Respiratory

A 5-year-old girl developed high fever, ear pain, and vomiting 1 week ago. She was seen in the emergency center, diagnosed with otitis media, and started on amoxicillin-c1avulanate. Her symp¬toms continued, and on the third day of this medication she was seen with persistent findings of otitis media, fever, and pain. She was given a dose of ceftriaxone intramuscularly and switched to oral cefuroxime. After an additional 48, hours she continued to have fever, pain, and no improvement in her otitis media, but oth¬erwise was doing well. The next step in her management is:
A. Tympanocentesis and culture of middle ear fluid
B. High-dose oral amoxicillin
C. Oral trimethoprim-sulfamethoxazole
D. Addition of intranasal topical steroids to the oral cefuroxime
E. Adenoidectomy

A. After failing several antibiotic regimens, tympanocentesis and culture of the middle ear fluid are indicated.

A l-month-old boy has a fever to I02.7°F (39.3°C), is irritable, has diarrhea, and has not been eating well. On physical exami¬nation he has a red tympanic membrane that does not move and has pus behind it. The appropriate course of action is:
A. Oral high-dose amoxicillin
B. Oral amoxicillin-clavulanate
C. Oral cefuroxime
D. Intramuscular ceftriaxone and close out patient follow-up
E. Admission to the hospital with complete sepsis evaluation

E. Children with otitis media at very young age, especially with irritability or lethargy, are at a higher chance of bacteremia or other serious infection. Hospitalization and parenteral antibi¬otics are likely indicated in this child.

A 10-year-old boy presents to you with a history of recurrent si¬nusitis and multiple episodes of pneumonia. You obtain a sweat electrolyte test, and the result is within the normal range. Your differential diagnosis now includes atopy, primary ciliary dys¬kinesia, and:
A. Severe combined immunodeficiency
B. Cystic fibrosis
C. Aspergillosis
D. Chronic granulomatous disease
E. Coccidioidomycosis

B. Because of the possibility of a false negative sweat elec¬trolyte test, cystic fibrosis cannot be ruled out. The test should be repeated and/or consideration given to other diagnostic modalities. Bronchiectasis and chronic sinusitis are characteris¬tic of ciliary dyskinesia syndromes. If associated with visceral situs inversus, the diagnosis of Kartagener disease is given.

A 12-year-old girl with a history of asthma presents to the emer¬gency department with tachypnea, intercostal retractions, and perioral cyanosis. Minimal wheezing is auscultated. You imme¬diately begin administration of oxygen, nebulized albuterol, and 2 mg/kg of intravenous prednisone. Upon reassessment, wheez¬ing increases in all fields, but the child appears slightly more alert and her color has improved. Which of the following is the appropriate explanation for these findings?
A. The girl is not having an asthma attack.
B. The girl is not responding to the albuterol, and her symptoms are worsening .
C. The girl is responding to the albuterol, and her symptoms are improving.
D. She did not receive enough albuterol.
E. The albuterol was inadvertently left out of the nebulizer treatment, and the patient received only saline.

C. This child presented in severe respiratory distress. Her im¬proved color and level of alertness indicate that her asthma at¬tack is reversible. Increased wheezing is auscultated after the initial nebulizer treatment because areas of lung that were “shut down,” that is, obstructed, are now opening allowing additional airflow in those areas. Additional airflow in these areas is now able to produce wheezing. Prior to initiation of treatment wheezing was impossible because an inadequate quantity of air moved through therefore obstructed airways. Unfortunately, less-experienced examiners may misinterpret lack of air move¬ment as “clear” breath sounds, further delaying appropriate medical management.

A 4-month old boy presents to the emergency department on a cold winter night with the complaint of worsening wheezing. He has been receiving nebulized albuterol treatments at home since the age of 2 months for wheezing episodes. The father has given the baby 2 treatments at home prior to arrival in your center, but the baby’s respiratory difficulty has not significantly improved. The father notes that the baby always sounds “congested.” On your primary survey of the child, you note pallor and perioral cyanosis, a respiratory rate of 60 breaths per minute and loud wheezes throughout the chest that obscure the heart sounds. The examination is otherwise unremarkable. The most likely diag¬nosis is:
A. Bronchiolitis
B. Congenital anomaly
C. Cystic fibrosis
D. Gastroesophageal reflux
E. Tracheoesophageal fistula

