Q 1
Three
days ago, you diagnosed left acute otitis media in a 2-year-old boy and treated
him with high-dose amoxicillin. He returns with continued fever and left ear
pain.
Of
the following, the MOST appropriate antibiotic treatment for this child is:
A. amoxicillin-clavulanate
B. azithromycin
C. cephalexin
D. clindamycin
E. continued
amoxicillin
Answer
A
Answer
A
Because
Streptococcus pneumoniae causes a higher proportion of cases of acute otitis
media than beta-lactamase-producing bacteria, it makes sense to use high-dose
amoxicillin as first-line therapy. If the acute otitis media does not resolve
with high-dose amoxicillin, as described for the child in the vignette, the
infection may be due to a beta-lactamase-producing organism, which requires the
use of a beta-lactamase-resistant antibiotic, such as amoxicillin-clavulanate.
Clindamycin,
a lincosamide, and cephalexin, a first-generation cephalosporin, do not have
activity against either H influenzae or M catarrhalis. Because the patient in
the vignette is still symptomatic after 3 days of therapy, he has experienced
treatment failure. Thus, continued high-dose amoxicillin is not indicated.
Although azithromycin may be effective against H influenzae, amoxicillin-clavulanate
remains the drug of choice for those who have clinically failed treatment with
high-dose amoxicillin. Recent pneumococcal surveillance studies indicate
resistance to erythromycin at approximately 10%. Substantial cross-resistance
between erythromycin and beta-lactam agents exists. Therefore, patients who
have already failed amoxicillin treatment are more likely to have
macrolide-resistant infections as well.
----
Q 2
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Q 2
A
mother of one of your children's classmates asks your opinion about her
10-year-old child, who has had a cough for the past 5 months. She has had
intermittent yellow-green nasal discharge and was wheezing once. The symptoms
began in July, the day after she flew home from Europe. Her pediatrician had
tried cough suppressants and several courses of antibiotics. Currently she is
taking inhaled corticosteroids, a long-acting beta agonist, and a short-acting
beta agonist, but she is not experiencing much improvement. On careful
questioning, the mother states that the courses of antibiotics may have been
helpful.
Of
the following, the MOST likely diagnosis is:
A. acute
sinusitis
B. bronchitis
C. chronic
sinusitis
D. mild
persistent asthma
E. moderate
persistent asthma
Answer
C
-------------
Q 3
Answer
C
The
child described in the vignette is suffering from chronic sinusitis. Signs and
symptoms suggestive of this condition may include cough, purulent nasal
discharge, facial pain, headaches, sore throat, nausea, fetid breath, fatigue,
and possibly exacerbation of asthma
.
Mild-to-severe
asthma usually begins slowly and subtly; some children present with an acute
first exacerbation in conjunction with a viral upper respiratory tract
infection. However, even in these cases, symptoms appear episodically and do
not last for many months, as they have for the child described in the vignette.
Bronchitis is rare in children, especially in the summer months, and it
responds at least to some extent to beta agonist therapy. The duration of the
symptoms rules out the possibility of acute sinusitis that, by definition, is
short-lived. Allergy could be a source of the child’s symptomatology if a new
pet or allergen has been introduced recently, but that is not evident in the
child’s history.
The
partial improvement on antibiotics followed by a return of symptoms argues for
the diagnosis of chronic sinusitis. Children who have chronic sinusitis
routinely improve on a short course of antibiotics, then worsen within 1 week
of discontinuing therapy.
The
time to refer a patient who has sinusitis is when he or she continues to have
recurrence of disease after adequate treatment. This usually requires 3 weeks
of antibiotic therapy, sometimes also including topical nasal therapy. Referral
to either an allergist or ENT physician is appropriate, depending on whether
allergy is suspected. The allergist would evaluate for possible triggers that
are causing the nasal obstruction and then causing the recurrence of the
sinusitis. The ENT physician is better able to evaluate the structural features
of the sinuses and perform any necessary surgical interventions.
-------------
Q 3
A
5-year-old boy who has had a cough and upper respiratory tract infection for
the past week presents with a rapid onset of expiratory stridor and dyspnea
with retractions. His temperature is 104°F (40°C). Chest radiography reveals an
irregular-appearing tracheal air column.
