The parents of a 6-week-old male infant bring in their son for evaluation of noisy breathing of 2
weeks’ duration. They state that the vaginal delivery was uncomplicated and the infant has been
bottle-feeding with appropriate weight gain on a cow milk formula. The noise occurs during
inspiration and worsens when the infant is placed supine or cries. The parents have not noticed
any rhinorrhea, fever, or other symptoms consistent with an upper respiratory tract infection.
A. airway foreign body
B. gastroesophageal reflux
C. laryngomalacia
D. milk protein allergy
E. vascular ring
Answer :
C
Laryngomalacia is the most common congenital laryngeal abnormality resulting in stridor.
Symptoms may begin shortly after birth, although typically they occur between 1 and 2 months of age.
As described for the boy in the vignette, infants are happy, thriving, and not having difficulty during feedings, but stridor usually worsens during supine positioning, increased crying or agitation, or a viral illness
. Direct viewing of a
n omega-shaped epiglottis that prolapses during inspiration is a hallmark of the condition.
Severe cases may require surgical correction, although most children spontaneously improve by the second postnatal year.
Extrinsic compression of the trachea by vascular anomalies such as a vascular ring can result in
recurrent wheezing that is worsened with crying, feeding, or neck flexion.
The rightsided ortic arch with left ligamentum arteriosum and the double aortic arch account for most
cases.
The presence of
inspiratory stridor for this infant, rather than expiratory wheezing, makes a vascular ring unlikely.
Milk protein allergy is an immunoglobulin E-mediated food allergy that is the most common food allergy in the first year after birth.
Approximately 80% to 90% of affected children present with cutaneous symptoms (eg, eczema, urticaria, flushing, perioral rash), and the absence of skin symptoms for this infant makes milk allergy unlikely.
The more common adverse reaction to cow milk occurring within the first 3 postnatal months is milk protein enterocolitis, which typically results in hematochezia.
Gastroesophageal reflux (GER) is extremely common in infants younger than 6 months of age.
Typical symptoms can include choking, gagging, irritability, arching, and vomiting. In addition, supine and side positions result in increased GER more than prone positioning.
A foreign body lodged in the upper airway proximal to the glottis opening could result in inspiratory stridor.
However, a foreign body typically is reported in older children who inadvertently swallow the object. Although not present in all cases, a history of coughing, choking, or airway obstruction frequently is reported at the time of aspiration. Radiography or bronchoscopy often is required for definitive diagnosis.
A key approach to evaluating stridor or wheezing is to determine if the symptoms are localized or diffuse.
Localized wheezing may be due to a foreign body, vascular ring, or tracheomalacia; diffuse or migratory
wheezing can occur during a viral infection, GER, or an asthma exacerbation.
---------------------------------------
Q 2:
A 1-year-old boy presents with a 2-month history of "wet" coughing. He was delivered at term but had delayed passage of meconium due to a meconium plug. Over the past 3 to 6 months, he has been treated each month for acute otitis media. His parents are concerned that, despite a good appetite, their son has been losing weight and has four to six loose, foul-smelling stools per day.
Of the following, the MOST appropriate next test or study is
A. 24-hour pH probe monitoring
B. pulmonary function testing
C. serum immunoglobulins (IgG, IgA, and IgM)
D. sweat chloride measurement
E. tuberculin skin test
Answer :
D
An infant or toddler who presents with loose, foul-smelling stools; poor weight gain; and recurrent ear, sinus, or lung infections, as described for the boy in the vignette, should be evaluated for cystic fibrosis.
The classic initial screening for cystic fibrosis is measurement of sweat chloride via the quantitative pilocarpine iontophoresis test.
Values of 60 mmol/L or greater are consistent with cystic fibrosis and should be repeated at least once, 1 month after the first test.
Chronic cough or poor weight gain may represent extraesophageal manifestations of gastroesophageal reflux disease (GERD), although the more common symptoms of vomiting or epigastric pain are not present in this child.
If GERD is suspected, intraesophageal pH probe monitoring can aid in determining the frequency of reflux.
One index, termed the reflux index, is considered consistent for GERD if the pH is less than 4.0 more than 12% of the time in children older than 1 year or more than 6% of the time in children younger than 1 year of age.
