Q1 :
A
3-year-old boy was admitted to the hospital with respiratory distress after
ingesting kerosene. Chest radiography revealed bilateral diffuse atelectasis.
Although initially hypoxic, he gradually improved and never required
ventilation.
Of
the following, the MOST likely sequela for this patient is the long-term
development of:
A. cardiomyopathy
B. encephalopathy
C. esophageal
stricture
D. obstructive
pulmonary disease
E. pulmonary
hemorrhage
answer
D
Q2
Answer
A
-------------------
Q 3:
Answer :
D
------------------------------
Q 4
answer
D
Because
of their low viscosity and high volatility, hydrocarbons may be aspirated
during ingestion and cause a secondary pneumonitis, although most children who
ingest hydrocarbons do not develop respiratory difficulties. The onset of
respiratory symptoms and radiographic findings may be delayed.
Patients who are asymptomatic after 6 hours of observation and have negative
radiographic findings are unlikely to develop symptoms. Those who do develop
clinical pneumonitis may experience dyspnea and hypoxia and require oxygen
treatment. Occasionally, ventilatory assistance is necessary. Rarely, there is
a rapid progression to respiratory failure and death.
Acute
complications of pneumonitis include pneumothorax, subcutaneous emphysema of
the chest wall, and pleural effusions. A secondary pneumonia may develop during
the ensuing week. Pneumatoceles may be a late development, but they rarely
require treatment. Most children survive hydrocarbon pneumonitis without
complications or sequelae. They are at risk for obstructive pulmonary disease,
although results of long-term pulmonary function studies have been inconclusive.
Although
ingestion of hydrocarbons may cause acute gastrointestinal irritation,
esophagitis and subsequent esophageal stricture are not expected. Ingestion of
corrosive household cleaning products is associated with acute esophagitis and
long-term development of strictures.
Pulmonary
hemorrhage has not been described in hydrocarbon pneumonitis. Chronic
inhalation abuse or “huffing” has been associated with the sequelae of
cardiomyopathy and encephalopathy. An acute effect of inhalant abuse can be
death due to cardiac arrhythmia.
-----Q2
Your
practice group has decided to create a comprehensive plan of action for your
patients who have asthma. You have been assigned to create the new hospital
discharge plan. The current plan includes the initiation of inhaled
corticosteroids, as-needed short-acting beta agonists.
Of
the following, The BEST option to add to the plan is:
A. an
assessment of asthma triggers
B. daily
oral antihistamines
C. excuse
from gym class for 2 months
D. pneumococcal
vaccine for children
E. weekly
spirometry for the 2 months following discharge
Answer
A
Identifying
the triggers of asthma exacerbations assists the clinician in planning
discharge therapy, including future medications. For example, if an upper
respiratory tract infection is found to be the trigger, the hospitalization may
have been unavoidable. However, if there were no triggers and the admission was
due to noncompliance with therapy, a change in management may be appropriate.
If the trigger is an allergen, identification and removal of the allergen will
be extremely helpful. Returning a child to an environment in which there is an
allergen trigger may result in repeated hospitalizations despite appropriate
medications. In contrast, elimination of a trigger, such as home remodeling, a
new pet, or the addition of a feather pillow, may be the first step toward
dramatic improvement in the child’s overall health.
The
use of daily oral antihistamines is an inappropriate part of a discharge plan
unless the child has been identified as atopic. Excusing a child from gym is
not helpful because asthmatic children need regular exercise. Only the rare
child who has severe disease should be excused from activities.
The
pneumococcal vaccine is recommended for all children younger than age 2 years,
but it is not normally included as part of a standard asthma plan. Although
weekly spirometry would allow for charting a child’s slow improvement over
time, it is of little clinical benefit.
Peak flow meters generally are not used in children younger than 6
years of age.
-------------------
Q 3:
A
12-year-old boy who has cystic fibrosis is hospitalized for treatment of a
pulmonary exacerbation. Gram stain of sputum reveals many polymorphonuclear
leukocytes and gram-negative rods.
Of
the following, the MOST appropriate antibiotic choice for this patient is an
aminoglycoside plus:
A. azithromycin
B. ceftriaxone
C. cefuroxime
D. ticarcillin
E. vancomycin
Answer :
D
Pseudomonas
aeruginosa is found in the respiratory tracts of most patients who have cystic
fibrosis.
This bacterium is virtually specific for cystic
fibrosis, and once acquired, generally is not eradicated from the respiratory
tract.
Antibiotics
have been one of the cornerstones of treatment for the patient who has cystic
fibrosis. Intravenous antipseudomonal antibiotic therapy is well tolerated and
when used in pulmonary exacerbations, often results in improved lung function
and reduced bacterial colonization of the airway. The most commonly used drugs
include aminoglycosides, semisynthetic penicillins, and cephalosporins.
Two-drug therapy is usually administered to patients who have a pulmonary
exacerbation. The two agents act synergistically for enhanced bactericidal
activity and may prevent the emergence of resistant organisms.
Ticarcillin
is a carboxypenicillin whose spectrum of activity includes P aeruginosa. It
often is used in conjunction with an aminoglycoside for treatment of pulmonary
exacerbations due to P aeruginosa.