Of
the following, the MOST appropriate treatment is:
A. antimicrobial
coverage with ceftriaxone
B. bronchoscopy
to remove purulent debris and antibiotics to cover Staphylococcus aureus
C. bronchoscopy
to remove purulent material and antibiotics to cover Haemophilus influenzae
type b
D. emergency
tracheotomy
E. esophagoscopy
for biopsy and antibiotics to cover Haemophilus influenzae type b
Answer
B
Answer
B
Bacterial
tracheitis is an uncommon infection of the airway that does not involve the
epiglottis. Staphylococcus aureus is the most common isolated pathogen.
Moraxella catarrhalis, Haemophilus influenzae type b, and parainfluenza virus
have also been implicated in this entity, also called membranous croup. Most
patients are younger than 3 years of age when diagnosed, although older
children have been affected.
The
most common presentation of bacterial tracheitis is a preceding viral illness
followed by worsening illness with high fever, copious thick purulent
secretions, toxic symptoms, and respiratory distress, as described for the boy
in the vignette. A brassy, productive cough is common. The usual treatment for
croup (mist, hydration, and racemic epinephrine) is ineffective, and intubation
or preparation for tracheotomy often is contemplated. Chest radiography, if
performed, may demonstrate patchy infiltrates, and an irregular tracheal air
column often suggests purulent tracheal debris. Bronchoscopy generally is
recommended to establish a diagnosis and to remove thick purulent material to
improve the airway and obtain material for culture. This is followed by
appropriate antimicrobial treatment to cover S aureus. Most patients require
intubation but only rarely, tracheotomy.
Direct
laryngoscopy in the operating room typically is employed for a definitive
diagnosis of epiglottitis and to obtain cultures, which usually reveal H
influenzae type b. Antibiotic coverage of H influenzae type b is not
inappropriate for patients who have bacterial tracheitis, but coverage for S
aureus, the predominant pathogen, is more suitable. Ceftriaxone is not the drug
of choice for staphylococcal infections.
--------------------
Q4
--------------------
Q4
A
12-year-old previously healthy child, is seen for chronic nasal congestion. His symptoms include nasal obstruction, copious
nasal discharge, and poor sense of smell. He has been tested for allergies and
found to be positive to grass and tree pollen. His symptoms began about 10
months ago and are worsening. He has not responded to antihistamines,
decongestants, or a prolonged course of antibiotics.
Of
the following, the MOST likely cause of his symptoms is:
A. acute
sinusitis
B. allergic
rhinitis
C. cystic
fibrosis
D. nasal
polyps
E. viral
upper respiratory tract infection
Answer
D
The nasal symptoms, their duration, and the lack of response to several types of medications suggest the diagnosis of nasal polyps. Nasal polyps rarely are seen in children younger than age 10 years. When they do occur, there is a high probability of concomitant cystic fibrosis.
-----------
Q 5
Answer
D
The nasal symptoms, their duration, and the lack of response to several types of medications suggest the diagnosis of nasal polyps. Nasal polyps rarely are seen in children younger than age 10 years. When they do occur, there is a high probability of concomitant cystic fibrosis.
-----------
Q 5
An
12-year-old boy presents with a 4-day history of progressive dysphagia, odynophagia,
and fever. Findings on physical examination include erythema and edema of the
left tonsil pillar and rightward deviation of the uvula.
Of
the following, the MOST appropriate initial treatment is:
A. amoxicillin
B. ceftriaxone
C. external
drainage of the retropharyngeal space
D. incision
and drainage of the tonsil pillar
E. ultrasonographic-guided
needle biopsy
Answer
D
---------------------
Q 6
Answer
D
Peritonsillar
abscess occurs in the potential space between the superior constrictor muscle
and the tonsil. Most affected patients present with severe progressive pain,
trismus, dysphagia, and fever. Neck stiffness is not uncommon.
The
oral examination can be difficult to accomplish because of trismus. The
affected tonsil is usually erythematous, and there is marked edema and erythema
of the peritonsillar pillar. The edema and abscess push the tonsil on the
involved side toward the midline and the uvula toward the opposite side, as
reported for the boy in the vignette. Cervical adenopathy is common.
Beta-hemolytic streptococci with or without oral anaerobes almost always are
the cause of the infection.
The
initial treatment of choice for peritonsillar abscess includes incision and
drainage or needle aspiration of the affected tonsil and coverage with
antibiotics.
Q 6
A
12-month-old boy has had four episodes of acute otitis media requiring
antibiotics and persistent middle ear effusion for 3 months.
