13: 6-year-old female with chronic cough

Question 1

Diagnosis of TB

Answer 1

• The Mantoux skin test (formerly called a “PPD” but now more correctly referred to as a “TST,” which stands for “tuberculin skin test”) is the only practical tool for diagnosing TB infections in asymptomatic children.
• Blood based testing with Interferon-Gamma Release Assays (IGRAs) such as QuantiFERON-TB Gold may be considered in children 5 years and older.
• A TST test is considered positive if it is: > 5 mm in high-risk children, > 10 mm in moderate-risk children and > 15 mm in low-risk children.
• In symptomatic children, a culture of the M. tuberculosis organism should be obtained from a sputum sample, or from a first morning gastric aspirate in young children.

Question 2

Common Terms for Physical Findings

Answer 2

–Allergic shiners: Darkening of the lower eyelids as a result of venous stasis
–Allergic salute : A gesture that involves pushing the nose upward and backward with the hand to relieve nasal
itching and obstruction. Over time, this may result in the development of a transverse nasal crease.
–Dennie-Morgan lines: Infraorbital creases that appear due to intermittent edema caused by allergies.
–Clubbing: Change in the appearance of the fingers so that the distal phalanx is rounded and bulbous and the angle between the nail plate and the nail fold is increased past 180 degrees. This phenomenon is suggestive of chronic hypoxia.

Question 3

Diagnosis of Asthma requires:

Answer 3

• Symptoms of recurrent airway obstruction by history and exam
• Demonstration that airway obstruction is at least partially reversible
• Exclusion of other causes of obstruction

Question 4

Asthma severity classification based on history of impairment in a school-age child:

Answer 4

• Daytime sx; Intermittent; Quick relief (SABA) as needed
• Nighttime awakening <2/month; Intermittent; Quick relief (SABA) as needed
• No interferene with activity; Intermittent; Quick relief (SABA) as needed
• More frequent symptoms, more interference with activity; Persistent; Daily controller + quick relief as needed

Question 5

steroid medications most commonly prescribed include

Answer 5

Beclomethasone, Fluticasone and Budesonide.

Question 6

Tracheal deviation

Answer 6

Tracheal deviation from midline may suggest a mediastinal mass, pneumothorax, or foreign body aspiration.

Question 7

Retractions

Answer 7

• Abnml retraction of the intercostal, supraclavicular, or subcostal spaces d/r inspiration.
• May be seen in severe obstructive airway disease in children, including asthma, bronchiolitis, and foreign body obstruction.

Question 8

Use of accessory muscles of respiration

Answer 8

• Inspiratory contraction of the sternocleidomastoid muscles at rest.
• This is a sign of significant respiratory distress.

Question 9

Hyperinflated thorax

Answer 9

• -Increased anteroposterior (AP) chest diameter, sometimes referred to as “barrel chest.”
• -This is suggestive of air-trapping due to chronic lung disease.

Question 10

Increased I:E

Answer 10

• -“I:E” refers to the ratio of time for full inspiration to time for full expiration (normally 1:1 or 1:2).
• -In obstructive disorders, expiration is prolonged, and ratio is decreased.

Question 11

Abnormal chest sounds on percussion

Answer 11

–“Hyperresonance” may be heard when there is localized air trapping behind a mucus plug, foreign body or mass.
–“Dullness” of breath sounds may be due to lobar consolidation from pneumonia or atelectasis.


Question 12

Egophony

Answer 12

• -This is when the patient is asked to say “ee” and the examiner hears “ay” through the stethoscope).
• -The phenomenon is suggestive of a lobar consolidation (an airless lung).

Question 13

Wheezing

Answer 13

• -Wheezing is the sound of airflow through narrowed airways.
• -It may be due to many different conditions, but one of the most common reasons for wheezing in children is asthma.

Question 14

most common indoor aeroallergens that are responsible for sensitizing susceptible people include:

Answer 14

House dust mites, Animal dander, Cockroaches

Question 15

4-year-old boy who recently emigrated from eastern Europe presents with his mother to your general pediatrics clinic. His mother reports that he has a chronic nonproductive cough during the day and night, mild wheezing for one month and failure to gain weight (his weight has dropped from the 50th to the 10th percentile for his age). His mother denies any high fevers, rhinorrhea, or night sweats. Which of the following are the next best diagnostic tests?

Answer 15

CXR and tuberculin skin test (TST) is the best choice. Signs and symptoms of primary pulmonary tuberculosis are few to none. Toddlers may present with nonproductive cough, mild dyspnea, wheezing, and/or failure to thrive (defined as weight < 5th percentile or drop in two percentile curves for weight). In children, TB can present without systemic complaints (fever, night sweats, and anorexia), severe cough, and sputum production. Regarding diagnostic tests, the TST is a practical tool for diagnosing TB infections. All children with chronic cough (more than three weeks) should be evaluated with a chest x-ray, as other pathology-such as lung abscess or malignancy-can also be detected on CXR.

Question 16

patients with intermittent asthma and have symptoms fewer than two days a week or two nights a month

Answer 16

Rescue inhaler (a short-acting beta agonist) i PRN

Cough and wheezing that occur intermittently (< 2 days/week) are consistent with intermittent asthma, which is treated with short-acting beta agonist PRN

Question 17

mild persistent asthma. His symptoms occur 3-6 days/week and 3-4 nights/month.

Answer 17

Low dose inhaled corticosteroid

Persistent cough and wheezing that affect the patient every other day (3-4 days with symptoms/week) are consistent with mild persistent asthma, which is appropriately treated with short-acting beta agonist PRN and low dose inhaled corticosteroid.

Question 18

patient with moderate persistent asthma when symptoms occur daily and more than one night per week

Answer 18

Medium dose inhaled corticosteroids with a course of oral corticosteroids

Short-acting beta agonist PRN with medium dose inhaled corticosteroid is the preferred treatment for moderate or severe persistent asthma, which corresponds to daily symptoms or symptoms throughout the day

Question 19

severe persistent asthma

Answer 19

Medium dose inhaled corticosteroids, LABA, and oral corticosteroids

The use of a long-acting beta agonist is reserved for severe persistent asthma, which corresponds to symptoms throughout the day.

Question 20

more asthma

Answer 20

Asthma frequently presents with nighttime exacerbations. The cough often presents with wheezing and is usually a dry cough.

Question 21

10-year-old male comes to the clinic with a chief complaint of progressive cough for two weeks that began gradually. His cough is described as productive and wet with whitish sputum. His mother denies throat pain, vomiting, and diarrhea in his review of systems. His mother reports that he has been febrile up to 101.5°F daily. She thinks he is fatigued and has not eaten well in the past week. On exam, there is air passage throughout all lung fields, with crackles in the lower right lung field, but no other abnormal sounds. What would you likely find in your workup?

Answer 21

Pneumonia is the most likely cause for his symptoms and a chest x-ray would be a great confirmation of your suspected diagnosis. Eliciting a complete history might reveal history of an upper respiratory infection. Localization of crackles (discontinuous inspiratory sounds) to one lobe makes pneumonia more likely.