Mrcpch 1a

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. 3. It is strictly forbidden to talk to, read the work of, or attempt in any way to communicate with, other candidates whilst the examination is in progress. Please exercise vigilance to ensure that no other candidate can attempt to copy your work. The College has tools which can identify copying of answers or collusion between candidates to share answers. In any situation the suspicion of guilt falls upon both parties until it can be proved otherwise. Breaches of these instructions, or misbehaviour in any other way, including continuing to write after the allotted time, may lead to suspension from the examination at the discretion of the invigilators. Serious breaches, such as cheating or colluding to gain advantage, could incur permanent suspension from College examinations. 4. Question papers and individual questions must not be copied or removed from the examination room. 5. Answer all the following 24 questions. 6. Time allowed: 1 hour.

MULTIPLE CHOICE QUESTIONS Question 1

Erythema nodosum A

characteristically leaves scarred areas after resolution

B

consists of painless subcutaneous nodules on extensor surfaces

C

has a recognized association with inflammatory bowel disease

D

is a complication of poorly controlled insulin dependent diabetes mellitus

E

is associated with the use of oral contraceptives

Question 2

In the developed world contra-indications to breast feeding include

A

a family history of eczema

B

AIDS in the mother

C

mother on Warfarin therapy

D

the occurrence of haemorrhagic disease of the newborn in a previous infant

E

the occurrence of secondary lactose intolerance in a previous infant

Question 3

Vesicoureteric reflux

A

implies bladder neck obstruction

B

is a common cause of urinary tract infection in adolescent girls

C

is attributed to an abnormally long intramural course of the ureter

D

is excluded by a normal renal ultrasound examination

E

is inherited in an autosomal recessive manner

Question 4

Concerning child sexual abuse, A

adults frequently do not believe children’s allegations of sexual abuse

B

intrafamilial abuse is generally less traumatic for the child than extra familial abuse

C

it is a common cause of behavioural problems in childhood

D

it is associated with precociously sexualised behaviour

E

there is an increased risk to the child if one of the carers has been sexually abused as a child

Question 5

In a twin pregnancy A

feto-fetal transfusion is associated with hydrops fetalis

B

the incidence of cerebral palsy is higher for a monozygotic than a dizygotic twin

C

the perinatal mortality rate is higher for a monozygotic than a dizygotic twin

D

there is an increased incidence of neonatal hypoglycaemia

E

two separate placentae confirm dizygosity

Question 6

The following occur in individuals with Down’s syndrome more commonly than in the general population: A

Acute lymphoblastic leukaemia

B

Alzheimer’s disease

C

Coeliac disease

D

Hirschsprung’s disease

E

Hypothyroidism

Question 7

Recognized findings in normal puberty include A

acne vulgaris in girls

B

asymmetrical breast enlargement in girls

C

diffuse enlargement of the thyroid

D

enlargement of the penis before the testes in boys

E

gynaecomastia in boys

Question 8

When compared with truants, children not attending school for emotional reasons are A

less likely to come from large families

B

more likely to have anxious parents

C

more likely to have difficulties in reading

D

more likely to show behavioural problems at school

E

of lower intellectual ability

Question 9

It is true of deliberate self harm that A

boys are more likely than girls to complete suicide in adolescence

B

deliberate self harm can result in an improvement in family functioning

C

in teenage girls deliberate self harm is generally indicative of physical or sexual abuse

D

in the teenage years deliberate self harm occurs with equal frequency in males and females

E

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

Question 10

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

BEST OF FIVE QUESTIONS Question 11 An infant is born at term weighing 3.2Kg. He cries immediately at birth, Apgar 9 at 1 minute. At 36 hours of age he has developed central cyanosis. What is the most likely diagnosis? SELECT ONE ANSWER ONLY A

Anomalous pulmonary venous drainage

B

Fallot’s tetralogy

C

Hypoplastic left heart

D

Pulmonary stenosis

E

Transposition of the great arteries

Question 12

A 14-month-old boy is not yet walking unaided. He has “bottom-shuffled” from the age of 10months. His cognitive development is normal. His five-year-old brother crawled at 9 months and walked at 12 months of age. What is the best action to take at this stage? SELECT ONE ANSWER ONLY A

Measure his creatine kinase (CK) level

B

Refer him for physiotherapy

C

Request MRI brain scan

D

Review him in three months

E

Send blood for chromosome analysis

Question 13 A 4-year-old boy complains of pain in the groin and has been walking with a limp for two days. He lies on the examination couch with his hip flexed and externally rotated. His temperature is 37o 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 Perthe’s disease.

