Pediatric Written Board Exam Sample Questions
Book 2 - 2004
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QUESTION

143. An infant is born at 28-weeks gestation with severe Respiratory Distress Syndrome (RDS). The infant requires assisted ventilation and surfactant replacement therapy. Secondary to poor oxygenation, the positive end-expiratory pressure (PEEP) is increased from 4-6 cm H20. Shortly thereafter, you are called to the bedside for an acute decrease in oxygenation and an increase in the partial pressure of carbon dioxide (PaC02).

Which of the following therapeutic interventions would be MOST indicated at this time?

     A) Transillumination of the chest
     B) Increase the ventilator peak inspiratory pressure (PIP)
     C) Decrease the PEEP
     D) Begin oscillatory high-frequency ventilation
     E) Administer a bolus of normal saline at 10 cc/kg

ANSWER

143.     A     Transillumination of the chest

The patient in this question developed acute clinical deterioration following a change in ventilation (increased PEEP). Pulmonary air leaks (PIE-pulmonary interstitial emphysema and pneumothorax) are common serious complications of ventilator therapy. Ventilator-induced air leaks are more likely to occur when lung compliance is improving. As compliance increases, there must be adequate expiratory time and minimal expiratory resistance (PEEP) to prevent expiratory gas trapping. Pneumothoraces occurring during assisted ventilation should be quickly diagnosed by transillumination of the chest or chest radiograph and quickly decompressed with a chest tube.

1. Boros SJ. Principles of Ventilator Care. In: Thibeault DW, Gregory GA, eds. Neonatal Pulmonary Care 2nd. Norwalk CT: Appleton-Century-Crofts; 1986:367-85.

QUESTION

161. A 12-year-old boy who is at the 90th percentile for weight complains of slight pain in the right thigh and knee for about a month. His complains are made worse by physical activity and he has a mild limp. He has no history of recent infections or trauma. Physical examination reveals a slight decrease in internal rotation of the right hip. There is mild right-sided metaphyseal osteopenia on radiograph.

Of the following, which would be the MOST likely diagnosis in this boy?

     A) Transient synovitis
     B) Septic arthritis
     C) Osteomyelitis
     D) Slipped capital femoral epiphysis
     E) Legg-Calve-Perthes disease


ANSWER

161.      D      Slipped capital femoral epiphysis

Slipped Capital Femoral Epiphysis occurs as the result of acute or repetitive microtrauma to a probable abnormal femoral growth plate. It is unilateral in 40%-80% of cases and occurs during or just prior to the adolescent growth spurt (age 10 to 13 years). It is more commonly seen in boys and in very obese and/or very tall adolescents. Onset prior to age 10 years may indicate an underlying endocrine problem such as hypothyroidism. The clinical presentation is a limp with pain related to the hip joint. There may be some shortening of the involved limb, and internal rotation is limited. Biplanar radiographs or computed tomographic scans will establish the diagnosis. Mild demineralization of the metaphysis on the involved side is often associated.

1. Renshaw TS. The child who has a limp. Pediatrics in Review 1995; 16:458-465.

QUESTION

TRUE or FALSE

249. In order to standardize the care of asthmatic children in the US, the National Institute of Health of the United States has published an expert panel report in which bronchial asthma is classified into four clinical types.

The classification is based on:

     a) The number of attacks in the day time per week
     b) Number of nighttime symptoms per month
     c) Predicted lung function
     d) Peak flow variability

ANSWER

249.      True

The guidelines for diagnosing and managing asthma are based on current science. There are four components of the guidelines:

o Assessment. Precise measurement of lung function to determine the severity of asthma and to monitor the course of therapy.
o Contributing factors. Avoidance or elimination of factors that prompt asthma symptoms or exacerbation.
o Pharmacotherapy. Medications for reversal and long-term prevention of airway inflammation, plus medications to manage asthma exacerbation.
o Patient education. A knowledgeable patient and family, working in partnership with health professionals.

The accurate diagnosis of asthma is critical. In order to establish the diagnosis of asthma, we need to determine that:

o Episodic symptoms of airflow obstruction are present.
o Airflow obstruction is at least partially reversible.
o Alternative diagnosis is excluded - particularly COPD and vocal cord obstruction in adults, and aspiration and cystic fibrosis in children.

1. National Asthma Education and Prevention Program., Expert Panel Report 2. Guidelines for the Diagnosis and Managemment of Asthma. Bethesda, MD. National Institute of Health:National Heart, Lung and Blood Institute;1997. Report No. 97-4051.

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