Pediatric Examination and Board Review (111 page)

Kim MK, Karpas AK. The limping child.
Clin Pediatr Emerg Med.
2002;3:129-137.

Miller ML, Cassidy JT. Postinfectious arthritis and related conditions. In: Behrman R, Kliegman R, Jenson H, eds.
Nelson Textbook of Pediatrics.
18
^th
ed. Philadelphia, PA: WB Saunders; 2007.

CASE 68: A 2-YEAR-OLD WITH RECURRENT WHEEZING

A 2-year-old boy presents to your clinic for evaluation of respiratory difficulties. His mom reports he was in his usual state of health until yesterday when he began having shortness of breath, cough, and an occasional wheeze. Mom gave him 2 puffs of his brother’s albuterol inhaler, which initially provided some relief. Mom denies any preceding symptoms, such as rhinorrhea, fever, or other URI symptoms. Mom also denies smokers in the home, pets, or carpets, but she notes that the symptoms did start after playing next door with his 4-year-old neighbor. The patient has wheezed once before when he was 4 months old and was diagnosed with RSV.

On physical examination, the patient is in moderate respiratory distress. His oxygen saturation is 92% on RA, with a RR of 44. Other vital signs are normal. His lung examination is notable for diffuse expiratory wheezing with variably decreased breath sounds at the right base, obvious retractions, and nasal flaring. There is decreased air exchange and an inspiratory-toexpiratory ratio of 1:3.5. The rest of his examination is normal except for erythematous, dry, pruritic plaques on the flexor surface of his elbows.

SELECT THE ONE BEST ANSWER

1.
What is the most likely cause of this patient’s respiratory distress?

(A) viral infection

(B) foreign body aspiration

(C) asthma

(D) bacterial pneumonia

(E) anaphylaxis

2.
Your initial step in treatment in your office is

(A) supplemental oxygen

(B) oral steroids

(C) systemic steroids

(D) inhaled bronchodilator

(E) subcutaneous epinephrine

3.
Metered-dose inhalers can be as effective as a nebulizer in delivering medication if used correctly

(A) True

(B) False

4.
After 2 treatments, the patient improves, and you continue to obtain a history from Mom. Which topic would have no correlation with the prevalence of asthma?

(A) history of breastfeeding

(B) socioeconomic status

(C) suburban versus inner-city residence

(D) gender

(E) smoke exposure

5.
Which of the following can be safely eaten by breastfeeding moms hoping to delay onset of foodassociated atopic dermatitis?

(A) milk

(B) fish

(C) eggs

(D) peanuts

(E) none of the above

6.
The mom reports that her son has excessive cough with viral infections. He gets short of breath and coughs when running around almost every day. He also often coughs at night (waking up 1-2 times per night). You diagnose what type of asthma?

(A) mild intermittent

(B) mild persistent

(C) moderate persistent

(D) moderate intermittent

(E) severe persistent

7.
You are concerned by the patient’s respiratory status and obtain a chest radiograph. It demonstrates hyperinflation with peribronchial cuffing and a right upper lobe volume loss. He is afebrile. What is the next appropriate step?

(A) chest tube

(B) ceftriaxone IM

(C) azithromycin PO

(D) bronchoscopy

(E) no procedure or antibiotic

8.
What is the best treatment for discharge from the outpatient facility?

(A) inhaled bronchodilator daily

(B) inhaled bronchodilator as needed (PRN)

(C) inhaled bronchodilator PRN and oral leukotriene inhibitor daily

(D) inhaled steroid daily and oral leukotriene inhibitor daily

(E) inhaled bronchodilator PRN and daily inhaled steroid

9.
All of the following are true regarding asthma education except

(A) asthma action plans are warranted and efficacious

(B) peak flow monitoring and/or symptom monitoring are not reliable methods of self-management

(C) asthma action plans must be reviewed and revised by the physician

(D) all action plans should include contacts for urgent care

(E) skill sets to be taught include inhaler use, selfmonitoring, and environmental control