A. While bronchiolitis is the most frequent diagnosis in a wheezing infant in the winter months, all other choices are pos¬sibilities in this case. Because respiratory infections are so common and many chronic conditions present for the first time in infancy, the differential diagnosis for wheezing is more exten¬sive in a baby than in an older child. Initial treatment in this baby is oxygen, nebulized albuterol, and a stable chest radiograph. Infants with wheezing caused by bronchiolitis do not always respond as well to β- agonists as do older children so failure to respond will not rule out this possibility. Chest radiographs may assist in identification of a congenital anomaly such as congenital heart disease, a vascular ring, or a tracheoesophageal fistula, although often the films may appear deceptively normal in these conditions. A careful history may provide important clues concerning the possibilities of cystic fibrosis and gastroesophageal reflux.

A 15-year-old boy uses his albuterol inhaler shortly after mild feeling of “tightness” in his chest while playing in his friends garden. He is required to return home early from dinner at a friend’s house when about 3 hours later he has the sudden onset of wheezing, persistent cough, and chest pain. The most likely explanation for these circumstances is:
A. He likely aspirated a piece of grass.
B. His albuterol inhaler must be empty.
C. His albuterol inhaler must be outdated.
D. He is having a “late-phase reaction.”
E. He has been exposed to a new allergen that is more irritat¬ing to his immune system than grass.

D. a late phase reaction occurs hours after an initial wheezing episode caused by inflammatory cell accumulation in the airway.

A pregnant woman comes to you for a prenatal visit: As her family pediatrician, your advice to her should include which one of the following information about reducing the risk of SIDS:
A. Reduce the infant’s exposure to prenatal and environmental smoke, and always place the baby in the supine position when she sleeps.
B. Always keep her in the prone position, even while awake.
C. Administer supplemental infant vitamins.
D. Attempt to make breast milk the infant’s primary source of nutrition.
E. Protect the infant from people who are ill.

A. Although your advice to this woman might also include choices C, D, and E, these measures have not been shown to re¬duce the infant’s risk of SIDS.

The investigation of the unexpected death of an infant must in¬clude a clinical history, a postmortem examination, and:
A. DNA studies.
B. An arterial blood gas measurement.
C. A venous blood gas measurement.
D. A death scene investigation.
E. Stool studies.

D. A death scene investigation is crucial to rule out trauma, both intentional and accidental.

A 4-year-old boy presents to the emergency center with nasal drainage for 2 months. His mother has asthma and eczema, otherwise his family history is negative. On examination there is left sided nasal drainage that is foul smelling and blood tinged. It is completely obstructed on that side, but his other nostril is clear without drainage or edema. The next step in managing this patient should be:
A. Nasal steroids and oral antihistamines
B. Computerized tomography of the sinuses
C. Oral antibiotics
D. Otolaryngology evaluation for-possible foreign body
E. Reassurance that his condition is benign and observation only

D. This young patient with unilateral purulent nasal discharge is likely to have a foreign body in his nostril that should be removed as soon as possible. Although a malignancy is possible a foreign body is more likely.

A 4-year-old boy presents with a 3-month history of bilateral purulent nasal drainage. His father reports that he is afebrile and has no other complaints. Your examination reveals several small shiny gray pedunculated masses partially occluding the nasal meatus on both sides. a diagnostic workup should include:
A. Nasal smear for eosinophilia
B. Total immunoglobulin levels
C. Nitroblue tetrazolium (NBT) test
D. Sweat chloride test
E. Complete blood count with peripheral smear

D. While nasal polyps can result from chronic inflammation associated with allergic rhinitis and chronic sinusitis, a child with polyps who is less than 10 to 12 years old should be tested for cystic fibrosis. Approximately 25% of patients with cystic fibrosis have nasal polyps. The child in this case has no other symptoms of cystic fibrosis, but his age and the presence of nasal polyps make testing for cystic fibrosis a priority. Immotile cilia syndrome (Kartagener syndrome: situs inversus, chronic sinusitis and otitis media, and airway disease) is another diagnostic possibility in this patient, but the test to confirm this choice (electron microscopy of cilia) was not listed in the question

