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Flashcards in Peds -Fahim Deck (63):
1

What is inspiratory stridor due to? Where is the problem?

at or above the vocal cords

due to the collapse of the soft tissues w/negative pressure during inspiration

epiglottis, cysts

2

What is expiratory stridor due to? Where is the problem?

due to decrease Airway caliber with expiration (wheezing)

usually obstruction below the vocal cords

3

What is the most common cause of acute lanyngotracheitis (croup)?

Parainfluenza virus

4

What does a Steeple sign on an x-ray indicate?

Croup (narrowing in the subglottic area)

5

What does the thumb sign on an x-ray indicate? What normally causes this?

Epiglottitis

H. influenzae (ask parents about vaccinations)

6

What physical exam finding will be seen with epiglottitis?

cherry-red epiglottis

drooling

toxic appearance

thumb sign on x-ray

7

Should you examine the throat if epiglottitis is suspected?

NO! can cause more respiratory distress--> wait until in hospital setting

8

What are the treatment options for croup?

Mist treatment

racemic epinephrine --> constrict capillary arterioles

corticosteroids --> anti-inflammatory

antibiotics when things not getting better or if get better then worse again (superinfection)

9

What is the most common cause of Laryngotracheobronchitis (tracheitis)?

Staphylococcus aureus

and strept pyogenes

10

A 3-year-old boy is brought to the emergency department because of a worsening cough over the past week. His temperature is 38.9 C(102 F), and inspiratory stridor is noted. A plain film of the neck reveal subglottic swelling. He is noted to have copious thick secretions and a barking cough. He has not had such events previously, and his parents deny recent contact with sick children. The patient is in respiratory distress and is noted to be retracting his subcostal muscles to breathe. Which of the following is the next most appropriate step in management?
(a) Administer albuterol
(b) Administer racemic epinephrine
(c) Administer corticosteroids
(d) Administer IV penicillin
(e) Endotracheal intubation

(b) Administer racemic epinephrine

11

A 4-year-old previously healthy but unimmunized body 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

(a) epiglottitis

12

What is Laryngomalacia? What are the presenting symptoms?

softening of the arytenoid cartilages and epiglottis

--> collapse during inspiration =inspiratory stridor

most common cause of stridor in kids

stridor exacerbated during agitation

prone position diminish stridor

Omega shaped epiglottis*

13

What is associated with an omega shaped epiglottis?

laryngomalacia

epiglottis collapses in inspiration and is relieved with expiration

14

When is surgical intervention recommended in laryngomalacia?

if failure to thrive ==> may alleviate obstruction and promote growth

most cases resolve spontaneously in first year

15

What is the hallmark of tracheomalacia?

expiratory wheeze:
-central and low-pitched, unchanged after SABA, prone position may alleviate

asthma would have a diffuse, high-pitched wheeze that responds to SABA

16

What are associated with tracheomalacia?

tracheoesophageal fistula

trisomy 21

history of intubation

17

A 3 yr old boy is brought to the emergency department in respiratory distress. He has a temp of 103. He has difficulty swallowing and on exam an inspiratory stridor. X-ray shows epiglottic swelling. He has not received any vaccinations. What is the most likely agent?
A- Haemophilus influenza
B- Legionella pneumonia
C- Klebsiella pneumonia
D- Mycoplasma pneumonia
E- streptococcus pyogenes

A- Haemophilus influenza

18

3 month old F presents with difficulty breathing and snoring. Mother mentioned baby getting blue while feeding while stridor disappears with crying. On examination, the stridor was noted to be inspiratory in nature. What may be the underlying cause of this infant’s condition ?
A. Tumor of nasopharynx
B. Deviated nasal septum
C. Choanal Atresia
D. Laryngomalacia

D. Laryngomalacia

19

What is likely to be the problem if a nurse claims they cannot put an NG tube in an infant?

Coanal atresia/stenosis

20

What will vascular rings present with?

trouble feeding--> esophageal notch on a barium swallow

--> aortic arch has a branch around the esophagus

stridor

21

2 year old M presents with difficulty breathing while feeding. Mother mentioned noisy breathing and also feeding difficulties. On examination, expiratory stridor was noted. Barium swallow showed compression of the esophagus. What might be causing the above problem ?
A. Subglottic Stenosis
B. Vocal cord paralysis
C. Vascular Ring
D. Thymic cyst

C. Vascular Ring

22

A newborn started to gag and turn blue after is first feeding. The mother states that his abdomen seems to swell after he cries. Pulmonary exam reveals mild wheezes bilaterally. What is the most likely diagnosis?
A- Barrett’s esophagus
B- pulmonary hypoplasia
C- Pyloric stenosis
D- Respiratory distress syndrome
E- Tracheoesophageal fistula

E- Tracheoesophageal fistula

23

What is the most common cause of bronchiolitis?