Second-generation
cephalosporins, such as cefuroxime, have gram-positive activity, increased gram-negative
activity, and beta-lactamase stability. The second-generation drugs may be
active against some strains of Acinetobacter, Citrobacter, Enterobacter,
Klebsiella, Neisseria, Proteus, Providencia, and Serratia sp as well as
Escherichia coli, but they have no activity against Pseudomonas sp.
Third-generation
cephalosporins, such as ceftriaxone, are less active than first-generation
cephalosporins against gram-positive cocci, but they are much more active
against Enterobacteriaceae and beta-lactamase-producing strains of Haemophilus
influenzae, Moraxella catarrhalis, and Neisseria gonorrhoeae. A subset of
third-generation cephalosporins, such as ceftazidime, also has good
antipseudomonal activity.
Azithromycin
is a macrolide antibiotic that is active against group A streptococci and
Staphylococcus aureus as well as common pediatric pathogens such as
pneumococcus, M catarrhalis, and H influenzae. Mycoplasma pneumoniae and
Chlamydia pneumoniae also are susceptible. It has no activity against Pseudomonas
sp.
Vancomycin,
a glycopeptide antibiotic, is selectively bactericidal against most
gram-positive organisms, but it has no activity against gram-negative organisms
such as Pseudomonas sp.
------------------------------
Q 4
A
6-month-old previously healthy child presents in January with fever of 3 days'
duration and wheezing that has increased in severity for 2 days. On physical
examination, the child is awake and interactive. Respiratory rate is 60
breaths/min, and there are marked wheezes bilaterally and intercostal
retractions. Because there is no improvement after two treatments with
nebulized albuterol, you admit the child to the hospital. Upon re-evaluation 4
hours later, the child is agitated and has a respiratory rate of 80
breaths/min. Arterial blood gas while receiving 35% oxygen reveals pH of 7.24,
Po2 of 65 mm Hg, and Pco2 of 60 mm Hg.
Of the
following, the MOST appropriate next step in management is:
A. administration
of intramuscular dexamethasone
B. administration
of racemic epinephrine
C. continuous
albuterol nebulization
D. immediate
endotracheal intubation
E. increase
of inspired oxygen to 50%
Answer :
D
Answer :
D
The
agitation, significantly increased respiratory rate, and acute carbon dioxide
retention described for the girl in the vignette indicate impending respiratory
failure. The most appropriate management is immediate endotracheal intubation.
Agitation
is common in hypoxia; somnolence or tachycardia may be due to either carbon
dioxide retention or severe hypoxemia. Bradycardia is an ominous development,
usually indicating severe respiratory failure, hypoxemia, and impending cardiac
arrest. Acute carbon dioxide retention (hypercapnia) often results in flushing,
agitation, confusion, tachycardia, and headache.
The
child described in the vignette has symptoms of bronchiolitis. The wheezing
results from necrosis and sloughing of the respiratory epithelium caused by the
toxic effect of the virus on the cells. Partial airway obstruction ensues.
Although bronchodilators may be of some benefit in affected children who have
underlying reactive airways, they are of little to no benefit for most children.
Steroids
have no proven benefit in the management of bronchiolitis, although they may be
beneficial in the respiratory distress caused by croup. Similarly, racemic
epinephrine is of limited value in bronchiolitis. The initial management of
hypoxemia is administration of oxygen at the highest concentration available,
but increasing the inspired concentration of administered oxygen is not
appropriate treatment of carbon dioxide retention.
--------------
Q 5
You are asked to consult on a 9-month-old boy who has been hospitalized five times for
wheezing. His history reveals occasional coughing with feedings, but results of a pH probe
performed during his last admission were normal. His weight and height are at the 50th
percentile. Except for scattered wheezes with good aeration bilaterally, results of his physical
examination are normal.
Of the following, the test that is MOST likely to reveal the cause of his recurrent wheezing is
A. chest computed tomography scan
B. immunoglobulin panel
C. inspiratory and expiratory chest radiographs
D. pulmonary function testing
E. videofluoroscopic swallow study
Answer
E
Recurrent wheezing can be caused by many diseases, including reactive airway disease, cystic
fibrosis, extrinsic airway compression, and aspiration with and without gastroesophageal reflux.
The history of coughing with feedings described for the boy in the vignette should alert the
clinician to the possibility of swallowing dysfunction, with aspiration as the cause of his recurrent
symptoms. Accordingly, a videofluoroscopic swallow study is the best diagnostic procedure to
reveal the cause of his wheezing.
--------------
Q 5
You are asked to consult on a 9-month-old boy who has been hospitalized five times for
wheezing. His history reveals occasional coughing with feedings, but results of a pH probe
performed during his last admission were normal. His weight and height are at the 50th
percentile. Except for scattered wheezes with good aeration bilaterally, results of his physical
examination are normal.
Of the following, the test that is MOST likely to reveal the cause of his recurrent wheezing is
A. chest computed tomography scan
B. immunoglobulin panel
C. inspiratory and expiratory chest radiographs
D. pulmonary function testing
E. videofluoroscopic swallow study
Answer
E
Recurrent wheezing can be caused by many diseases, including reactive airway disease, cystic
fibrosis, extrinsic airway compression, and aspiration with and without gastroesophageal reflux.
The history of coughing with feedings described for the boy in the vignette should alert the
clinician to the possibility of swallowing dysfunction, with aspiration as the cause of his recurrent
symptoms. Accordingly, a videofluoroscopic swallow study is the best diagnostic procedure to
reveal the cause of his wheezing.
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