10.
What are the long-term adverse effects of daily use of inhaled low to medium doses of corticosteroids?

(A) suppression of the hypothalamic-pituitary axis

(B) irreversible linear growth reduction

(C) decreased bone density

(D) cataracts

(E) none of the above

11.
Which of the following patients would be classified with mild intermittent asthma?

(A) symptoms 2-3 times per week, rare night symptoms, and 90% forced expiratory volume in the first second of expiration (FEV
₁
)

(B) symptoms daily, night symptoms 1-2 times per week, and 75% FEV
₁

(C) symptoms once per week, night symptoms less than 2 times per month, and 85% FEV
₁

(D) symptoms daily, night symptoms nightly, and less than 60% FEV
₁

(E) none of the above

12.
Which of the following is not known to exacerbate asthma symptoms?

(A) weather changes

(B) mite exposure

(C) beta-agonist drugs

(D) aspirin

(E) smog

13.
Which of the following statements is false regarding a child’s risk of having an atopic disease based on family history?

(A) 29% chance of an atopic disease if a sibling has an atopic disease

(B) 50% chance of an atopic disease if one parent has an atopic disease

(C) 72% chance of the same atopic disease as the parents if the parents share a common atopic disease

(D) 13% chance of atopic disease if neither parent has an atopic disease

(E) none of the above

14.
Which of the following statements is true regarding atopic diseases?

(A) more than 50% of atopic dermatitis cases do not present until after 2 years of age

(B) allergic rhinitis usually precedes asthma and atopic dermatitis

(C) atopic dermatitis is the most common atopic disease

(D) hot and humid climates are risk factors for atopic dermatitis

(E) allergic rhinitis prevalence is increasing most in 2- to 5-year-olds

15.
Which of the following contribute to or exacerbate asthma or allergies?

(A) maternal tobacco smoking

(B) indoor pets

(C) dust mites

(D) B and C

(E) A, B, and C

16.
All of the following are recommended for prolonged dust mite exposure reduction except

(A) encase mattress and pillow in an allergenimpermeable cover

(B) wash sheets in water hotter than 130°F (54.4°C) weekly

(C) decrease indoor humidity

(D) remove bedroom carpet

(E) use a chemical cidal agent such as benzyl benzoate

17.
The underlying pathology of asthma is characterized by inflammation of the airway. This inflammation is mediated by many factors, one of which is major basic protein. What is the source of major basic protein?

(A) mast cells

(B) IgE receptors

(C) neutrophils

(D) interleukin (IL)-2

(E) eosinophils

18.
What percentage of asthmatic children will outgrow symptoms by adulthood?

(A) 10%

(B) 20%

(C) 30%

(D) 40%

(E) 50%

ANSWERS

1.
(C)
The combination of a history of RSV, current wheezing, and a family history of asthma suggests the most likely diagnosis is asthma. Although foreign body is a consideration for this patient with his history of playing with a neighbor his age, the diffuse symptoms on physical examination do not support such a diagnosis. Viral infection and bacterial pneumonia are not likely considering his lack of associated symptoms, and anaphylaxis is not supported by the vital signs (which would demonstrate hypotension and laryngeal edema along with bronchospasm).

2.
(D)
The first-line therapy for an acute asthma exacerbation is an inhaled bronchodilator (such as albuterol). Oral steroids are often used in conjunction with inhaled steroids to decrease the airway edema, but they have a much slower onset of action. Supplemental oxygen is a good supportive measure but will not treat the underlying pathology.

3.
(A)
Studies have demonstrated that when used properly, both the nebulizer and inhaler with spacer are equally efficacious in the treatment of acute asthma.

4.
(A)
Although breastfeeding in the first year of life in combination with certain food avoidance can delay the onset of atopic disease, this is mostly with respect to food-associated atopic dermatitis. There is no change in the incidence or age of onset of asthma or incidence of allergic rhinitis. Male gender, low socioeconomic status, inner-city residence, and smoke exposure (both secondhand and maternal smoking) are all risk factors for asthma.