5-year-old girl developed high fever, ear pain, and vomiting 1 week ago. She was seen in the emergency center, diagnosed with otitis media, and started on amoxicillin-c1avulanate. Her symp¬toms continued, and on the third day of this medication she was seen with persistent findings of otitis media, fever, and pain. She was given a dose of ceftriaxone intramuscularly and switched to oral cefuroxime. After an additional 48, hours she continued to have fever, pain, and no improvement in her otitis media, but oth¬erwise was doing well. The next step in her management is:
A. Tympanocentesis and culture of middle ear fluid
B. High-dose oral amoxicillin
C. Oral trimethoprim-sulfamethoxazole
D. Addition of intranasal topical steroids to the oral cefuroxime
E. Adenoidectomy

A. After failing several antibiotic regimens, tympanocentesis and culture of the middle ear fluid are indicated.

A l-month-old boy has a fever to I02.7°F (39.3°C), is irritable, has diarrhea, and has not been eating well. On physical exami¬nation he has a red tympanic membrane that does not move and has pus behind it. The appropriate course of action is:
A. Oral high-dose amoxicillin
B. Oral amoxicillin-clavulanate
C. Oral cefuroxime
D. Intramuscular ceftriaxone and close out patient follow-up
E. Admission to the hospital with complete sepsis evaluation

E. Children with otitis media at very young age, especially with irritability or lethargy, are at a higher chance of bacteremia or other serious infection. Hospitalization and parenteral antibi¬otics are likely indicated in this child.

A 10-year-old boy presents to you with a history of recurrent si¬nusitis and multiple episodes of pneumonia. You obtain a sweat electrolyte test, and the result is within the normal range. Your differential diagnosis now includes atopy, primary ciliary dys¬kinesia, and:
A. Severe combined immunodeficiency
B. Cystic fibrosis
C. Aspergillosis
D. Chronic granulomatous disease
E. Coccidioidomycosis

B. Because of the possibility of a false negative sweat elec¬trolyte test, cystic fibrosis cannot be ruled out. The test should be repeated and/or consideration given to other diagnostic modalities. Bronchiectasis and chronic sinusitis are characteris¬tic of ciliary dyskinesia syndromes. If associated with visceral situs inversus, the diagnosis of Kartagener disease is given.

A 12-year-old girl with a history of asthma presents to the emer¬gency department with tachypnea, intercostal retractions, and perioral cyanosis. Minimal wheezing is auscultated. You imme¬diately begin administration of oxygen, nebulized albuterol, and 2 mg/kg of intravenous prednisone. Upon reassessment, wheez¬ing increases in all fields, but the child appears slightly more alert and her color has improved. Which of the following is the appropriate explanation for these findings?
A. The girl is not having an asthma attack.
B. The girl is not responding to the albuterol, and her symptoms are worsening .
C. The girl is responding to the albuterol, and her symptoms are improving.
D. She did not receive enough albuterol.
E. The albuterol was inadvertently left out of the nebulizer treatment, and the patient received only saline.
.

C. This child presented in severe respiratory distress. Her im¬proved color and level of alertness indicate that her asthma at¬tack is reversible. Increased wheezing is auscultated after the initial nebulizer treatment because areas of lung that were “shut down,” that is, obstructed, are now opening allowing additional airflow in those areas. Additional airflow in these areas is now able to produce wheezing. Prior to initiation of treatment wheezing was impossible because an inadequate quantity of air moved through therefore obstructed airways. Unfortunately, less-experienced examiners may misinterpret lack of air move¬ment as “clear” breath sounds, further delaying appropriate medical management

A 4-month old boy presents to the emergency department on a cold winter night with the complaint of worsening wheezing. He has been receiving nebulized albuterol treatments at home since the age of 2 months for wheezing episodes. The father has given the baby 2 treatments at home prior to arrival in your center, but the baby’s respiratory difficulty has not significantly improved. The father notes that the baby always sounds “congested.” On your primary survey of the child, you note pallor and perioral cyanosis, a respiratory rate of 60 breaths per minute and loud wheezes throughout the chest that obscure the heart sounds. The examination is otherwise unremarkable. The most likely diag¬nosis is:
A. Bronchiolitis
B. Congenital anomaly
C. Cystic fibrosis
D. Gastroesophageal reflux
E. Tracheoesophageal fistula

A. While bronchiolitis is the most frequent diagnosis in a wheezing infant in the winter months, all other choices are pos¬sibilities in this case. Because respiratory infections are so common and many chronic conditions present for the first time in infancy, the differential diagnosis for wheezing is more exten¬sive in a baby than in an older child. Initial treatment in this baby is oxygen, nebulized albuterol, and a stable chest radiograph. Infants with wheezing caused by bronchiolitis do not always respond as well to β- agonists as do older children so failure to respond will not rule out this possibility. Chest radiographs may assist in identification of a congenital anomaly such as congenital heart disease, a vascular ring, or a tracheoesophageal fistula, although often the films may appear deceptively normal in these conditions. A careful history may provide important clues concerning the possibilities of cystic fibrosis and gastroesophageal reflux.