Primary humoral immunodeficiency (eg, Bruton agammaglobulinemia, common variable immunodeficiency), transient hypogammaglobulinemia of infancy, or secondary immunodeficiency due to protein-losing states may present in infancy with
diarrhea and recurrent infections.
Common variable immunodeficiency also has pulmonary manifestations (eg, bronchiectasis) similar to those of cystic fibrosis. However, the diarrhea is due to viral or bacterial infections, in contrast to the fat malabsorption in cystic fibrosis.
Assessment of immunoglobulin G, A, and M concentrations may be warranted for this child, but the initial
presentation, coupled with the foul-smelling stools and poor weight gain, make cystic fibrosis more likely.
Tuberculosis may present with chronic cough, poor weight gain, fever, and decreased energy.
Common risk factors for children include foreign travel, association with a person(s) who has tuberculosis, or growing up in an area that has high tuberculosis prevalence.
Although the Mantoux purified protein derivative is used as a screening tool for latent tuberculosis
infection,
the gold standard for diagnosing pulmonary tuberculosis is identification of the organism from respiratory tract specimens.
Pulmonary function testing is used to measure inspiratory and expiratory airflow.
Three patterns typically are identified: normal, obstructive, and restrictive.
Patients who have cystic fibrosis or moderate-to-severe asthma generally have obstructive lung disease.
Measuring lung function for the child in the vignette would be helpful, but children typically are not able to
perform the coordinated expiration and inspiration required for pulmonary function testing until
5 to 7 years of age.
When evaluating a chronic cough in a child, a thorough history and physical examination often suggest the most likely diagnosis.
-------------------------------
Q3 :
6-month-old boy presents with a cough and rhinorrhea of several days’ duration. His parents deny that he has a fever but report constant “noisy breathing” that does not seem to change with position since birth. The boy is alert and has normal findings on physical examination except for mild stridor. Nasal suctioning elicits a very weak and ineffective cough. Of the following underlying conditions, the MOST likely reason for why this child’s cough is weak is
A. cerebral palsy
B. cystic fibrosis
C. laryngomalacia
D. ribcage abnormality
E. vocal cord paralysis
Answer :
E
The boy described in the vignette has had noisy breathing since birth that does not change with position. This finding is very suggestive of vocal cord paralysis. Unilateral paralysis often causes a hoarse cry and mild stridor; bilateral paralysis causes stridor and respiratory distress. Vocal cord paralysis can be congenital, due to neurologic or cardiac abnormalities, or acquired after trauma or infections. Children who have vocal cord paralysis often exhibit a weak cough because of paralysis of the lateral cricoarytenoid and arytenoid muscles.
-----------------------
Q 4:
An
8-month-old child who has bronchopulmonary dysplasia and chronic hypercapnia
presents to the emergency department with a fever. The child has a mild cough,
congestion, and rhinorrhea consistent with a viral upper respiratory tract
infection. He is awake, alert, and interactive, with a respiratory rate of 42
breaths/min. After he is placed in a room, the nurse disconnects him from his
portable oxygen tank, places a nonrebreather mask with reservoir over his face,
and connects the apparatus to the hospital oxygen source. Thirty minutes later,
you find the child barely responsive, with a respiratory rate of 10 breaths/min.
Of
the following, the MOST likely reason for this child's respiratory failure is:
A. congestive
heart failure
B. excessive
inspired concentration of oxygen
C. occult
pneumonia
D. respiratory
muscle fatigue
E.
upper
airway obstruction
Answer :
B
The
patient described in the vignette is hypoventilating because of an excessive
inspired concentration of oxygen. Patients who have some forms of chronic
pulmonary disease (eg, bronchopulmonary dysplasia [BPD]), often have some
degree of carbon dioxide retention and depend on their hypoxemic respiratory
drive to maintain adequate ventilation. Thus, they may hypoventilate if too
high a concentration of oxygen is administered to them, although in practice,
this is a rare occurrence.
The
rapid onset of respiratory failure reported for the child in the vignette makes
either pneumonia or congestive heart failure highly unlikely. Further,
respiratory muscle fatigue would be unusual in a child whose respiratory rate
was normal and who showed no signs of respiratory distress during the initial
physical examination. An upper airway obstruction usually is recognized
immediately as the patient makes efforts to re-establish an airway.
----------------
Q5 :
You
are seeing a 2-year-old child in the office for a recheck visit after a local
emergency department physician diagnosed sinusitis. She has continued to have
symptoms of unilateral purulent nasal discharge and fetid breath. She has not
responded to a 10-day course of amoxicillin therapy.
