Q1:
Otitis media occurring during the first 4 weeks of life deserves special consideration, because the bacteria responsible for infections during this time may be different from those that affect older infants and children. Which of the following organisms is the most likely to cause otitis media in these infants?
(A) Chlamydia trachomatis
(B) E. coli
(C) Neisseria gonorrhoeae
(D) Treponema pallidum
(E) Toxoplasma gondii
Answer:
(B)
C. trachomatis is considered an unusual cause of otitis media at any age. N. gonorrhoeae causes conjunctivitis in the newborn. Syphilis and toxoplasmosis cause congenital infections. E. coli is one of the neonatal pathogens that also causes otitis media in neonates. The symptoms of otitis media in newborns are often similar to those of sepsis; they are subtle and nonspecific and may include poor feeding, lethargy,
vomiting, or diarrhea. Once the diagnosis is established, the initial therapy should be similar to that for neonatal sepsis, such as parenteral ampicillin and cefotaxime. Under ideal circumstances, the results of cultures obtained by tympanocentesis may then allow further treatment with a more specific antibiotic of low
toxicity. Older infants may respond well to oral therapy but require frequent observation.
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Q 2:
A 6-month-old infant is diagnosed with her first episode of otitis media. She does not have any allergies to medications. Which of the following medications would be the recommended initial therapy for this infant?
(A) amoxicillin
(B) amoxicillin-clavulanic acid
(C) cephalexin
(D) ceftriaxone
(E) erythromycin
Answer
(A) H. influenzae, S. pneumoniae, and Moraxella catarrhalis are the most common bacterial pathogens in otitis media of children. Amoxicillin is still the initial drug to use in uncomplicated otitis media because of its good coverage, except for beta-lactamase-positive organisms, and its excellent safety profile. The other drugs (except for erythromycin) are acceptable second-line medications.
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Q 3:
A 4-year-old previously healthy but unimmunized boy presents with sudden onset of high fever, inspiratory stridor, and refusal to drink. Of the following causes of inspiratory stridor, which best fits this clinical scenario?
(A) epiglottitis
(B) vascular ring
(C) croup
(D) foreign body aspiration
(E) laryngeal tumor
Answer:
(A)
Croup and epiglottitis have similar presentations but need to be distinguished immediately. Croup usually results from a viral infection of the larynx and epiglottitis from a bacterial (H. influenzae type B) infection of the epiglottis. Children with epiglottitis tend to be toxic in appearance. Croup involves the airway,
and epiglottitis involves the airway and the digestive tract. Children with croup usually will swallow and drink. Children with epiglottitis most often will refuse to drink and may even drool as a result of their refusal to swallow saliva. Patients with foreign bodies in their upper airways do not typically have fever.
Patients with vascular rings and laryngeal tumors have more gradual onset of symptoms.
----
Q 4:
A 10-year-old boy is brought in with a chief complaint of multiple colds. On further questioning, you elicit a history of chronic, clear nasal discharge with no seasonal variation. Other symptoms include sneezing, itching of the nose and eyes, as well as tearing and occasional eye redness. Some relief is obtained with
an over-the-counter cold medicine containing antihistamine and a decongestant. His history suggests which of the following?
(A) nasal foreign body
(B) immunologic deficiency
(C) rhinitis medicamentosa
(D) chronic sinusitis
(E) allergic rhinitis
Anser
(E)
The symptoms are suggestive of perennial allergic rhinitis. Causative agents are usually those to which the child is exposed year round, such as house dust, mold spores, or pet danders.
Seasonal allergic rhinitis is attributable to sensitization to pollens of trees, grasses, and weeds. Nasal foreign bodies usually result in a foul smelling, unilateral purulent, and occasionally blood tinged, discharge. Recurrent
infections may rarely be attributable to immunologic deficiencies. Recurrent pneumonias are the most common complaint.
Rhinitis medicamentosa occurs secondary to excessive use of vasoconstrictor nose drops or sprays,
resulting in rebound nasal obstruction.