A 15-year-old boy uses his albuterol inhaler shortly after mild feeling of “tightness” in his chest while playing in his friends garden. He is required to return home early from dinner at a friend’s house when about 3 hours later he has the sudden onset of wheezing, persistent cough, and chest pain. The most likely explanation for these circumstances is:
A. He likely aspirated a piece of grass.
B. His albuterol inhaler must be empty.
C. His albuterol inhaler must be outdated.
D. He is having a “late-phase reaction.”
E. He has been exposed to a new allergen that is more irritat¬ing to his immune system than grass.

D. a late phase reaction occurs hours after an initial wheezing episode caused by inflammatory cell accumulation in the airway.

A pregnant woman comes to you for a prenatal visit: As her family pediatrician, your advice to her should include which one of the following information about reducing the risk of SIDS:
A. Reduce the infant’s exposure to prenatal and environmental smoke, and always place the baby in the supine position when she sleeps.
B. Always keep her in the prone position, even while awake.
C. Administer supplemental infant vitamins.
D. Attempt to make breast milk the infant’s primary source of nutrition.
E. Protect the infant from people who are ill.

A. Although your advice to this woman might also include choices C, D, and E, these measures have not been shown to re¬duce the infant’s risk of SIDS.

The investigation of the unexpected death of an infant must in¬clude a clinical history, a postmortem examination, and:
A. DNA studies.
B. An arterial blood gas measurement.
C. A venous blood gas measurement.
D. A death scene investigation.
E. Stool studies.

D. A death scene investigation is crucial to rule out trauma, both intentional and accidental.

A 4-year-old boy presents to the emergency center with nasal drainage for 2 months. His mother has asthma and eczema, otherwise his family history is negative. On examination there is left sided nasal drainage that is foul smelling and blood tinged. It is completely obstructed on that side, but his other nostril is clear without drainage or edema. The next step in managing this patient should be:
A. Nasal steroids and oral antihistamines
B. Computerized tomography of the sinuses
C. Oral antibiotics
D. Otolaryngology evaluation for-possible foreign body
E. Reassurance that his condition is benign and observation only

D. This young patient with unilateral purulent nasal discharge is likely to have a foreign body in his nostril that should be removed as soon as possible. Although a malignancy is possible a foreign body is more likely.

A 4-year-old boy presents with a 3-month history of bilateral purulent nasal drainage. His father reports that he is afebrile and has no other complaints. Your examination reveals several small shiny gray pedunculated masses partially occluding the nasal meatus on both sides. a diagnostic workup should include:
A. Nasal smear for eosinophilia
B. Total immunoglobulin levels
C. Nitroblue tetrazolium (NBT) test
D. Sweat chloride test
E. Complete blood count with peripheral smear

D. While nasal polyps can result from chronic inflammation associated with allergic rhinitis and chronic sinusitis, a child with polyps who is less than 10 to 12 years old should be tested for cystic fibrosis. Approximately 25% of patients with cystic fibrosis have nasal polyps. The child in this case has no other symptoms of cystic fibrosis, but his age and the presence of nasal polyps make testing for cystic fibrosis a priority. Immotile cilia syndrome (Kartagener syndrome: situs inversus, chronic sinusitis and otitis media, and airway disease) is another diagnostic possibility in this patient, but the test to confirm this choice (electron microscopy of cilia) was not listed in the question.