RSV

get in the fall/winter

24

Who is at risk for an RSV infection? What should be given to protect this population?

(bronchiolitis)

Prematurity, age < 3 months

give Palivizumab (IgG against RSV) to premature babies

25

What is the single largest cause of death worldwide?

pneumonia
(lower respiratory tract infection)
leading killer of children

26

What is considered a hospital acquired pneumonia?

developed AFTER 48 hours after hospital admission (including chronic care facilities)

27

What are the most common causes of pneumonia in neonates?

bugs of the vaginal tract

viruses: Herpes, entervirus, adenovirus, mumps, congenital rubella, cytomegalovirus

bacterial: group B strept, gram - enteric bacteria, listeria, chlamydia trachomatis, strept pneumonia, group D strept, anarobes

fungi: candida

other: toxoplaxmosis, syphilis

28

What are the most common causes of pneumonia in infants ?

Viruses: CMV, RSV, parainfluenza, influenza, adenovirus, metapneumovirus

Bacterial: Strep pneumoniae, Haemophilus influenzae, Mycoplasma pneumoniae, Mycobacterium tuberculosis, Chlamydia trachomatis, Mycoplasma hominis, Ureaplasma urealyticum, Bordetella pertussis

29

What are the most common causes of pneumonia in children < 5 yo?

Viruses: RSV, Influenza A & B, Parainfluenza viruses(type 3), Adenovirus serotypes, Human metapneumovirus, Rhinovirus, Coronaviruses, Human bocavirus, Human parechovirus types 1,2,3

Bacterial: *Strep pneumoniae, H influenzae type b, Nontypable H influenzae, Moraxella catarrhalis, Staph aureus(CA-MRSA), Strep pyogenes, Mycobacterium tuberculosis

30

What are the most common causes of pneumonia in children >5 yo?

Viruses: RSV, rare causes(Coronavirus, Varicella-zoster, EBV, mumps)

Bacterial: Strep pneumoniae, **Mycoplasma pneumoniae, Chlamydia pneumoniae, Mycobacterium tuberculosis, Chlambydia psittaci, Coxiella burnetti, Klebsiella pneumoniae, Legionella, Strep pyogenes, brucella abortus

Fungi: Coccidioides immitis, Histoplasma capsulatum, Blastomyces dermatitidis

31

What medication should not be given to children < 8 yo? why?

Doxycycline because of its affect on the teeth

32

How do we test for RSV?

rapid antigen test of the nasal aspirate

NO chest x-ray

33

A 7 –month-old boy is brought to his physician because of increased agitation and restless. Lung examination reveals crackles and decreased breath sounds bilaterally. Chest x-ray films are notable for bilateral pneumonia. Arterial blood gas analysis reveals an oxygen tension of 45 mm Hg and a carbon dioxide tension of 60 mm Hg. Which of the following is the most appropriate next step in management?

(a) Obtain blood cultures
(b) Administer oxygen
(c) Administer bronchodilation
(d) Administer antibiotics
(e) Insert endotracheal tube

(e) Insert endotracheal tube

34

If pertussis is suspected, what medication should be started immediately? What side effect should be monitored?

Azithromycin

look out for pyloric stenosis in babies

35

What type of infection will cause lobular pneumonia?

bacterial (viral shows ground-glass opacity)

36

What should be the first line treatment for children (< 5 yo) with bacterial PNA in the outpatient setting? Adolescents?

young children: amoxicillin or amoxicillin-clavulonate
(bugs likely staph or strept)

adolescents: azithromycin
second line adolescents=add a macrolide or doxycycline (>8yo)

37

When should pertussis be suspected? What are the stages?

gasping cough for a long time (> 2weeks)

stages: CPC --> catarrhal, paroxysmal, convalescent

38

You are seeing a 10yoF who presents for routine examination. She lived in LA until 3yr ago and has lived in multiple cities over the last few years as her father is a truck driver. She is about to enroll in your local school district. Documentation of her immunization status cannot be found and the courthouse in LA that held her records has been destroyed by a hurricane. Her father cannot reliably tell you which immunizations she received and when. He does know that she had the chickenpox last year. Based on this information, itis best to
A. Reinstitute the entire immunization sequence for Hepatitis B, polio, measles, mumps, rubella, pertussis, diphtheria and tetanus.
B. Reinstitute the entire immunization sequence for Hepatitis B, polio, measles, mumps, rubella, pertussis, diphtheria and tetanus.
C. Reinstitute the entire immunization sequence for Hepatitis B, polio, measles, mumps, rubella, Haemophilus influenzae, pertussis, diphtheria and tetanus
D. Since she is 10, and assuming she had some vaccines as a child, only give her Td and Hepatitis B for now.
E. Send titers and see if she is immune.