Sinusitis is suggested by a bilateral purulent nasal discharge, often accompanied by fever,
cough, headache, and sometimes sinus tenderness.
Answer:
(B)
C. trachomatis is considered an unusual cause of otitis media at any age. N. gonorrhoeae causes conjunctivitis in the newborn. Syphilis and toxoplasmosis cause congenital infections. E. coli is one of the neonatal pathogens that also causes otitis media in neonates. The symptoms of otitis media in newborns are often similar to those of sepsis; they are subtle and nonspecific and may include poor feeding, lethargy,
vomiting, or diarrhea. Once the diagnosis is established, the initial therapy should be similar to that for neonatal sepsis, such as parenteral ampicillin and cefotaxime. Under ideal circumstances, the results of cultures obtained by tympanocentesis may then allow further treatment with a more specific antibiotic of low
toxicity. Older infants may respond well to oral therapy but require frequent observation.
-----
Q 2:
A 6-month-old infant is diagnosed with her first episode of otitis media. She does not have any allergies to medications. Which of the following medications would be the recommended initial therapy for this infant?
(A) amoxicillin
(B) amoxicillin-clavulanic acid
(C) cephalexin
(D) ceftriaxone
(E) erythromycin
Answer
(A) H. influenzae, S. pneumoniae, and Moraxella catarrhalis are the most common bacterial pathogens in otitis media of children. Amoxicillin is still the initial drug to use in uncomplicated otitis media because of its good coverage, except for beta-lactamase-positive organisms, and its excellent safety profile. The other drugs (except for erythromycin) are acceptable second-line medications.
---
Q 3:
A 4-year-old previously healthy but unimmunized boy presents with sudden onset of high fever, inspiratory stridor, and refusal to drink. Of the following causes of inspiratory stridor, which best fits this clinical scenario?
(A) epiglottitis
(B) vascular ring
(C) croup
(D) foreign body aspiration
(E) laryngeal tumor
Answer:
(A)
Croup and epiglottitis have similar presentations but need to be distinguished immediately. Croup usually results from a viral infection of the larynx and epiglottitis from a bacterial (H. influenzae type B) infection of the epiglottis. Children with epiglottitis tend to be toxic in appearance. Croup involves the airway,
and epiglottitis involves the airway and the digestive tract. Children with croup usually will swallow and drink. Children with epiglottitis most often will refuse to drink and may even drool as a result of their refusal to swallow saliva. Patients with foreign bodies in their upper airways do not typically have fever.
Patients with vascular rings and laryngeal tumors have more gradual onset of symptoms.
----
Q 4:
A 10-year-old boy is brought in with a chief complaint of multiple colds. On further questioning, you elicit a history of chronic, clear nasal discharge with no seasonal variation. Other symptoms include sneezing, itching of the nose and eyes, as well as tearing and occasional eye redness. Some relief is obtained with
an over-the-counter cold medicine containing antihistamine and a decongestant. His history suggests which of the following?
(A) nasal foreign body
(B) immunologic deficiency
(C) rhinitis medicamentosa
(D) chronic sinusitis
(E) allergic rhinitis
Anser
(E)
The symptoms are suggestive of perennial allergic rhinitis. Causative agents are usually those to which the child is exposed year round, such as house dust, mold spores, or pet danders.
Seasonal allergic rhinitis is attributable to sensitization to pollens of trees, grasses, and weeds. Nasal foreign bodies usually result in a foul smelling, unilateral purulent, and occasionally blood tinged, discharge. Recurrent
infections may rarely be attributable to immunologic deficiencies. Recurrent pneumonias are the most common complaint.
Rhinitis medicamentosa occurs secondary to excessive use of vasoconstrictor nose drops or sprays,
resulting in rebound nasal obstruction.
Sinusitis is suggested by a bilateral purulent nasal discharge, often accompanied by fever,
cough, headache, and sometimes sinus tenderness.
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