A 10-year-old girl complains of 5 months of left-sided nasal con¬gestion. She has tried decongestants and antihistamines without success. She denies placing any object in her nose. Her mother brought her in today because she noticed increasing swelling and tenderness over the left side of her face. Her examination reveals a pink, nontender, fleshy mass in her left nares that is completely occluding the airway. Initial management should include:
A. Sweat chloride test
B. Nasal steroids with antihistamines
C. Computerized tomography of the face
D. Foreign-body removal with alligator forceps
E. Reassurance and observation

C. Rhabdomyosarcoma is the most common pediatric soft tissue sarcoma, and the head and neck location accounts for approximately half of these tumors. Rhabdomyosarcoma typically present as a mass that is sometimes tender, causing symptoms relating to the displacement of normal structures. When arising from nasal tissue, Rhabdomyosarcoma can obstruct the nares and extend into the skull, causing cranial nerve involvement. The first logical step in evaluating such a patient is a computerized tomography or magnetic resonance imaging scan to determine the size and location of the tumor. A Rhabdomyosarcoma that is completely respectable has the best prognosis.

A fully immunized 14-year-old boy complains of fever and stiff neck for 2 days. He also complains of a sore throat, and has not been able to eat anything for 1 day because of the pain. On phys¬ical examination he is alert and oriented, but he has nuchal rigidity and midline fullness in the posterior oropharynx. He is drooling to avoid the pain associated with swallowing. The next step in managing this patient is to:
A. Order computerized tomography of the head
B. Perform a lumbar puncture
C. Order lateral neck radiographs
D. Prescribe intravenous antibiotics
E. Prescribe intramuscular antibiotics

C. This boy has a retropharyngeal abscess causing his neck stiff¬ness; he does not have meningitis. He has a normal mental sta¬tus, dysphagia, and fullness in his oropharynx. Lateral neck films are a simple way to confirm this diagnosis.

A 7-year-old boy presents to the emergency department with a chief complaint of right-sided abdominal pain and fever to 102°F (38.9°C). His mother reports that he has had poor ap¬petite and a cough for 2 days, and he had two loose bowel movements earlier on the day of presentation. On physical ex¬amination, he has a temperature of 101. 7°F (38.7°C), his heart rate is 120 beats per minute, and his respiratory rate is 50 breaths per minute. Breath sounds are diminished, and the ab-domen is diffusely tense with hypoactive bowel sounds. His ex¬amination is otherwise normal. The initial, diagnostic work-up should include:
A. Chest radiograph
B. Stool leukocytes
C. Stool for culture, ova, and parasites
D. Liver function tests
E. Abdominal computerized tomography

A. Pneumonia in the lower lobes can cause abdominal pain, which may be the most distressing symptom in a young pa¬tient. This child has cough, fever, tachypnea, and diminished breath sounds, which together make pneumonia the most likely Diagnosis

A 4-year-old girl presents to the emergency department with fever of 102.4°F (39.1 °C), difficulty swallowing, vomiting and abdominal pain. The diagnostic test that is most likely to yield the appropriate diagnosis is:
A. A streptococcal antigen test (“rapid strep test”).
B. An antigen test for Epstein-Barr virus (“monospot”).
C. A lateral neck radiograph.
D. An abdominal ultrasonograph.
E. A complete blood count

A. This child’s symptoms are most consistent with a diagnosis of streptococcal throat infection. In addition to throat pain and fever, acute infec¬tion with Group A streptococcus commonly causes abdominal pain and emesis in children.

A 2-year-old child presents to the emergency department with the complaint of sudden onset of inspiratory stridor, tachypnea, and chest retractions. He had been playing with his 6-year-old brother before this episode. He is afebrile. Apart from the stri¬dor, his lung sounds are clear, and his physical examination is otherwise normal. A chest radiograph reveals no abnormalities. What is the next best step in management of this child?
A. Administer aerosolized racemic epinephrine.
B. Administer oral dexamethasone.
C. Evaluate the airway with bronchoscopy.
D. Administer parenteral antibiotics.
E. Perform nasotracheal intubation.

C. Children younger than age 3 years commonly put nonfood ob¬jects into their mouths. In this child with no cough, fever, or cold symptoms, a history of sudden onset of stridor, and no ill con¬tacts, foreign-body aspiration is a strong diagnostic possibility. Many objects (e.g., an older sibling’s plastic toy) are radiolucent and thus will not be visible on radiographs. Bronchoscopy is both diagnostic and therapeutic in these cases. Alternatively, in¬spiratory and expiratory routine chest radiographs can be help¬ful: a normal inspiratory film with unilateral hyperexpansion on the expiratory film may indicate air trapping on the hyperinflated side as a consequence of obstruction of a bronchus.