Of
the following, the MOST important risk factor for chronic otitis media to look
for in this boy is:
A. allergic
rhinitis
B. bronchopulmonary
dysplasia
C. cystic
fibrosis
D. submucous
cleft palate
E. tonsil
hypertrophy
Answer
D
The most important risk factors for otitis media
are patient age (as noted previously) and time of year, with an increased
incidence in winter and spring. Otitis media also is common among children who
have cleft palate and craniofacial anomalies. Submucous cleft, a subtle anomaly
associated with otitis media, consists of bifid uvula, inappropriate palatal
muscle attachment to the posterior hard palate, and notching of the posterior
hard palate with intact palate mucosa.
-----
Q 7:
Answer
D
Acute
otitis media is the most prevalent disease of childhood after upper respiratory
tract infections. Nearly 85% of children have at least one episode of acute
otitis media by age 3 years, and 50% have two or more. Otitis media occurs most
commonly between 3 and 36 months of age, with the probability of infection
waning thereafter.
-----
Q 7:
At
a 6-month health supervision visit, a child's parents express concern that he
does not seem to respond to sound.
Of
the following, the GREATEST risk factor for sensorineural hearing loss is
associated with:
A. choanal
atresia
B. family
history of hearing loss
C. history
of recurrent otitis media
D. history
of respiratory syncytial virus infection
E. preauricular
skin tags
Answer
B
Congenital sensorineural hearing loss occurs in approximately 2 to 5 per 1,000 births. In most children who have congenital hearing loss, the etiology is either unknown or hereditary. Most hereditary hearing losses result from autosomal recessive inheritance.
-------------------
Q 8:
Answer
B
Congenital sensorineural hearing loss occurs in approximately 2 to 5 per 1,000 births. In most children who have congenital hearing loss, the etiology is either unknown or hereditary. Most hereditary hearing losses result from autosomal recessive inheritance.
-------------------
Q 8:
A 3-month-old boy presents with a 48-hour history of nasal congestion
and rhinorrhea without fever. He appears to be in no distress. Physical
examination reveals normal tympanic membranes, a slightly congested nose, and a
normal oral cavity.
Of the following, the MOST appropriate treatment for this child is:
A. amoxicillin-clavulanate
B. nasal
endoscopy for culture
C. phenylephrine
hydrochloride
D. prednisolone
E. saline
drops and suctioning as needed
Answer
E
Answer
E
Systemic
or topical therapy generally is prescribed to alleviate nasal congestion in
children and adults. Pseudoephedrine and phenylephrine are commonly used
over-the-counter decongestants that must be administered with caution in
patients who have hypertension, hyperglycemia, hyperthyroidism, and cardiac
disease. Nervousness, restlessness, insomnia, and arrhythmias occur rarely.
Topical decongestants, including phenylephrine 0.125% to 0.25% and
oxymetazoline, may have similar adverse effects as systemic products. Prolonged
use of topical decongestants may result in marked rebound nasal congestion and
damage to nasal mucosa, known as rhinitis medicamentosa.
For
infants such as the one described in the vignette, saline drops and bulb
suctioning frequently are adequate to relieve obstruction and allow for
feeding. Topical decongestants rarely are necessary, and the risk of
cardiovascular sequelae may be increased in these children.
Steroids usually
are not necessary for simple upper respiratory tract infection, and antibiotics
do not alter the course of disease or reduce the risk of suppurative
complications. Antibiotics should be prescribed only for bacterial sinusitis
that is suggested by a prolonged duration or unusually severe symptoms. Nasal
endoscopy can be used to obtain a culture from the maxillary sinus, but this is
difficult to perform in infants and usually is not necessary unless bacterial sinusitis
caused by resistant organisms is suspected or the host is immunocompromised or
unusually ill.
-----------------
A 2-year-old boy presents with bloody drainage from the left ear. According to his mother, he has had upper respiratory tract infection symptoms for the past 3 days, and last night he was crying and holding his left ear. His pain seemed to improve after she cleaned out the ear with a cotton swab, but this morning there was blood on his pillow and around his left ear. On physical examination of his ears, you are unable to see the left tympanic membrane because of seropurulent fluid in the external auditory canal.
Of the following, the MOST likely cause of the bloody ear drainage is
A. basilar skull fracture
B. foreign body in the external auditory canal
C. otitis externa
D. otitis media with tympanic membrane perforation
E. traumatic tympanic membrane perforation
Answer
D
Purulent or seropurulent drainage is most characteristic of acute otitis media with a tympanic
membrane perforation. Purulent drainage also may be seen with otitis externa. An uncommon
cause of purulent discharge from the external auditory canal in children is an infection in a first
branchial cleft cyst.
