10 year old boy in the 95 Percentile for Weight - Pediatric Board Sample Question Vignette 

You are asked to evaluate a 10-year-old boy who is currently at the 95th%ile for weight and 5th percentile for height. Up until age 7 the child was at the 75th% ile for both weight and height.
He is currently taking no medication and his appetite has not changed. His diet is nutritionally balanced. On physical exam, in addition to marked obesity, you notice several small bruises on his hands and feet.

LABS: WBC- 19.5 45% neutrophils 45% lymphocytes 10% monocytes Na/ 139 K/ 2.5 Cl/105 Bicarb/ 25 Glucose/ 75 Bun/ 19 Cre/ 0.4

Question 1: The most likely explanation for the physical findings in this child is:
A) Prader Willi Syndrome
B) Nutritional obesity
C) Hypothyroid
D) Cushing Syndrome
E) Addison’s Disease

Question 2: Which of the following studies would be most appropriate in establishing a diagnosis?

A) Genetic Karyotyping
B) Renal ultrasound
C) TSH/ T4/ T3
D) Dexamethasone suppression study
E) 17-hydroxyprogesterone level

Here is how you can break down the question and decode it so that you can easily identify what is being asked and how to answer it. Our method takes the guest work out 

Here you can see the patient has a decreased height velocity with increased height aka shorter and fatter. This tells you the child has an endocrine disorder  This reduces it down to 2 choices, hypothyroid and Cushing syndrome. Short and overweight can also be Prader Willi syndrome,  But these children eat a lot and that is not included in the clinical vignette. 

Well you have additional information which practically gives the question away. On your scratch paper you should have written easy bruising , hypokalemia and leukocytosis ( remember to put numbers into words) . The answer is now obvious Cushing syndrome. 

You now have to know how to diagnosis it. If you have been studying you instantly know dexamethasone suppression test is the correct answer. 

That's 2 questions answered correctly and can be the difference between passing and failing the pediatric boards. 

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