A 2-year-old boy with a 3-day history of upper respiratory con¬gestion and cough now has inspiratory stridor, a respiratory rate of 50 breaths per minute, chest retractions, and a fever of 101 F (38.3°C). The therapies most likely to ameliorate his current symptoms are:
A. Pseudoephedrine and dextromethorphan
B. Albuterol and cromolyn
C. Ampicillin and gentamicin
D. Cool mist and herbs
E. Aerosolized racemic epinephrine, and dexamethasone

E. Aerosolized epinephrine and steroids are the only therapies that significantly improve symptoms of croup. steroids also reduce hospital admissions, length of hospital stay, and hospital re-attendance.

A 6-month-old infant has been growing poorly. His parents have changed his formula three times, but he continues to grow poorly. His physical examination is remarkable for a pale, emaciated child with little subcutaneous fat and fullness to his anterior fontanelle. His laboratory screening tests are notable for a he¬molytic anemia and prolonged bleeding times. Which of the fol¬lowing laboratory tests is an appropriate next step to diagnose his condition?
A. Serum factor IX levels
B. Urine for pH and electrolytes
C. Serum immunoglobulin
D. Sweat chloride
E. Hemoglobin electrophoresis

D. The patient appears to have failure to thrive (FTT) with defi¬ciencies of vitamin K (bleeding problems), vitamin A (fullness to fontanelle), and vitamin E (hemolytic anemia). Cystic fibrosis (associated with malabsorption of these vitamins) would explain the condition

The diet of a 3-year-old child with cystic fibrosis should be sup-plemented with:
A. Vitamin C
B. Folate
C. Vitamin B 12
D. Sodium
E. Vitamin D

E. In addition to pancreatic enzyme replacement therapy supplementation with fat-soluble vitamins (A, D, E. and K) often iron and sometimes zinc is recommended.

A 2-year-old girl presents to the office with the complaint of acute onset of wheezing. Her mother reports that she has never wheezed before, and states that their family history is negative for asthma and atopy. The mother says that she left the child playing in her older brother’s room and approximately 20 min¬utes later was alerted by the sound of the child coughing and wheezing. The girl has been healthy recently except for a slight runny nose. The best next step includes:
A. Determining what the girl was playing with and ordering a chest radiograph
B. Referring the child to a pulmonologist
C. Prescribing antibiotics for a likely pneumonia
D. Administering an injection of intramuscular prednisone and sending her home
E. Accusing the mother of poor supervision of her child’s health, as this is obviously not the first time that the child has had these symptoms

A. The most likely diagnosis in this case is foreign-body aspira¬tion. Young children, generally between the ages of 4 months and 3 years, are particularly prone to putting objects into their mouths. Oral exploration is a normal part of development, but can be a significant cause of morbidity. A pulmonologist may ultimately be needed to retrieve the object, but this would not be a first step

A 16-year-old girl arrives to your office as a new patient com¬plaining of monthly upper respiratory tract infections over the last few years. She said her last doctor would always prescribe antibiotics, and she would eventually improve. She complains of clear nasal drainage with congestion, itchy eyes, itchy nose, and cough: The next step in managing this patient should be:
A. Nasal steroids and oral antihistamines
B. Computerized tomography of the sinuses
C. Oral antibiotics
D. Evaluation for possible foreign body
E. Reassurance that her condition is benign and observation only

A. This patient has a classic history for allergic rhinitis. Patient frequently are told they have recurrent colds when in fact the¬y have allergic symptoms. Although occasionally difficult to distinguish, a careful history and physical will usually distinguish allergic rhinitis from other causes of rhinitis.

An 8-year-old child arrives in the emergency room with his parents complaining of persistent fever and headaches. Her parents report that for the 2 weeks prior she has complained of her frontal headache, recently significant enough to keep her out of school. Her parents also note intermittent temperature elevation 101 F (38.3°C). She started vomiting a nonbloody, nonbilious fluid a few days prior to arrival. The family has no history of headache or migraine. Her past medical history is significant for frequent episodes of otitis media and sinusitis, with the last episode of otitis media about 5 weeks ago. On physical examination you find a lethargic girl who appears to be in no respira¬tory distress. She has a temperature of l00°F (37.7°C) rate of 109 beats per minute, and a blood pressure 100/60 mmHg. She has nuchal rigidity and frontal sinus tenderness. The next step in managing this patient is:
A. Computerized tomography of the head
B. Intravenous promethazine for emesis
C. Trial of subcutaneous sumatriptan for migraine
D. Sinus radiographs
E. Lumbar puncture

