Q1 :
A 12-year-old female is brought to the emergency department. She is breathing 30 times per minute,
is unable to speak in full sentences, and has a peak expiratory fl ow rate (PEFR) 50% predicted.
Th e preferred firs tline therapy for her asthma exacerbation is :
(A) Aminophylline IV.
(B) B-agonist nebulization.
(C) Hydrocortisone IV.
(D) Magnesium sulfate IV
(E) B and D
(F) B and C
Answer
F
Patient is obviously in respiratory distress. Aggressive treatment with oxygen, systemic steroids, and shortacting bronchodilators is indicated. Ipratropium could also be added to the albuterol in the acute setting.
---------------------------------
Q 2:
A 12-year-old boy who has mild persistent asthma is brought to the emergency department
because of increased work of breathing of 1 day’s duration. He reports a low-grade fever and
nonproductive cough for the past 4 days, but this morning he developed difficulty breathing and
a cough that produced a small amount of yellowish sputum. His respiratory rate is 24
breaths/min, heart rate is 80 beats/min, and temperature is 99.0°F (37.3°C). He appears in no
respiratory distress, but his lung examination reveals bilateral rales and occasional wheezes. A
chest radiograph shows bilateral diffuse infiltrates with no effusions.
Of the following, the MOST likely etiologic agent causing his symptoms is
A. Haemophilus influenzae
B. Mycobacterium tuberculosis
C. Mycoplasma pneumoniae
D. Staphylococcus aureus
E. Streptococcus pneumoniae
Answer
C
Mycoplasma pneumoniae is a common cause of community-acquired pneumonia in school-age
children and adolescents, but it is rare in infants and toddlers. Other clinical manifestations of M
pneumoniae infection include upper respiratory tract infection, pharyngitis, bullous myringitis, and
bronchitis. Occasionally, systemic symptoms such as malaise and fever are present. Among
the rarer clinical presentations are hemolytic anemia, aseptic meningitis, and Stevens-Johnson
syndrome.
M pneumoniae is responsible for many cases of pneumonia and acute chest syndrome in children who have sickle cell disease.
Infection also may precipitate an exacerbation of asthma, as described for the boy in the vignette. A recent study showed that children of different ages may respond differently to infection with M pneumoniae.
Children younger than 5 years of age were more likely to experience coryza, vomiting and diarrhea, and
tachypnea than were older children.
Typical radiographic findings are bilateral, diffuse infiltrates, but occasionally a
lobar infiltrate or pleural effusion may be seen. The diagnosis frequently can be made clinically,
but serologic testing is available.
The complement fixation test and, more recently, immunofluorescence and enzyme immunoassay can be used to measure levels of immunoglobulin M (IgM) and IgG antibodies to M pneumoniae. High concentrations of IgM may be present for months after acute infection.
Comparing acute and convalescent IgG titers allows for more accurate diagnosis, although this may be impractical. Serum cold hemagglutinin titers also may be positive in patients who have acute infection but have limited sensitivity and specificity.
Direct polymerase chain reaction is both sensitive and specific for the diagnosis but is not widely available. Macrolide antibiotics generally are used for treatment, although many infections are self-limited, and a recent review found no conclusive evidence that antibiotics are effective in reducing symptoms
-------------------------------
Q 3:
You are evaluating a 12-year-old girl during her biannual asthma follow-up visit. She has a
history of mild persistent asthma that is well-controlled on a low-dose inhaled corticosteroid. You
review the asthma guidelines and recommend that she receive the influenza vaccine. Her
mother immediately replies, "Oh no, my daughter has a severe egg allergy and was told to never
get the influenza vaccine."
Of the following, the vaccine that is contraindicated in a patient who has a severe immunoglobulin E-mediated egg allergy is
A. human papillomavirus vaccine
B. measles-mumps-rubella
C. tetanus diphtheria
D. varicella
E. yellow fever
Answer
F
Patient is obviously in respiratory distress. Aggressive treatment with oxygen, systemic steroids, and shortacting bronchodilators is indicated. Ipratropium could also be added to the albuterol in the acute setting.
---------------------------------
Q 2:
A 12-year-old boy who has mild persistent asthma is brought to the emergency department
because of increased work of breathing of 1 day’s duration. He reports a low-grade fever and
nonproductive cough for the past 4 days, but this morning he developed difficulty breathing and
a cough that produced a small amount of yellowish sputum. His respiratory rate is 24
breaths/min, heart rate is 80 beats/min, and temperature is 99.0°F (37.3°C). He appears in no
respiratory distress, but his lung examination reveals bilateral rales and occasional wheezes. A
chest radiograph shows bilateral diffuse infiltrates with no effusions.
Of the following, the MOST likely etiologic agent causing his symptoms is
A. Haemophilus influenzae
B. Mycobacterium tuberculosis
C. Mycoplasma pneumoniae
D. Staphylococcus aureus
E. Streptococcus pneumoniae
Answer
C
Mycoplasma pneumoniae is a common cause of community-acquired pneumonia in school-age
children and adolescents, but it is rare in infants and toddlers. Other clinical manifestations of M
pneumoniae infection include upper respiratory tract infection, pharyngitis, bullous myringitis, and
bronchitis. Occasionally, systemic symptoms such as malaise and fever are present. Among
the rarer clinical presentations are hemolytic anemia, aseptic meningitis, and Stevens-Johnson
syndrome.
M pneumoniae is responsible for many cases of pneumonia and acute chest syndrome in children who have sickle cell disease.
Infection also may precipitate an exacerbation of asthma, as described for the boy in the vignette. A recent study showed that children of different ages may respond differently to infection with M pneumoniae.
Children younger than 5 years of age were more likely to experience coryza, vomiting and diarrhea, and
tachypnea than were older children.
Typical radiographic findings are bilateral, diffuse infiltrates, but occasionally a
lobar infiltrate or pleural effusion may be seen. The diagnosis frequently can be made clinically,
but serologic testing is available.
The complement fixation test and, more recently, immunofluorescence and enzyme immunoassay can be used to measure levels of immunoglobulin M (IgM) and IgG antibodies to M pneumoniae. High concentrations of IgM may be present for months after acute infection.
Comparing acute and convalescent IgG titers allows for more accurate diagnosis, although this may be impractical. Serum cold hemagglutinin titers also may be positive in patients who have acute infection but have limited sensitivity and specificity.
Direct polymerase chain reaction is both sensitive and specific for the diagnosis but is not widely available. Macrolide antibiotics generally are used for treatment, although many infections are self-limited, and a recent review found no conclusive evidence that antibiotics are effective in reducing symptoms
-------------------------------
Q 3:
You are evaluating a 12-year-old girl during her biannual asthma follow-up visit. She has a
history of mild persistent asthma that is well-controlled on a low-dose inhaled corticosteroid. You
review the asthma guidelines and recommend that she receive the influenza vaccine. Her
mother immediately replies, "Oh no, my daughter has a severe egg allergy and was told to never
get the influenza vaccine."
Of the following, the vaccine that is contraindicated in a patient who has a severe immunoglobulin E-mediated egg allergy is
A. human papillomavirus vaccine
B. measles-mumps-rubella
C. tetanus diphtheria
D. varicella
E. yellow fever
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