A. Reinstitute the entire immunization sequence for Hepatitis B, polio, measles, mumps, rubella, pertussis, diphtheria and tetanus.

39

Which of the following is least likely to be the infectious etiology causing pneumonia in an 2 month old infant?
A. Chlamydia trachomatis
B. S. pneumoniae
C. RSV
D. Mycoplasma
E. Bordetella pertussis

D. Mycoplasma

40

A 4-month-old infant boy has had a fever (100.6°F), a persistent cough, and nasal discharge for the past week. You are considering a diagnosis of pertussis. The most practical and rapid laboratory study to confirm the diagnosis is
A. Complete blood count with differential
B. Culture on Regan-Lowe medium
C. Fluorescent antibody testing
D. Polymerase chain reaction testing
E. Serum antibody titer

D. Polymerase chain reaction testing

41

The diagnosis of pertussis is confirmed. The antibiotic of choice for an infant this age is
A. Azithromycin
B. Erythromycin
C. Penicillin
D. Trimethoprim-sulfamethoxazole
E. Vancomycin

A. Azithromycin

42

What are the stages of whooping cough?

CPC
Catarrhal stage (1-2 weeks)
Paroxysmal stage (2-6 weeks): sudden bouts of coughing
Convalescent stage

43

A healthy 5-year-old girl gets an upset stomach when she eats eggs. The parents deny hives or respiratory distress. Which of the following statements would best describe her ability to receive the yearly influenza vaccine?
A. She has a serious egg allergy and should not receive the vaccine.
B. She can receive the live attenuated intranasal vaccine but not the inactivated type.
C. She does not have a significant egg allergy and can receive the vaccine safely.
D. Do not vaccinate. Use chemoprophylaxis instead.
Give vaccine preceded by injection of epinephrine.

C. She does not have a significant egg allergy and can receive the vaccine safely.

44

A 2-year-old boy has a croup-like illness. Which of the following statements is FALSE?
A. Parainfluenza types 1 and 2 are common causes of croup.
B. Previously healthy children should receive ribavirin as antiviral therapy.
C. Child may benefit from receiving dexamethasone and epinephrine.
D. Croup-like symptoms accompanied by high temperatures most likely represent an infection by influenza virus.
E. Subglottic stenosis is a known complication.

B. Previously healthy children should receive ribavirin as antiviral therapy.

45

What is the main strategy for prevention against influenza?

yearly vaccination

6 months+ should be vaccinated

46

Can you vaccinate individuals with a history of only hives?

yes

use recombinant vaccine

47

What antivirals are available for the treatment and chemoprophylaxis of influenza?

1. The Adamantanes (amantadine, rimantadine)
-Works by interfering with the viral M2 ion channel to prevent the release of viral RNA into the host cell after endocytosis
-No activity against influenza B


2. The Neuraminidase Inhibitors (oral oseltamivir and inhaled zanamivir)
-Blocks viral neuraminidase, which prevents the budding and release of viral progeny
-Have activity against both influenza A and B,

48

What is a disease of airway inflammation? How does this work?

asthma
early phase: IgE mediated immediate response to an allergen which causes mast cells and basophils to degranulate which precipitates bronchospasm and the release of cytokines and chemokines

late phase: obstruction of air flow (4-12 hours after exposure)

49

What is one of the most important risk factors for the development of asthma?

atopy

ask family about asthma, eczema, allergies

50

Based on the NHLBI EPR 3 asthma guidelines, the most preferred first step in therapy for moderate persistent asthma would be which of the following?
A. Short-acting beta agonists
B. Low-dose inhaled corticosteroids
C. Low-dose inhaled corticosteroids and long-acting bronchodilator
D. High-dose inhaled corticosteroids and long-acting bronchodilator

C. Low-dose inhaled corticosteroids and long-acting bronchodilator

51

12 year old female with a history of moderate persistent asthma presents for routine follow-up. At the time of her initial visit, you prescribed low-dose inhaled steroids and a leukotriene modifier. She reports that since her initial visit, she has had minimal daytime symptoms. She has required her rescue inhaler only 2-3 times a week and awakes form sleep only about 3-4 times a month. She reports that, overall, she feels the medications are working great. She denies significant exercise limitation. She has had no exacerbations requiring oral steroids or acute intervention by another physician. Based on the history provided by the patient, you would classify her control as which of the following?
A. Well controlled
B. Not well controlled
C. Very poorly controlled
D. Unable to assess based on this information