Of
the following, the MOST likely cause of her nasal symptoms is:
A. antimicrobial-resistant
sinusitis
B. nasal
foreign body
C. recurrent
sinusitis
D. seasonal
allergic rhinitis
E.
viral
upper respiratory tract infection
Answer :
B
The
unilateral purulent nasal discharge and fetid breath described for the child in
the vignette are strongly suggestive of the presence of a nasal foreign body
rather than an episode of sinusitis.
With
antimicrobial-resistant sinusitis, the discharge would be expected to be
bilateral, and because the symptoms never resolved, recurrent sinusitis is not
a possibility. Seasonal allergic rhinitis is not characterized by these types
of symptoms and would be extremely uncommon in a 2-year-old child. A viral
upper respiratory tract infection usually is associated with bilateral clear
nasal discharge.
Children,
especially younger than age 2 years, commonly place objects in their nares.
Frequently it is difficult to discern the objects on routine inspection,
although unilateral discharge is highly suggestive of the diagnosis.
Occasionally, a radiograph may be helpful in identifying a radiopaque foreign
body, if it cannot be seen on physical examination. Proper evaluation of a
suspected foreign body includes rhinoscopy with administration of a topical
decongestant to decrease the localized swelling so that the foreign body can be
visualized and then removed.
----------------------------
Q6 :
A
6-year-old boy who presented to the local emergency department for treatment of
status asthmaticus is being admitted to the pediatric ward. The emergency
department attending physician tells you that the patient's capillary blood gas
revealed a pH of 7.46 and Pco2 of 34 mm Hg, and the pulse oximetry reading was
94%. The patient has a respiratory rate of 50 breaths/min and diffuse wheezing.
He is admitted for further treatment with beta agonists and corticosteroids.
Of
the following, oxygen therapy should be initiated for this patient:
A. after
measuring the arterial blood gas concentrations
B. only
if respiratory distress increases
C. only
if the oxygen saturation falls below 92%
D. to
maintain an oxygen saturation of 100%
E. until the respiratory rate improves
Answer :
E
The
child described in the vignette is presenting with a significant exacerbation
of his reactive airway disease. Data obtained from sampling the capillary blood
gas demonstrate that the patient still is ventilating well. This information is
gleaned from the finding of a low Pco2, which would be expected in a person who
has an increased respiratory rate, and the compensatory elevated pH that
documents a respiratory alkalosis. The pulse oximetry reading of 94%
demonstrates reasonable oxygenation. However, the capillary blood gas is a poor
method of determining oxygen saturation because it is obtained after the blood
already has begun to go through the tissues.
Because oxygen has virtually no adverse effects, its use is recommended in
affected children, such as the boy described in the vignette.
Oxygen
therapy should be administered until the patient’s respiratory rate improves.
There is no reason to maintain an oxygen saturation of 100%, and it is
inappropriate to wait until the oxygen saturation falls below 92% in a patient
who is showing signs of respiratory distress. It is not appropriate to wait
until existing respiratory distress worsens before beginning oxygen
administration.
Routine
measurement of arterial blood gases is not recommended because such evaluations
are associated with complications and are quite painful, and changes in oxygen
saturation can be monitored via pulse oximetry.
The
illustrated oxygen saturation curve demonstrates that Pao2 can vary greatly,
depending on the patient’s pH. A patient who is experiencing a moderately
severe exacerbation of asthma would have an elevated pH, which would shift the
curve up and to the left, giving a falsely elevated value. In contrast, a
severe exacerbation with an acidotic pH would result in a shift down and to the
right, obscuring a lower Pao2.
Routine
measurement of arterial blood gases is not recommended because such evaluations
are associated with complications and are quite painful, and changes in oxygen
saturation can be monitored via pulse oximetry.
-------------------------------
Q 7 :
A
5-year-old boy presents with a 14-day history of purulent rhinorrhea, facial
pain, and cough. Physical examination reveals bilateral purulent rhinorrhea.
