Case 12: 10-month old with a cough

Question 1

True or false: bronchodilators and steroids are mainstays of bronchiolitis treatment.

Answer 1

false - they’re usually not helpful unless the patient has a strong family history of asthma and a clear response to bronchodilators

Question 2

What are the three main pathogenesis features of asthma?

Answer 2

airway inflammation
mucus hypersecretion
bronchoconstriction

Question 3

What are common triggers for bronchoconstriction in asthmatics?

Answer 3

URIs
allergies
cold air
exercise
smoke expposure

Question 4

What are some common signs of respiratory distress?

Answer 4

paradoxical breathing (severe)
tachypnea
nasal flaring
head bobbing
grunting (in infants)

Question 5

Describe the triphasic course of bordetella pertussis.

Answer 5

catarrhal stage (1-2 wks URI)
paroxysmal stage (4-6 wks with repetitive whooping cough)
convalescent stage (months of gradually lessening cough)

Question 6

Can you get pertussis if you’ve been vaccinated?

Answer 6

yes - efficacy is only in 70-90% and protection wanes with time, so adolescents should be reimmunized

Question 7

Epiglottitis is usually due to what organism?

Answer 7

Hib (but we vaccinate for it now)
Staph
Strep

Question 8

How will a kid with epiglottitis present?

Answer 8

child between 2-5 yrs of age with fever, stridor, drooling, dysphonia, dysphagia, respiratory distress

they’ll position their airway in a sniffing position

Question 9

What is the management for epiglottitis?

Answer 9

establish an airway is the first priority

Question 10

what’s the finding on xray for epiglottitis?

Answer 10

thumb sign

Question 11

A child has pharyngitis with a low-grade fever and hoarse voice. Exam shows a gray membrane at the back of the pharynx. What’s the diagnosis?

Answer 11

diptheria

Question 12

What are three extrinsic causes of wheezing? (things that cause extrinsic compression of an airway)

Answer 12

a vascular ring/sling
adenopathy
mass or other lesion

Question 13

Is stridor usually heard during inspiration or expiration?

Answer 13

inspiration, but can be biphasic if obstruction is severe

Question 14

What is the difference (physiologically) between stridor and wheezing?

Answer 14

stridor is airway narrowing above the thoracic inlet

wheezing is airway narrowing below the thoracic inlet

Question 15

Is wheezing usually heard in inspiration or expiration?

Answer 15

expiration unless obstruction is bad (and can disappear when it’s really bad)

Question 16

What does polyphasic wheezing suggest? What does monophonic wheezing suggest?

Answer 16

polyphonic = asthma
monophonic = focal airway obstruction

Question 17

What causes rhonchi?

Answer 17

coarse low-pitched rattling sounds heard best in expiration thought to be due to secretions and narrowing of airways

Question 18

What causes crackles?

Answer 18

fluid in the alveoli or opening/closing of stiff alveoli in interstitial disease

Question 19

What’s the difference between coarse and fine crackles?

Answer 19

coarse are associated with purulent secretions with PNA

fine crackles are associated with pulmonary edema or interstitial lung disease

Question 20

If you hear bronchial breath sounds (lower, more hollow-sounding) in the lower lobes, what’s the likely diagnosis?

Answer 20

consolidation

Question 21

What might you see on CXR with an asthma exacerbation?

Answer 21

hyperinflation due to air trapping, increased interstitial markings and patchy atelectasis

Question 22

What is the most common cause of pneumonia in children?

Answer 22

viral: Adenovirus, RSV, parainfluenza, influenza

Question 23

In neonatal period, what are the most common bugs causes pneumonia?

Answer 23

GBS
E coli
Klebsiella

Question 24

When and how does a pneumonia from chlamydia present?

Answer 24

4-12 weeks with staccato cough

Question 25

What is the most common bacterial cause of pneumonia in infants beyond the neonatal period through age 5-6 yrs?

Answer 25

strep pneumo

Question 26

What is the most common bacterial cause of pneumonia in school-aged children?

Answer 26

mycoplasma,followed by strep pneumo

Question 27

When does stranger anxiety happen?

Answer 27

9-10 months of age

Question 28

Croup presents with a bark-like cough, in ages 2-5. What virus?

Answer 28

parainfluenza

Question 29

What imaging should you get when evaluating for a foreign body?

Answer 29

bilateral decubitus and/or inspiratory/expiratory films lateral decubitus should have the dependent lung deflating slightly compared to the non-dependent lung due to effect of gravity. If one does not deflate as expected, there could be an obstruction in the airway.