Pediatric Board Review Practice Questions
Book 1 - 2004
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QUESTION

8. A 10-month-old female is brought to your office for a routine health evaluation. Her diet consists of table food and whole milk and she is a “good drinker”. Her weight and length are at the 50th percentile and no changes are noted in her growth curves. Her physical examination is notable for pallor; otherwise there are no abnormalities. Her hemoglobin is 7.5 grams per deciliter and the peripheral blood smear reveals microcytic hypochromic cells.

Which of the following is the MOST likely etiology of this anemia?

A) Thalassemia
B) Sickle cell anemia
C) Transient viral suppression of her bone marrow
D) Anemia of chronic disease
E) Iron deficiency anemia

ANSWER

8. E - Iron deficiency

Iron deficiency anemia is the most common cause of microcytic hypochromic anemia in this age group. This etiology is also suggested by the history of whole milk intake. Thalassemia is a possibility but less likely given the patient's history and the known frequency of the disease. Sickle cell anemia and transient viral suppression do not usually present with a microcytic hypochromic anemia. Anemia of chronic disease is not supported by the clinical presentation given the healthy physical examination and weight at the 50th percentile without any changes in her growth curves.

1. Behrman RE, Kliegman RM, Jenson HB, Eds. Nelson textbook of pediatrics, 17th ed. Philadelphia, PA: Saunders, 2004: 1614-1616.

QUESTION

200. A previously well 15-year-old girl presents to your emergency department complaining of severe headache and diplopia. She has also had a single episode of emesis, which was described as nonbilious and non-projectile. She had a routine health examination the previous week at which time she was started on oral contraception. She denies trauma.

On examination, she is slightly obese, alert, and cooperative but anxious teenager. The eye examination is significant for bilateral papilledema and bilateral inferior nasal visual field defects. Her neck is supple. The remaining examination, including full neurological examination, is unremarkable.

Head CT is unremarkable. Cerebrospinal fluid evaluation has an opening pressure of 49mm water, 0 WBC, 0 RBC, glucose 68, protein 18, gram stain negative. She reports improvement in the headache following the lumbar puncture

This teenager has:

A) Pseudotumor cerebri
B) A brain tumor not visible on the head CT
C) HSV encephalitis
D) Undeclared head trauma
E) Nothing, she is malingering

ANSWER

200. A - Pseudotumor cerebri

This child has pseudotumor cerebri, a condition consisting of signs and symptoms of elevated intracranial pressure with normal ventricles and normal CSF. Many things cause pseudotumor cerebri, including medications (e.g. tetracycline, steroids and oral contraceptive pills), metabolic or nutritional derangements (e.g. hypoparathyroidism, Vitamin A excess or deficiency, iron deficiency anemia and pregnancy), and infections (e.g. roseola, chronic otitis media). It classically presents with headache, and/or mild to moderate emesis and/or papilledema. “Constitutional” symptoms (e.g. failure to thrive, fatigue), severe emesis, focal neurologic symptoms not referable to the optic nerve or altered sensorium are all signs that something other than pseudotumor is the cause. Diagnosis is made by exclusion of an intracerebral focal lesion and confirmation of normal ventricles by imaging, measurement of the opening pressure as well as obtaining cerebrospinal fluid to demonstrate normal cytology and protein, as well as a thorough neurologic exam. The treatment is to first remove the “trigger”, followed by therapeutic lumbar puncture and removal of cerebrospinal fluid. Alternatively, either steroids or acetazolamide have shown limited efficacy. Tumors should be visible on CT scans of the head. The diagnosis of encephalitis is not supported by the cerebrospinal fluid cytology.
Head trauma severe enough to cause signs and symptoms of elevated intracranial pressure should have findings demonstrated on the head CT. There are no reasons to believe that this child is feigning illness and she has objective signs of neurologic problems

1. Behrman RE, Kliegman RM, Jenson HB, Eds. Nelson textbook of pediatrics, 17th ed. Philadelphia, PA: Saunders, 2004:2048-9.

QUESTION

221. A 3-year-old boy is seen in the emergency department after coughing and gagging while eating a peanut. He now has difficulty breathing. His physical examination is significant for wheezing on the right side hemithorax. What radiographic finding is classic for this condition?

A) Atelectasis on the side of aspirated content
B) An expiratory film demonstrating air trapping with hyperinflation of the lung shifting away from aspirated side
C) Bilateral hyperexpansion
D) Peanut seen on the radiograph
E) An inspiratory film demonstrating a left lower lobe consolidation

ANSWER

221. B - An expiratory film demonstrating air trapping with hyperinflation of the
lung shifting away from aspirated side

In foreign body aspiration, inspiratory films are typically normal. In expiration, the lung with the aspirated contents remains hyperinflated and the mediastinal shift away from the lung with the aspirated contents occurs. Breath sounds are diminished on the affected side. Air enters the distal portion of the lung on inspiration, but is blocked on expiration by the foreign body producing an obstructive hyperinflation. The peanut is not radiopaque and will not be visible on the radiograph.

1. Behrman RE, Kliegman RM, Jenson HB (Eds). Nelson Textbook of Pediatrics. 17th Edition. Saunders, Philadelphia PA 2004:1410-1411.

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