Of
the following, the MOST appropriate treatment is:
A. amoxicillin
B. azithromycin
C. hydroxyzine
D. oxymetazoline
E. pseudoephedrine
Answer :
A
Acute
bacterial sinusitis and URIs share many of the same clinical symptoms, the most
common of which are nasal congestion and rhinorrhea. Purulent rhinorrhea does
not distinguish a simple URI from acute sinusitis. Postnasal discharge, cough,
facial pain and pressure, malodorous breath, headache, and facial swelling are
common symptoms of sinusitis. Nasal congestion with erythematous mucosa and
purulent exudate are more consistent with infection; edema, clear secretions,
and pale mucosa are more consistent with an allergic etiology.
However,
symptoms alone do not reliably differentiate a simple URI from acute sinusitis.
The differentiation should be based on either severity or duration of symptoms.
Persistent or worsening symptoms beyond 10 days’ duration, as described for the
boy in the vignette, are predictive of acute sinusitis. Patients whose symptoms
decrease by 10 days may be treated symptomatically. Subacute sinusitis is
defined by a duration of more than 30 days, and chronic sinusitis is defined as
symptom duration beyond 3 months. The less common presentation of acute
sinusitis in children is an unusually severe URI, which may manifest as very
high fever (>102.2ºF [39ºC]), marked purulent rhinorrhea, or an unusually
toxic appearance. Although fever is common with URI, it is usually low grade
and resolves a few days after the onset of illness.
Acute sinusitis typically is diagnosed by
clinical criteria.
Radiographs
are not commonly recommended, but an occipitomental (Waters) radiograph of the
sinuses, which demonstrates the maxillary and ethmoid sinuses, is the best
single view for evaluation. It may be supplemented with lateral and
posteroanterior views for evaluation of the sphenoid sinus. Findings on plain
films of greater than 4 mm of mucosal thickening, an air fluid level, or
complete opacification are associated with bacterial sinusitis in
up to 75% of symptomatic patients. Sinus radiography is unreliable in infants
younger than 1 year of age. Unfortunately, false-positive and false-negative
results are common.
Computed
tomography (CT) of the sinuses provides the best anatomic detail and may
identify abnormalities not noted on plain films. CT scans rarely are indicated
for evaluation of acute sinusitis, but are important for patients who have
chronic sinusitis and for surgical planning.
Amoxicillin 80
mg/kg per day remains the drug of choice for acute sinusitis. This high dose
covers most intermediately resistant S pneumoniae. Alternatives include amoxicillin-clavulanate,
cefprozil, cefuroxime axetil, cefixime, cefpodoxime, loracarbef, and
clarithromycin.
----------------------
Q 8:
A
10-year-old boy who has cystic fibrosis presents with the sudden onset of sharp
chest pain and tachypnea.
Of
the following, the MOST likely cause of respiratory distress in this patient is:
A. atelectasis
B. lung
abscess
C. pneumonia
D. pneumothorax
E.
pulmonary
hemorrhage
Answer :
D
The
major life-threatening complications of cystic fibrosis (CF) are pneumothorax
and hemoptysis. These complications are usually seen in patients whose lung
disease is advanced, often in association with an acute exacerbation.
Pneumothorax usually presents as the sudden onset of sharp chest pain in a
patient who has a severe exacerbation of pulmonary disease. Rapid respiratory
decompensation can take place because of existing lung disease.
-------
Q 9
A
3-month-old boy, who has had repair of a tracheoesophageal fistula at 1 week of
age, is experiencing expiratory stridor and intermittent apnea.
Of
the following, the test that would be MOST helpful to confirm the diagnosis is:
A. barium
swallow to demonstrate recurrent tracheo-esophageal fistula
B. computed
tomography of the chest to rule out mediastinal abscess
C. esophagoscopy
to assess for gastroesophageal reflux
D. flexible
bronchoscopy to demonstrate tracheomalacia
E. magnetic
resonance imaging of the brain to evaluate for Arnold-Chiari malformation
Answer
D
The
diagnostic procedure of choice to evaluate tracheomalacia is airway endoscopy,
which usually is performed with a flexible endoscope, but may be undertaken
with a rigid ventilating bronchoscope. Airway endoscopy reveals classic
anterior-posterior collapse of the airway with exhalation in patients who have
tracheomalacia. This procedure is also used to diagnose laryngomalacia,
subglottic and tracheal stenosis, webs, and masses.
Tracheal
narrowing on a lateral chest radiograph cannot exclude tracheal stenosis.