A. This girl has a history of sinusitis and a prolonged headache with worsening emesis and nuchal rigidity. She likely has an in¬tracranial abscess as a complication of her sinusitis. In this in¬stance, imaging (preferably with contrast) is performed prior to a lumbar puncture; performing a lumbar puncture in a patient such as this who may have a mass lesion causing increased in¬tracranial pressure can result in herniation of the brain and death of the patient

A 4-year-old boy presents with torticollis, fever, and a sore throat. He complains of difficulty swallowing but has not been drooling. He denies headache and dyspnea and has continued to be playful. Physical examination reveals edema of the right pos¬terior pharynx. The best next step in management is to:
A. Examine his cerebrospinal fluid.
B. Obtain imaging studies of the airway and soft tissues of the neck.
C. Send a throat culture and begin antibiotic therapy based on the results of the culture.
D. Begin oral penicillin.
E. Prescribe ibuprofen and neck stretching exercises.

B. This child has signs and symptoms of having a retropharyn¬geal cellulitis or abscess. Patients with retropharyngeal abscess may have dysphagia, drooling, stiff neck, dyspnea, or airway stridor. Physical finding include a midline or unilateral swelling which may progress to become a fluctuant mass. Management includes antibiotic therapy and incision and drainage of the abscess. Computerized tomography sometimes is helpful in early identification of abscess formation.

A 14-month-old girl presents to the emergency department with a 6-hour history of fever to 102.6°F (39.2°C) and an increas¬ingly ill appearance. She appears very anxious and does not want to leave her mother’s arms, but she gives only a faint cry when approached. Her respiratory rate is 70 breaths per minute, with chest retractions and inspiratory stridor. A spot of moisture is noted on the shoulder of the mother’s blouse. What is the next most appropriate step in management of this child?
A. Perform a complete physical examination with Particular emphasis on examination of the mouth and upper airway.
B. Secure the airway in the emergency department with an endotracheal tube.
C. Secure the airway in the operating room via tracheal intubation or tracheostomy.
D. Administer aerosolized racemic epinephrine and budes¬onide (nebulized steroids).
E. Obtain blood, urine, and cerebrospinal cultures and begin parenteral antibiotics.

C. This child’s clinical picture is most consistent with epiglotti¬tis. This is a medical emergency. She must be kept calm and immediately transported to an operating room where the airway can be examined and secured by a surgeon who is skilled in both tracheal intubation and tracheostomy. An attempt at visualizing the pharynx may lead to complete airway obstruction. Clini¬cians who care for children must remember that even though epiglottitis is now rare due to routine vaccination against Haemophilus influenzae type B, it is occasionally seen in hy¬poimmunized children, or a result of infection with Strepto¬coccus pyogenes, S. pneumoniae or Staphylococcus aureus.

A previously well 1-year-old infant has had a runny nose and has been sneezing and coughing for 2 days. Two other members of the family-had similar symptoms. Four hours ago, his cough became much worse. On physical examination, he is in moderate respiratory distress with nasal flar¬ing, hyperexpansion of the chest, and easily audible wheezing without rales. Which of the following is the most likely diagnosis?
a. Bronchiolitis
b. Viral croup
c. Asthma
d. Epiglottitis
e. Diphtheria

The answer is a. Of the choices given, bronchiolitis is the most likely, although asthma, pertussis, and bronchopneumonia can present similarly. The family history of upper respiratory infections, the previous upper respiratory illness in the patient, and signs of intrathoracic airway obstruction make the diagnosis of bronchiolitis more likely. Viral croup, epiglottitis, and diphtheria are not reasonable choices because there are no signs of extrathoracic airway obstruction. The most likely cause of the illness is infection by respiratory syncytial virus, which causes outbreaks of bronchiolitis of varying severity, usually in the winter and spring. Other viruses, such as parainfluenza and the adenoviruses, have also been implicated in producing bronchiolitis. Treatment is generally supportive in this usually self-limited condition.

