Pediatric Examination and Board Review (108 page)

On physical examination, his height is 88 cm and weight is 13.2 kg. Significant findings include mild pallor of the oral mucosa, a I/VI systolic ejection murmur with good pulses, dry plaques on the antecubital fossae bilaterally, and no focal neurologic findings. Otherwise his examination is unremarkable.

SELECT THE ONE BEST ANSWER

1.
What screening test should be ordered for this patient?

(A) folate level

(B) lipid panel

(C) complete blood count

(D) PPD

(E) echocardiography

2.
A CBC is obtained. The patient has a hemoglobin of 10.3, hematocrit of 30.7, and a mean corpuscular volume (MCV) of 65. Which of the following is not in your differential?

(A) iron deficiency anemia

(B) thalassemia

(C) folate deficiency

(D) lead poisoning

(E) anemia of chronic disease

3.
Which of the following iron studies are consistent with iron deficiency anemia?

(A) low MCV, normal red [blood cell] distribution width (RDW), normal total iron-binding capacity (TIBC), high free erythrocyte porphyrin (FEP)

(B) low MCV, normal RDW, normal TIBC, normal FEP

(C) low MCV, high RDW, high TIBC, high FEP

(D) low MCV, normal RDW, low TIBC, high FEP

(E) none of the above

4.
Based on your history, what other tests might be warranted for this child?

(A) Denver II developmental screening

(B) serum lead level

(C) environmental exposure screen

(D) A and B

(E) A, B, and C

5.
Which of the following situations would not warrant a risk-based evaluation for lead poisoning?

(A) patient lives in a house built in 1960

(B) patient has a history of pica

(C) patient has a sibling with history of lead poisoning

(D) patient frequently visits a house built in 1960 that was renovated 4 months ago

(E) A and D

6.
The Centers for Disease Control and Prevention (CDC) recommends universal screening for lead poisoning for all children between 9 and 12 months.

(A) true

(B) false

7.
Which of the following is not an effect of elevated blood lead levels?

(A) colic

(B) nephropathy

(C) advanced pubertal development

(D) encephalopathy

(E) hemolytic anemia

8.
The patient’s lead level is 18 μg/dL. What is the next step?

(A) begin oral chelation therapy

(B) repeat the lead level in 1 week

(C) begin nutritional and environmental counseling

(D) stop the supplemental iron therapy

(E) none of the above

9.
At what lead level should chelation be initiated?

(A) 25 μg/dL

(B) 35 μg/dL

(C) 45 μg/dL

(D) 55 μg/dL

(E) 70 μg/dL

10.
Which of the following is true regarding chelation?

(A) dimethylsuccinic acid (DMSA) is initially given for 21 days

(B) hospitalization for therapy is not required until a level is higher than 75 μg/dL

(C) parenteral agents include DMSA and calcium disodium ethylenediaminetetraacetic acid (EDTA)

(D) calcium disodium EDTA is toxic when given with iron

(E) DMSA side effects include decreased absolute neutrophil count (ANC) and increased liver function tests (LFTs)

11.
Which of the following is not a potential side effect of bronchoalveolar lavage (BAL)?

(A) fever

(B) anaphylaxis

(C) tachycardia

(D) hypotension

(E) salivation

12.
Which of the following is a contraindication to BAL therapy?

(A) iron therapy

(B) renal insufficiency

(C) hepatic insufficiency

(D) G6PD

(E) encephalopathy

13.
Which of the following is not a potential environmental exposure for lead in the United States?

(A) old furniture

(B) food cans

(C) folk remedies

(D) nearby industry

(E) target shooting

14.
According to the second National Health and Nutrition Examination Survey (NHANES II) data, which of the following are independent risk factor for elevated blood lead levels?

(A) poverty

(B) age younger than 6 years

(C) African American ethnicity

(D) dwelling in the city

(E) all of the above

15.
Which of the following is a method of prevention for lead intoxication?

(A) frequent meals

(B) meals with high vitamin C, low calcium

(C) use of a low-phosphate detergent for cleansing

(D) limit iron intake

(E) increase fat in meals

16.
All of the following regarding lead toxicity and postexposure prevention are true except

(A) painting over existing lead-based paint creates only temporary protection

(B) soil coverage with fabric and ground cover limits ground exposure to lead

(C) use of glass and carbon water filters prevents water transmission

(D) use of high-efficiency particulate air (HEPA) vacuum for cleaning is necessary to remove lead from the home

(E) cleaning can temporarily increase the ingestion risk

17.
Which of the following is an indication for cholesterol screening in a child older than 2 years of age?

(A) a grandmother who died of a myocardial infarction (MI) at the age of 60 years

(B) a grandfather with documented hypercholesterolemia

(C) an uncle with an MI at age 45 years

(D) a father with angina at age 45 years

(E) none of the above

18.
Which of the following patients should be immediately screened for TB?

(A) an international adoptee from Thailand

(B) a sibling of an asymptomatic known HIVinfected patient

(C) the child of a mother with a positive PPD and normal chest radiograph treated with a 9-month course of isoniazid

(D) A and C

(E) B and C

19.
Which of the following findings would be considered a developmental delay on the Denver II for a 2-year-old?

(A) inability to wash and dry hands

(B) inability to combine words

(C) inability to kick a ball forward

(D) having half understandable speech

(E) inability to point to 4 pictures

FIGURE 66-1.
A.
The peripheral blood in severe megaloblastic anemia.
B.
The bone marrow in severe megaloblastic anemia. (Reproduced, with permission, from Fauci AS, Kasper DL, Braunwald E, et al. Harrison’s Principles of Internal Medicine, 17th ed. New York: McGraw-Hill; 2008: Fig. 100-2ab.)

ANSWERS

1.
(C)
With his nutritional history and physical symptoms, this patient is at risk for iron-deficiency anemia. A CBC would be beneficial to address an immediate and treatable concern; measuring the hemoglobin and hematocrit alone would not be enough information to diagnose iron deficiency because a high RDW and low MCV, if present, would be strongly suggestive. Both a PPD and lipid screen would be appropriate at this age if the history suggested corresponding risk factors. Echocardiography and a folate-level determination are not routine screening tests based on this patient’s history and clinical examination.

2.
(C)
Folate deficiency is a macrocytic anemia, not a microcytic anemia (see
Figure 66-1
). The remaining 4 disease states can all be associated with microcytic anemia.

3.
(C)
Iron studies can often be used to differentiate the main causes of microcytic anemia. The iron studies in option C are most consistent with lead poisoning, thalassemia trait, and chronic disease. Patients with iron deficiency anemia will also have a low serum iron, unlike thalassemia trait and lead poisoning.

4.
(E)
The given history of development is consistent with developmental delay. To assess this delay, a complete Denver II should be performed. If the patient has 2 or more “delays” on examination, he should be referred for evaluation for services. With developmental delay and microcytic anemia, this patient may have an elevated lead level. Both a serum lead level and an environmental exposure screen are warranted at this time.

5.
(A)
The AAP and CDC recommend screening questions for lead poisoning risk. Children who live in or visit homes built before 1950 or those built before 1978 with renovations in the past 6 months warrant lead screening. Also, if they have any demonstrated pica or siblings/playmates with lead poisoning, they warrant testing.

6.
(B)
False. The CDC recommends universal screening in all high-risk areas based on the prevalence of elevated lead levels. Patients in low-to-moderate risk areas should be tested based on screening criteria given in answer 5.