Airway fluoroscopy demonstrates anterior-posterior collapse of the tracheal
airway, but it is less reliable in ruling out laryngomalacia. When performed
with a barium swallow (Figure 58A), vascular rings can be seen as an
indentation of the posterior wall of the esophagus, and tracheoesophageal
fistulas are noted with leaking of barium into the trachea. Ultrafast computed
tomography with contrast or magnetic resonance imaging (MRI) of the chest are
the best procedures to evaluate for mediastinal masses and vascular anomalies.
MRI of the brainstem may demonstrate an Arnold-Chiari malformation in 10% of
patients who have associated congenital bilateral vocal cord paralysis. The
paralysis may improve with shunting or brainstem compression.
Esophagoscopy
is not useful for the assessment of tracheomalacia. In addition, it is not the
diagnostic procedure of choice for gastroesophageal reflux (GER) in this
population in whom GER may contribute to symptoms. Intraesophageal pH probe
testing would be appropriate.
---
Q 10
A
4-month-old infant develops severe paroxysmal coughing 10 days after the onset
of nasal congestion and rhinorrhea. His mother reports that often 15 to 20
coughs occur in rapid succession.
Of
the following, the BEST test to establish the diagnosis is:
A. bronchoscopy
that demonstrates the presence of a foreign body
B. culture
of a nasal swab that grows a small gram-negative coccobacillus
C. culture
of a nasal swab that shows viral growth
D. pH
probe that demonstrates gastroesophageal reflux
E. skin
testing with demonstration of allergies
Answer
B
Pertussis should be
suspected in a child who has severe paroxysmal coughing with posttussive emesis
that occurs after mild symptoms of an upper respiratory tract infection.
Culture of B
pertussis is the diagnostic test of choice and requires inoculation of
nasopharyngeal mucus onto special medium with incubation for 10 to 14 days. A
positive culture is diagnostic, but cultures may be negative late in the course
of disease.
--------------------------------
Q 11:
A
10-year-old previously healthy boy presents with intermittent hemoptysis of 8
hours' duration. Vital signs are temperature, 100°F (37.8°C); blood pressure,
96/60 mm Hg; respiratory rate, 24 breaths/min; and heart rate, 80 beats/min.
Results of the physical examination are normal. The hematocrit is 38% .
Of
the following, the MOST appropriate next diagnostic study is:
A. bronchoscopy
B. chest
radiography
C. radiolabeled
red blood cell study
D. sputum
culture
E. sweat
chloride test
Answer :
B
The
single most common cause is acute lower respiratory tract infection. Another
common cause is foreign body aspiration, particularly in children younger than
4 years of age. Chest trauma that involves a contusion also can cause
hemoptysis. Much less common causes include neoplasms, vascular diseases, and
arteriovenous malformation. In countries in which corrective cardiac surgery is
widely available, the incidence of hemoptysis due to congenital heart disease
has declined significantly.
Initial
laboratory tests for a child in whom hemoptysis is suspected include complete
blood count and coagulation studies. Chest radiography then should be performed
to localize the site of bleeding and to aid in diagnosis, although in one third
of cases the results are normal. If the radiographic findings are normal but
significant bleeding continues, bronchoscopy or the administration of
radiolabeled red blood cells may be warranted. Sputum culture may be helpful in
defining the specific bacterial cause of an infectious process, but it rarely
is useful for diagnostic purposes. A sweat chloride test may be considered if
there is a history of recurrent bleeding or if other information from the
history or physical examination suggests cystic fibrosis.
-----------------------------
Q 12
A
3-year-old boy presents with a 4-day history of nasal congestion, rhinorrhea,
and cough. He had a temperature of 101°F (38.3°C), but this has resolved.
Physical examination reveals nasal congestion with cloudy rhinorrhea.
Of
the following, the MOST appropriate treatment for this condition is:
A. adenoidectomy
B. amoxicillin
C. amoxicillin-clavulanate
D. nasal
decongestant
E.
trimethoprim-sulfamethoxazole
Answer
D
Upper respiratory
tract infections (URIs) are common in children and are the most frequent reason
for physician visits. The average child has six to eight colds per year, which
may be complicated by bacterial sinusitis. Differentiating
simple URI from sinusitis is important to prevent overuse of antibiotics.
