1.

An 8-year-old female is admitted to the hospital for an exacerbation of

asthma. She has recently moved to this area and has not seen a primary care
provider in more than six months. She reports complaints of dyspnea, cough
and wheeze intermittently for the last four months. Initially the symptoms were
only related to exercise which forced her to stop playing actively with her
friends. Now she has symptoms almost daily and awakens several times each
week with wheezing. She lives in a non-smoking environment. She and her
parents deny any known environmental factors which contribute to her
difficulty in breathing. Prior to the last several months, she has had no
respiratory problems.  Since admission, she has been stabilized with frequent
albuterol treatments and is feeling much better. She is alert and conversive,
able to speak and play without restriction when you see her in the emergency
room. Physical examination is significant for an only mildly elevated
respiratory rate and mild expiratory wheezing with no accessory muscle
use/WOB at this time. Spirometry done at this time reveals a reduced FEV1
and FEV1/FVC at 60% of predicted for age. You consider asthma education
needs for this patient and begin thinking about appropriate
medication regimens for her condition upon hospital discharge. WHICH of the
following is the MOST APPROPRIATE choice of medication(s) to recommend
to her and her parents for long-term maintenance therapy of her condition?

Inhaled short-acting beta-2 agonist medication (albuterol), every 4-6 hours,

as symptoms warrant

Inhaled long-acting beta-2 agonist medication (salmeterol), twice daily

Inhaled corticosteroid twice daily, plus short-acting beta-2 agonist

(albuterol) treatment as needed

Oral prednisone tablets, twice daily

Montelukast (Singulair) tablets, once daily

2.

A 10-month-old child is brought in for urgent evaluation by her worried

parents. She has been ill with low-grade fever, cough, and nasal congestion
for several days. Last night, her cough sounded "barky" like a seal and her
parents are worried about her ability to breathe. She seems to have more
difficulty breathing when she becomes upset. On examination, you note the
child who is fussy but consolable. She appears well hydrated and in no acute
respiratory distress, although audible breath sounds are noted when she
begins to cry. You note her high-pitched barking cough.  What clinical finding
would you expect to hear upon auscultation?

Decreased breath sounds over the right lung field

Prominent expiratory sounds caused by bronchospasm and inflammation of

small airways

Prominent inspiratory and expiratory sounds caused by mucous deposition in

both large and small airways

Prominent inspiratory sounds caused by re-expansion of collapsed of alveolar

air spaces

Prominent inspiratory sounds caused by subglottic airway narrowing

 3.
An 18-month-old girl is seen in the emergency department for sudden onset of
respiratory distress during a family picnic. She is afebrile and has otherwise
been well. Physical examination demonstrates unilateral wheezing in the right
lung field. What is the MOST LIKELY finding you will see on her chest x-ray?

A consolidation of the right lower lobe with mediastinal shift to the right

A foreign body in the right mainstem bronchus

A consolidation of the right lower lobe with no mediastinal shift

Hyperinflation of the right lung with mediastinal shift to the left

A normal chest X-ray

4.

A 6-year old child presents to the emergency room with a four-day history of
fever and cough. He is otherwise healthy, although he did have a flu-like
illness about 2 weeks ago. On further questioning, his mother tells you that he
has been having a lot of cough. She can t tell you if its productive or not, but
the child says he thinks that he swallows stuff after coughing. Physical
examination is significant for temperature of 39.3 C (102.7 F), and respiratory
rate in the 40 s. Oxygen saturation is normal. On exam, the patient is using
accessory muscles of breathing. There are decreased breath sounds over the
right base, and dullness to percussion in the same area. You obtain a PA and
lateral CXR which reveals a lobar consolidation in the right lower lobe. What is
the MOST likely etiology of this patient s pulmonary process?

