TDM Examination sample case E
Get familiar with the multiple-choice and short-menu question types you will see on the TDM Examination.
A 3-year-old girl is brought by her father to your clinic because he is worried about his daughter’s 3-month history of lethargy. He reports that she has not been playing with other children like she used to. She has been experiencing abdominal pain from time to time. His daughter has also been fussy about food but consumes a lot of cow’s milk. She enjoys making paper airplanes that she often chews afterwards. Other than indentations in her nails, physical examination findings are normal.
Which one of the following is the most appropriate management? Select 1.
Which of the following measures are most appropriate to address the patient’s condition? Select 2.
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The 3-month history of lethargy with intermittent abdominal pain, fussiness with food but heavy cow’s milk consumption, nail changes (suggesting koilonychia), and chewing nonfood items (paper airplanes) points to iron-deficiency anemia with pica. This is commonly made worse by excessive cow’s milk intake displacing iron-containing foods. An iron supplement directly treats the underlying deficiency and is the most appropriate initial management. Anthelmintic medications are not appropriate because there is no history suggesting parasitic infection (e.g., exposure risks, diarrhea, anal pruritus) as the primary driver. Lactase enzyme supplementation targets lactose intolerance, which would present with bloating, diarrhea, and symptoms tied to dairy. Polyethylene glycol 3350 treats constipation, and while abdominal pain can occur with constipation, it is not the most likely cause when symptoms of lethargy and pica as well as excessive cow’s milk intake are present. Vitamin D supplementation is not necessary in a child with a milk-rich diet because cow’s milk in Canada is fortified with vitamin D, and it would not address the iron deficiency. Restricting gluten would be appropriate in a child with celiac disease presenting with chronic diarrhea, weight or growth issues, or signs of malabsorption—none of which are described in this case.
Powers JM. Iron deficiency in infants and children <12 years: Screening, prevention, clinical manifestations, and diagnosis. UpToDate. Updated January 7, 2026. Accessed January 21, 2026.
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Encouraging iron-rich food supports rebuilding iron stores and complements supplementation, especially in a child who is “fussy about food” and likely has a low-iron diet. Reducing milk intake is also key because high milk consumption can both crowd out iron-rich foods and contribute to iron deficiency; addressing this dietary driver improves long-term correction and reduces recurrence. Encouraging calcium-rich food is not the priority because the problem is not calcium deficiency, and pushing more dairy may worsen the imbalance. Encouraging communication cues, a structured routine, or interaction with other children all target behavioural or developmental concerns (e.g., autism, anxiety) rather than addressing lethargy, pica, and nail changes from iron deficiency. Referral to a developmental pediatrician is less appropriate here because the core presentation is nutritional and hematologic rather than primarily developmental. There are no indicators of neglect or abuse that would warrant reporting the matter to child protection services.