Acute
bacterial sinusitis and URIs share many of the same clinical symptoms, making
differentiation difficult. The most common symptoms include nasal congestion
and rhinorrhea. Purulent rhinorrhea does not distinguish a simple URI from
acute sinusitis. Postnasal discharge, cough, facial pain and pressure,
malodorous breath, headache, and facial swelling are associated symptoms. Nasal
congestion with erythematous mucosa and purulent exudate are more consistent
with an infectious etiology; edema, clear secretions, and pale bluish mucosa
are more suggestive of an allergic etiology.
Symptoms
alone do not reliably differentiate a simple URI from acute sinusitis. Acute
sinusitis can be distinguished best from a simple URI based on either severity
or duration of symptoms. Persistent or worsening symptoms of a URI beyond 10
days’ duration is strongly predictive of acute sinusitis. Patients in whom
symptoms decrease by 10 days may be treated as having a simple URI. The less
common presentation of acute sinusitis in children is an unusually severe URI,
which may manifest as very high fever (>102.2°F [39°C]), marked purulent
rhinorrhea, or an unusually toxic appearance. Although fever is common with
URI, it usually is low grade and resolves a few days after the onset of illness.
The
short duration of symptoms and low-grade fever described for the child in the
vignette are most consistent with a simple URI. Appropriate treatment is
symptomatic. Nasal decongestants can relieve symptoms of congestion, and good
nasal hygiene may decrease the risk of secondary complications. Antibiotics and
surgery are not necessary.
In
acute sinusitis, both high-dose amoxicillin (eg, 80 mg/kg per day) and
amoxicillin-clavulanate are appropriate treatment choices.
Trimethoprim-sulfamethoxazole has been recommended in the past for the
treatment of acute sinusitis in patients who have allergies, but increasing
bacterial resistance has limited the usefulness of this drug. Adenoidectomy is
recommended for recurrent and chronic sinusitis in children who have failed medical
treatment.
---------------------------
Q13
A
15-month-old boy has had five episodes of acute otitis media, chronic
rhinosinusitis, and two episodes of pneumonia. Chest radiography reveals
dextrocardia.
Of
the following, the study that is MOST likely to provide a definitive diagnosis
is:
A. human
immunodeficiency virus testing
B. mucosal
biopsy for ciliary analysis
C. pH
probe to document gastroesophageal reflux
D. skin
testing to document inhalant allergies
E.
sweat
chloride test for cystic fibrosis
Answer
B
Kartagener
syndrome consists of the triad of chronic sinusitis, bronchiectasis, and situs
inversus. Recurrent acute otitis media and nasal polyps are also common. This
syndrome is due to an ultrastructural abnormality of the cilia in which absent
dynein arms are noted on electron microscopy. The resulting ciliary dysfunction
leads to mucus stasis and frequent sinopulmonary infections. Situs inversus is
due to the absence of the influence of cilia function on viscera development.
Bronchiectasis is irreversible dilation of the bronchi due to the loss of
elastic recoil. It is associated with impaired clearance of secretions and
recurrent infections.
Bronchoscopy
for cilia biopsy is most likely to lead to the correct diagnosis for the child
in the vignette, who has frequent sinopulmonary infections and dextrocardia.
The nasal mucosa more frequently is damaged by chronic infection with loss of
cilia than is the tracheal mucosa, resulting in a better diagnostic yield when
bronchoscopy is performed for cilia biopsy.
Gastroesophageal
reflux, which can be confirmed with an overnight pH probe study, has been
implicated as a cause of respiratory infections, but it is not associated with
dextrocardia. Allergic diatheses may increase the risk of sinusitis and
pneumonia, but they do not influence the risk of recurrent acute otitis media
and do not explain dextrocardia. Human immunodeficiency virus infection
generally is characterized by atypical infections, and dextrocardia is not
present. Cystic fibrosis is a common cause of chronic sinopulmonary infections
and bronchiectasis, but the risk of otitis media is not significantly
increased, and dextrocardia is not an associated feature.
----
Q 14
You
are seeing a 2-year-old child in the office for a recheck visit after a local
emergency department physician diagnosed sinusitis. She has continued to have
symptoms of unilateral purulent nasal discharge and fetid breath. She has not
responded to a 10-day course of amoxicillin therapy.
Of
the following, the MOST likely cause of her nasal symptoms is:
A. antimicrobial-resistant
sinusitis
B. nasal
foreign body
C. recurrent
sinusitis
D. seasonal
allergic rhinitis
E. viral
upper respiratory tract infection
Answer
B
The
unilateral purulent nasal discharge and fetid breath described for the child in
the vignette are strongly suggestive of the presence of a nasal foreign body
rather than an episode of sinusitis.