Mycoplasma pnemoniae

Streptococcus pneumoniae

Respiratory syncytial virus

Bordatella pertussis

Pseudomonas aeruginosa
 5.
A 3-week-old infant is brought to the emergency room by his parents. They
report that he seems to be breathing hard and had a couple of episodes
where it looked like he stopped breathing. They deny cyanosis or fever. When
you ask his mother about her pregnancy, she reports that it was uneventful.
She had prenatal care. She had no perinatal infections, and she was GBS
negative. The patient was born at full term via spontaneous vaginal delivery.
His nursery course was uneventful and he went home at approximately 36
hours of life. He established care with his pediatrician at 2 weeks of life, and
his mother proudly reports that he had already surpassed his birth weight. He
received his first vaccination, and his mother reports that his pediatrician said
he was in excellent health. He is exclusively breast fed, and had been eating
well (approximately 15 minutes per breast every 1-2 hours) until today. Of
note, the patient s 4-year-old brother has a cold. Physical examination reveals
the following: Temperature: 37.7 C (100 F), respiratory rate 65, blood
pressure 73/45, heart rate 168, oxygen saturation is 90% on room air. The
infant appears to be in respiratory distress. There are deep subcostal
retractions with inspiration. Exam of the lungs reveals diffuse wheezing and
poor air movement. Cardiovascular exam reveals tachycardia, but no
murmurs. Capillary refill is normal. After placing the infant on supplemental
oxygen, he appears much more comfortable and O2 sat increases to 95%.
You obtain a PA and lateral CXR which reveals hyperinflation and interstitial
infiltrates. You obtain appropriate laboratory studies to hopefully identify the
organism causing this infant s distress. Based upon the MOST LIKELY
etiology for this infant s respiratory difficulty, initial management should
include WHICH of the following measures:

Broad spectrum antibiotic therapy to cover most likely organisms

Inhaled corticosteroid therapy along with antibiotics

Systemic corticosteroid therapy along with antibiotics

Supportive care, including oxygen, hydration and bulb syringe suction as

needed

Ventilatory management as the infant is in significant respiratory distress

 6.
You see a 10-year-old boy in the emergency room with a 1 1/2 week history of
cough. He reports that his symptoms started with sore throat, headache,
malaise, and cough. He feels better overall, but his cough hasn t gone away.
In addition, he just started the little league season, and he notices that he gets
really out of breath when he s running the bases. On exam, the patient is
afebrile, but his respiratory rate is slightly increased. The patient appears
comfortable at rest. Auscultation of the lungs reveals diffuse rales. A PA
and lateral CXR shows diffuse fine interstitial infiltrates, and small bilateral
pleural effusions. Heart size is normal. WHICH of the following organisms is
the MOST LIKELY cause of this patient s pulmonary process?

Mycoplasma pneumoniae

Streptococcus pneumoniae

Respiratory syncytial virus

Bordatella pertussis

Pseudomonas aeruginos
 7.
A 16-month-old child is evaluated for respiratory distress in the middle of
winter. His anxious mother reports that he has had a few days of nasal
congestion and drainage. She also reports that the child has has felt warm to
her, although she did not measure his temperature. He started coughing
earlier today and his mother reports that the quality of his cough has recently
changed, in that it is now becoming more high-pitched and "barky" in nature.
He has been otherwise healthy and has no chronic illness. His mother thinks
that his breathing has become much more labored over the past several
hours. Your examination reveals a child who appears to be in mild respiratory
distress with an elevated respiratory rate of 36. Other vital signs, including
oxygen saturation, are within normal parameters. There is no accessory
muscle use or work of breathing noted. The child is not posturing in an
unusual position and has a non-toxic appearance. You note that most of the
child's work of breathing appears to be upon inspiration. WHICH of the
following findings are you MOST likely to appreciate upon auscultation of this
child's lung fields?

Expiratory wheezes

Fine crackles in bilateral lung fields

Inspiratory stridor

Rhonchi in bilateral lung fields

Whooping sound on inspiration

 8.
A 15-year-old girl with cystic fibrosis presents to the emergency room with
fever and worsening dyspnea. She has been admitted to the hospital several
times this year with pneumonia, and she just completed a course of antibiotics
as an outpatient about 2 weeks ago. She admits she may not have taken all
the doses as prescribed. In addition to bronchodilator therapy, she reports she
had been on inhaled tobramycin, but admits she hasn t taken it for awhile.
She says she has been having cough productive of yellowish-green sputum.
Physical examination is notable for vital signs as follows: temperature 38.5 C
(101.3 F), respiratory rate 28, blood pressure 105/67, heart rate 92, and
oxygen saturation 92% on 2L via nasal cannula. She is very thin and appears
younger than her stated age. She is barrel-chested (increased AP diameter of
the thorax). There is diffuse wheezing on auscultation of the lungs, and a
markedly prolonged expiratory phase. A CXR shows marked hyperinflation
and lobar consolidation in the right middle lobe. WHICH of following
statements regarding cystic fibrosis is true?

A finding of bronchiectasis is inconsistent with a diagnosis of cystic fibrosis

Cystic fibrosis is an autosomal recessive condition inherited through gene

expression on chromosome number 5

Exacerbation of illness due to serious infection (as in the vignette above) is

most often caused by gram positive organisms

Maintenance therapy of cystic fibrosis includes bronchodilators, airway

clearance and DNAse

The underlying defect of cystic fibrosis is in sodium and potassium transport

channels in the lungs and other organs