You are asked to evaluate an infant born vaginally three hours previously to a mother whose only pregnancy complication was poorly con¬trolled gestational diabetes. The nursing staff noticed that the infant was breathing abnormally. On examination, you find that the infant is cyanotic, has irregular, labored breathing, and has decreased breath sounds on the right side. You also note decreased tone in the right arm. You provide oxy¬gen and order a stat portable chest radiograph, which is normal. Which of the following students is most likely to confirm your diagnosis?
a. Nasal wash for viral culture
b. Fiberoptic bronchoscopy
c. Chest CT
d. Chest ultrasound
e. Induced sputum culture

The answer is d. Infants born to mothers with gestational diabetes are at risk for being large for their gestational age and thus at increased risk for peripheral nerve injuries such as Erb-Duchenne and phrenic nerve paralysis. An ultrasound or fluoroscopy of the chest would reveal asymmetric diaphragmatic motion in a seesaw manner. With a negative chest radiograph, a chest CT would not be help¬ful at this point. Bronchoscopy would help delineate airway abnormalities and foreign bodies, but would not identify phrenic nerve paralysis.

A 10-month-old infant has poor weight gain, a persistent cough, and a history of several bouts of pneumonitis. The mother describes the child as having very large, foul-smelling stools for months. Which of the follow¬ing diagnostic maneuvers is likely to result in the correct diagnosis of this child?
a. CT of the chest
h. Serum immunoglobulins
c. TB skin test
d. Inspiratory and expiratory chest x-ray
e. Sweat chloride test

The answer is e. Cystic fibrosis (CF) is a multisystem disease caused by an abnormally functioning cystic fibrosis transmembrane regu¬lator (CFTR) protein. Abnormal secretions are produced as a result of decreased permeability of ionized chloride in the secretory epithelium of a number of organs. Progressive lung failure is caused by accumulation of viscid secretions that obstruct the airway and lead to infection, bronchiectasis, and inflammatory changes. Survival has improved markedly during the past few decades as a result of prompt recognition of CF and aggressive treatment; the median age at death has increased from less than 10 years to more than 30 years. Therapeutic approaches have included inhalation therapy, chest physical therapy, aggressive antibiotic administration, bronchodilators, oxygen, and nutritional support. Heart-lung transplants have prolonged life and improved qualify of life for some terminal patients. Sev¬eral new approaches to the treatment of CF have been proposed, namely, the use of amiloride, recombinant DNAase, and gene therapy. The rationale for these therapeutic modalities is that they focus directly on ameliorating or correcting the basic deficit: amiloride by inhibiting sodium, and with it water reabsorption, thereby improving airway hydration; DNAase by reacting with DNA released by dead leukocytes to reduce sputum viscosity; and gene therapy by altering genetic material. Lung cancer does not appear to be associated with cystic fibrosis.
Unlike many other tests, there is almost no overlap in chloride values in sweat between patients with cystic fibrosis and normal control partici-pants. A chloride concentration of greater than 60 meq/L is diagnostic, val¬ues less than 40 are normal, and values between 40 and 60 are intermediate. Genetic studies that assay for about 30 of the most common mutations known to cause CF are available. A number of states have included a test for immunoreactive trypsinogen in their newborn screening programs, and when combined with confirmatory testing, the sensitivity has been re¬ported to be as high as 95%.
Conditions other than cystic fibrosis can manifest an elevated sweat chloride, including adrenal insufficiency, ectodermal dysplasia, nephrogenic diabetes insipidus, hypothyroidism. and malnutrition.

A 2-year-old girl is playing in the garage, only partially supervised by her father. He finds her in the garage, gagging and vomiting. She smells of gaso¬line. In a few minutes she stops vomiting, but later that day she develops cough, tachypnea, and subcostal retractions. She is brought to your emer¬gency center. Which of the following is the most appropriate first step in management?
a. Administer charcoal
b. Begin nasogastric lavage
c. Administer ipecac
d. Perform pulse oximetry and arterial blood gas
e. Administer gasoline binding agent intravenously .. .

The answer is d. Hydrocarbons with low viscosity and high volatil¬ity are the most likely agents to cause respiratory symptoms. Gasoline, kerosene, and furniture polish (which contain hydrocarbons) are common agents responsible for hydrocarbon aspiration. Hydrocarbon aspiration can produce dyspnea, cyanosis, and respiratory failure. Treatment is sympto-matic, sometimes requiring intubation and mechanical ventilation. Induc-tion of emesis is contraindicated, as this may cause” further aspiration. Placement of a nasogastric tube is used only in high-volume ingestions or when the hydrocarbon is mixed with another toxin. Charcoal is not useful, and no intravenous binding agent is available.