Bloody ear drainage most often is due to trauma to the canal, the tympanic membrane, or
temporal bone; chronic inflammation of the canal with granulation tissue or cholesteatoma; a
foreign body in the external canal; or less commonly in children, neoplasm or hematologic
abnormalities.
Clear drainage suggests leakage of serous fluid through a tympanic membrane perforation
or cerebrospinal fluid otorrhea through a congenital anomaly or traumatic defect in the temporal
bone or following mastoid or basilar skull surgery. Cerebrospinal fluid otorrhea is seen in 21% to
44% of temporal bone fractures.
-----------------
Q9:
Of the following, the MOST likely cause of the bloody ear drainage is
A. basilar skull fracture
B. foreign body in the external auditory canal
C. otitis externa
D. otitis media with tympanic membrane perforation
E. traumatic tympanic membrane perforation
Answer
D
Purulent or seropurulent drainage is most characteristic of acute otitis media with a tympanic
membrane perforation. Purulent drainage also may be seen with otitis externa. An uncommon
cause of purulent discharge from the external auditory canal in children is an infection in a first
branchial cleft cyst.
Bloody ear drainage most often is due to trauma to the canal, the tympanic membrane, or
temporal bone; chronic inflammation of the canal with granulation tissue or cholesteatoma; a
foreign body in the external canal; or less commonly in children, neoplasm or hematologic
abnormalities.
Clear drainage suggests leakage of serous fluid through a tympanic membrane perforation
or cerebrospinal fluid otorrhea through a congenital anomaly or traumatic defect in the temporal
bone or following mastoid or basilar skull surgery. Cerebrospinal fluid otorrhea is seen in 21% to
44% of temporal bone fractures.
-----------------------
Q10:
A 2-year-old boy comes to the emergency department because of a barking cough. His mother
reports that he has no fever or shortness of breath, but you note a barking, seal-like cough. His respiratory rate is 20 breaths/min, and there is no stridor. His lungs are clear, and other findings on the physical examination are normal.
Of the following, the MOST appropriate treatment is
A. cool mist therapy
B. helium/oxygen mixture
C. nebulized albuterol
D. nebulized racemic epinephrine
E. oral antibiotic
Answer
A
The child described in the vignette has a barking cough but no other respiratory symptoms,
which is most consistent with the diagnosis of laryngotracheobronchitis or croup. Croup may be
caused by a number of respiratory viruses, including parainfluenza, influenza, respiratory
syncytial virus, and adenovirus. Typical features are rhinorrhea and low-grade fever, followed
by a barking cough and hoarseness. In severe cases, inspiratory stridor may be noted. Children
who have croup generally appear well and tolerate oral intake well. Toxic appearance, drooling,
and significant respiratory distress should alert the clinician to the possibility of a more serious
airway infection, such as bacterial tracheitis or epiglottitis.
The mainstay of therapy for children who have simple viral croup is aerosolized cool mist
therapy, which is administered best with the child seated on the parent’s lap. The mist thins and
moistens airway secretions to improve clearance.
Q10:
A 2-year-old boy comes to the emergency department because of a barking cough. His mother
reports that he has no fever or shortness of breath, but you note a barking, seal-like cough. His respiratory rate is 20 breaths/min, and there is no stridor. His lungs are clear, and other findings on the physical examination are normal.
Of the following, the MOST appropriate treatment is
A. cool mist therapy
B. helium/oxygen mixture
C. nebulized albuterol
D. nebulized racemic epinephrine
E. oral antibiotic
Answer
A
The child described in the vignette has a barking cough but no other respiratory symptoms,
which is most consistent with the diagnosis of laryngotracheobronchitis or croup. Croup may be
caused by a number of respiratory viruses, including parainfluenza, influenza, respiratory
syncytial virus, and adenovirus. Typical features are rhinorrhea and low-grade fever, followed
by a barking cough and hoarseness. In severe cases, inspiratory stridor may be noted. Children
who have croup generally appear well and tolerate oral intake well. Toxic appearance, drooling,
and significant respiratory distress should alert the clinician to the possibility of a more serious
airway infection, such as bacterial tracheitis or epiglottitis.
The mainstay of therapy for children who have simple viral croup is aerosolized cool mist
therapy, which is administered best with the child seated on the parent’s lap. The mist thins and
moistens airway secretions to improve clearance.
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