Question 14 A 7-month-old boy 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. Which 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

Question 15 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. 2 friends have overtaken her in height in the last year. She goes to school every day. On examination 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

Crohn’s disease

D

Juvenile idiopathic arthritis

E

Turner’s syndrome

Question 16 A 6-month-old boy is brought to the Emergency Department because he is not using his right arm. He is found to have a spiral fracture of the right humerus. His mother says he rolled off a sofa 3 days ago. What is the most appropriate to take action now? SELECT ONE ANSWER ONLY A

Apply backslab, and arrange Fracture Clinic review the following day

B

Arrange a radioisotope bone scan

C

Discharge home for supervision by the Health Visitor

D

Take out an Emergency Protection Order

E

Telephone Social Services

Question 17

A previously well 10-year-old boy is brought by his parents with a very painful throat of 2 days duration. He has no fever and the only abnormal findings are a red throat, runny nose and cough. What is the management option? SELECT ONE ANSWER ONLY A

Advise gargling with soluble aspirin

B

Advise that he should not attend school for two days

C

Advise the parents that the condition needs no treatment

D

Prescribe nasal decongestants

E

Prescribe oral penicillin

Question 18 A 6-year-old boy presents with a complaint of persistent diarrhoea. He is visiting the toilet several times a day, producing small amounts of soft offensive stools. He is often unaware that he is opening his bowels. He soils his pyjamas and refuses to go to school, saying he is being bullied because he smells. He complains that he gets abdominal pain after meals. His mother tried a milkfree diet without benefit. His height and weight are on the 50th centile. He refuses to be examined but his pants are seen to contain smelly faeces with no blood or mucus. What is the most likely diagnosis? SELECT ONE ANSWER ONLY A

Coeliac disease

B

Constipation

C

Giardiasis

D

Inflammatory bowel disease

E

Threadworm infestation

Question 19

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 need for adenoidectomy

E

The long-term risk of cholesteatoma

Question 20

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 18 hours of age she is well but jaundiced. What is the most likely cause of the jaundice? SELECT ONE ANSWER ONLY A

ABO incompatibility

B

Congenital hypothyroidism

C

Prematurity

D

Rhesus incompatibility

E

Urinary tract infection

EXTENDED MATCHING QUESTIONS Question 21 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 38.5º. The illness started with runny nose and cough five days previously. His 3-year-old brother has recently started nursery.

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 38.5º and she has a heart rate of 150/minute, respiratory rate of 40/minute and capillary refill time of 2 seconds: Blood total white blood count 15 x 109/l neutrophil counts 11 x 109/l

This Question Continues on the next page.

Question 21 continued 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/minute, respiratory rate 30/minute and capillary refill time of 2 seconds. Blood total white blood count 15 x 109/l neutrophil count 12 x 109/l

Question 22

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 pan-cytopaenia. 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 pan-cytopaenia. Skeletal survey shows wide-spread abnormalities in the long bones.

This question continues on the next page.

Question 22 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.

Question 23 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 for the 2nd 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.

This question continues on the next page

Question 23 continued 3

A 7-year-old boy developed a squint following a tonsillectomy 3 months ago. He has a right 6th nerve palsy and is mildly ataxic.

Question 24

This is a list of diagnoses: A

Benign paroxysmal vertigo

B

Complex partial seizures

C

Daydreams

D

Hyperventilation

E

Idiopathic generalised epilepsy

F

Migraine

G

Night terrors

H

Non-epileptic seizures

I

Simple partial seizures

J

Syncope

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 with learning difficulties has infrequent episodes in which he looks frightened, goes pale and swallows repeatedly for 15-30 seconds, following which he seems tired.

2

A 12-year-old girl has episodes of twitching of her right leg accompanied by pain and parasthesiae for minutes to hours at a time. She remains fully conscious during these episodes. She lives with her pregnant single mother and grandmother, who are very worried about the episodes and have kept her off school since they began three weeks ago. Neurological examination is normal, as was her EEG during an episode.

This question continues on the next page.

Question 24 Continued 3

A 12-year-old girl has had three episodes of collapse during assembly at school. She felt hot, nauseated, and sounds seemed louder to her, then she dropped to the ground and briefly jerked all limbs. She was unreachable for 10-20 seconds. There was a short period of confusion before she recovered.

End of Paper