis
30. Angelo, a 15-month-old boy, had been unwell with a runny nose and cough for a day
when his father brings him to the Emergency Department. At lunch he suddenly
became stiff, his eyes rolled upwards and both his arms and legs started jerking for
2 minutes. He felt very hot at the time. When examined 2 hours later, he has
recovered fully. This is the first time this has happened. He has a normal
neurological examination and is acquiring his developmental milestones normally.
He has no other medical problems. The triage nurse performed a blood glucose test,
which indicated a glucose level of 4.2 mmol/L (within normal range). What would be
the most appropriate investigation?
A. CT scan of the brain
B. ECG
C. EEG (electroencephalography)
D. No investigation required
E. Oral glucose tolerance test
31. Gerald is a 10-year-old boy. He is seen in the special school clinic with his mother,
who is just recovering from cataract surgery. He has moderate learning difficulties
and is teased because of his marked facial weakness. He is unable to walk long
distances. His mother says that he struggles to release things once he grabs them. He
 has no other medical problems. He has not had any investigations performed. Select
the most useful diagnostic test from the list.
A. DNA testing for trinucleotide repeat expansion
B. Electromyography (EMG)
C. Muscle biopsy
D. Nerve conduction studies
E. Serum creatine kinase
32. Reece, a 4-week-old male infant living in the UK, is taken to his family doctor
because he is jaundiced. He was born at term and is breastfed. His mother reports
that he has always looked yellow and has started to develop bruises. His stools are
now pale in colour. On examination he has hepatomegaly. Which of the following
investigations would you undertake first?
A. Faecal elastase
B. Serum conjugated and unconjugated bilirubin
C. Sweat test
D. Ultrasound scan of the liver
E. Urinalysis
33. Ahmed, a 1-year-old boy, is brought to the Paediatric Assessment Unit. He has had a
high temperature for the last week. His mother has taken him to the general
practitioner on two occasions and he has completed a course of amoxicillin. His eyes
are injected and his throat is red. He has marked cervical lymphadenopathy. The
skin on his fingers has started to peel. Everyone else in the family is well. What is
the most likely diagnosis?
A. Infectious mononucleosis (glandular fever)
B. Kawasaki disease
C. Staphylococcal scalded skin syndrome
D. Scarlet fever
E. Tuberculosis
34. Tom is a 5-year-old boy who presents to hospital with a recent history of bruising
easily. Two weeks ago he had an upper respiratory tract infection which resolved
spontaneously. On examination today he is afebrile but has many, widespread
bruises with some scattered petechiae. Investigations reveal: • Hb (haemoglobin):
116 g/L • WBC (white blood cell count): 10.2 × 109/L • platelet count: 32 × 109/L
• prothrombin time: 15 seconds (control: 12–15 s) • activated partial thromboplastin
time: 30 seconds (control: 25–35 s) • fibrinogen: 2.5 g/L (normal: 2–4 g/L)
What is the most likely diagnosis?
A. Acute lymphoblastic leukaemia
B. Haemophilia A
C. Immune thrombocytopenic purpura
D. Non-accidental injury
E. Vitamin D deficiency
35. Samina is 12-years-old and has hepatomegaly. She is short for her age, suffers from
hypoglycaemia and needs an overnight feed via a nasogastric tube. What is the most
likely diagnosis?
A. Congenital adrenal hyperplasia
B. Familial hypercholesterolaemia
C. Glycogen storage disorder
D. Phenylketonuria
E. Urea cycle defect