B. Not well controlled
(not less than 2x/month)

52

All of the following are true regarding mechanisms of action of inhaled glucocorticoid therapy except:
A. Inhibition of cytokine production
B. Inhibition of inflammatory cell recruitment
C. Inhibition of mediator release
D. Decreases microvascular leak therefore decreases edema formation
E. Down-regulation of beta-adrenergic receptors

E. Down-regulation of beta-adrenergic receptors

(ICS causes up-regulation of Beta adrenergic receptors)

53

The sweat test result is 50 mEq/L and the laboratory reports that the diagnostic value is >60mEq/l. Which of the following in the most appropriate next response?
A.. measure pancreatic enzyme concentration in a duodenal aspirate
B. send blood for CFTR genotyping
C. reassure the family that the sweat test is negative and the child does not have CF
D. repeat the sweat chloride test
E. send the child to a research center for the measurement of nasal mucosal electrical potential difference.

D. repeat the sweat chloride test

many pts with CR have a false negative sweat chloride test

54

If you get a child with respiratory distress and ABG reveals an oxygen tension of 45 mm Hg and a carbon dioxide tension of 60 mm Hg. What should you do?

Intubate--> endotracheal tube

55

What are the diagnostic tests for Cystic Fibrosis? What is the gold standard?

1-Newborn screening + when increased immunoreactive trypsinogen (IRT)(pancreatic enzyme)

2-Confirmatory Sweat Chloride Test=Gold standard
Pilocarpine iontoelectrophoresis >60 meq/L --> + test

3-DNA analysis (Definitive diagnosis with 2 CFTR mutations)

4-Nasal potential difference test
(After chemical washing, patients with CF show no change in measured electrical potential)

56

What is the most common defunct in CF? What does this lead to?

Delta 508 deletion of 3 base pairs leading to the absence of phenylalanine at codon 508

57

Abnormalities in the receptor for which of the following neuropeptides have been identified in the brainstem of some infants with sudden infant death syndrome:
A. Acetylcholine
B. Epinephrine
C. Galanin
D. Serotonin
E. Vasoactive intestinal peptide

D. Serotonin

dysfunction of arousal and cardiorespiratory responses due to abnormalities in serotonin receptors

58

A mother of a 1-month-old infant comes in for a well-child visit. As you review the infant’s immunization schedule, she tells you that one of her friends’ children died of SIDS 48 hours after the infant received her 4-month diphtheria, pertussis, and tetanus vaccine. Of the following, which piece of information most accurately reflects current knowledge about immunizations and SIDS?
A. Infants who receive immunizations have a lower risk of SIDS
B. Infants who receive immunizations have the same risk of SIDS as infants who are not immunized
C. Infants who receive immunizations may have slightly higher risk of SIDS, but the benefit of the immunization far outweighs the risk
D. Only the 2-month diphtheria, pertussis, and tetanus vaccine has been associated with slightly increased risk of SIDS.
E. Infants at risk of SIDS should have their Haemophilus influenza vaccine series postponed until 12 months

A. Infants who receive immunizations have a lower risk of SIDS

59

The American Academy of Pediatrics Task Force on SIDS has recommended against parents sleeping in the same bed as their infants. According to the article, which of the following factors makes bed sharing especially hazardous?
A. Absence of blankets
B. Firm bed
C. Infants age

C. Infants age

60

An intervention recommended by authors to reduce the risk of infant SIDS is:
A. Avoid the use of pacifiers before bedtime
B. Home cardiorespiratory monitoring
C. Positioning the infant on the side
D. Sleeping in the same room as the infant
E. Swaddling the infant in a soft blanket

D. Sleeping in the same room as the infant

61

How do beta agonists work?

β2 receptors are activated on bronchial smooth muscle --> bronchodilation

Stimulation of adenylate cyclase--> closing of calcium channels --> relaxation of smooth muscles

62

What strategies are used to decrease risk factors for SIDS?

-Back to sleep for every sleep
-Use firm sleep surface
-Keep soft objects and loose bedding out of crib
-Avoid tobacco smoke exposure during pregnancy
-Room sharing without bed sharing is recommended
-Avoid overheating

63

How do pacifiers and immunizations affect a baby's risk of SIDS?

pacifiers decrease SIDS

immunizations also decrease SIDS

so does breastfeeding