With
antimicrobial-resistant sinusitis, the discharge would be expected to be
bilateral, and because the symptoms never resolved, recurrent sinusitis is not
a possibility. Seasonal allergic rhinitis is not characterized by these types
of symptoms and would be extremely uncommon in a 2-year-old child. A viral
upper respiratory tract infection usually is associated with bilateral clear
nasal discharge.
Children,
especially younger than age 2 years, commonly place objects in their nares.
Frequently it is difficult to discern the objects on routine inspection,
although unilateral discharge is highly suggestive of the diagnosis.
Occasionally, a radiograph may be helpful in identifying a radiopaque foreign
body, if it cannot be seen on physical examination. Proper evaluation of a
suspected foreign body includes rhinoscopy with administration of a topical
decongestant to decrease the localized swelling so that the foreign body can be
visualized and then removed
.
-----------------------------------
Q 15
A
10-year-old girl developed dyspnea 4 days after undergoing a left extended neck
dissection for a large cystic hygroma. Chest radiography reveals a left pleural
effusion. Pleurocentesis documents cloudy fluid that has a triglyceride content
of 120 mg/dL (normal, <50 mg/dL).
Of
the following, the MOST appropriate treatment for this child is:
A. a
diet high in saturated fats
B. a
high-carbohydrate diet
C. a
medium-chain triglyceride diet
D. restricted
access to protein
E.
transpyloric
elemental feedings
Answer
C
Chylothorax
is defined as the accumulation of chyle in the pleural space. Chest and neck
surgeries are common causes of chylothorax because of the proximity of the thoracic
duct to the great vessels in the mediastinum and lower aspect of the neck.
Chylothorax
usually presents within days of surgery, often when patients resume normal
feeding. Symptoms depend on both the rate at which chyle accumulates and the
amount of fluid present. A subtle pleural effusion may have minimal symptoms.
Respiratory distress is noted with larger effusions. Fever and signs of
infection are uncommon.
Pleurocentesis
is usually diagnostic of chylothorax, when milky fluid is withdrawn. A triglyceride
content of greater than 1.25 mmol/L (110 mg/dL), as noted for the girl in the
vignette, probably is chylous; less than 0.56 mmol/L (50 mg/dL) probably is not.
Initial
treatment for chylothorax is to modify the diet to a low-fat, medium-chain
triglyceride diet, which is available as a commercial formula. Medium-chain
triglycerides are directly absorbed into the intravascular space, decreasing
lymphatic flow. Total parenteral nutrition is necessary in recalcitrant cases.
If
the chylothorax persists or is associated with significant symptoms, surgical
management is required, including ligation of the thoracic duct and insertion
of a chest tube.
Low-protein
diets, high-fat diets, and high-carbohydrate diets do not improve the outcome
in chylothorax. The method of feeding is not important
.
---------------------------
Q 16
A
5-year-old boy is being evaluated for chronic sinusitis. Recent computed
tomography of his sinuses revealed panopacification without bony erosion. He
has had this problem for many years. The family is frustrated because he needs
chronic therapy.
Of
the following, the MOST appropriate next test to evaluate this child is:
A. complete
blood count with differential count
B. nasal
smear
C. rhinoscopy
for foreign body
D. serum
immunoglobulin E measurement
E. sweat
chloride test
Answer
E
Panopacification
of the sinuses may be associated with an immunologic disorder (eg,
hypogammaglobulinemia) or cystic fibrosis. Thus, such findings on radiography
warrant an evaluation of the child for these underlying diseases. The child
described in the vignette should have a sweat chloride test because this is the
diagnostic test of choice for suspected cystic fibrosis. Quantitative
measurement of serum immune globulins would be indicated to evaluate for immune
globulin deficiency. A complete blood count with differential would be
unhelpful in determining the cause of this child’s chronic sinusitis. A nasal
smear also is not necessary because it would be expected to reveal sheets of
neutrophils. Rhinoscopy would be indicated if a nasal foreign body is
suspected, but this would be a very unlikely cause of panopacification. Serum
immunoglobulin E measurement is unnecessary because allergic rhinitis rarely
causes panopacification of the sinuses.
