Pulmonary Flashcards
A 2-year-old boy presents acutely with:
Choking
Coughing
Wheezing
Diminished breath sounds on the right
Normal CXR
What is the most likely etiology of his symptoms?
Aspiration of a foreign body
Explanation
Promptly consider aspiration of a foreign body when a child ≤ 2 years of age acutely presents with choking, particularly if this is followed by the classic triad of cough, wheezing, and diminished breath sounds on physical exam. CXR may show asymmetric hyperinflation but is commonly normal. The most commonly aspirated objects are seeds, nuts, coins, hot dogs, balloons, jewelry, batteries, and firm vegetables.
A 2-year-old girl presents with:
High fever
Brassy cough
Stridor
She is given treatment for croup but does not respond and she deteriorates rapidly. She is intubated in the emergency department.
What is the most likely diagnosis?
Bacterial tracheitis
Explanation
This is the classic presentation for bacterial tracheitis. Initially, it appears that the patient has laryngotracheobronchitis (viral croup), but after receiving appropriate therapy, the child continues to deteriorate rapidly and may require intubation or tracheostomy. While a child with acute epiglottitis also presents with fever, stridor, and respiratory distress, the child would have drooling due to severe sore throat and difficulty swallowing and would not have a prominent cough, as seen in croup and bacterial tracheitis.
A 3-year-old girl presents with abrupt onset of:
High fever
Sore throat
Drooling
Stridor
She is given treatment for croup but does not respond. She deteriorates rapidly and is intubated in the emergency department. Her parents do not believe in immunizations.
What is the most likely diagnosis?
Epiglottitis
Explanation
This is a classic presentation for epiglottitis on the background of no Haemophilus influenzae Type b (Hib) immunization. Initially, it appears that the patient has laryngotracheobronchitis (viral croup), but after receiving appropriate therapy, the child continues to deteriorate rapidly and requires intubation (or tracheostomy).
A 17-year-old boy was visiting his grandparents in Indiana over the summer. Two months after cleaning out his grandfather’s chicken coop, he presents with:
Mild respiratory symptoms
Low-grade fever
CXR shows a few focal infiltrates with hilar adenopathy.
What is the most likely etiology of his symptoms?
Answer
Histoplasmosis
Explanation
Most cases of histoplasmosis are asymptomatic or only mild symptoms like our patient here, although some patients have more severe respiratory symptoms. Classically, this is seen in the Mississippi and Ohio River valleys. It is associated with the droppings of chickens and bats.
A 17-year-old girl known to have asthma presents with:
Cough, wheezing, and chest tightness with upper respiratory infection and exercise
Emergency department visit 2 years ago for an asthma exacerbation
Spirometry pulmonary function test (PFT) showed:
Forced expiratory volume in 1 second (FEV1) = 74%
FEV1/forced vital capacity (FVC) = 79%
Change in FEV1 postbronchodilator = 35%
What is the severity of her asthma based on PFT?
Moderate persistent asthma
Explanation
For pediatric patients ≥ 12 years of age, FEV1 > 60% but < 80% predicted is the defined range for moderate persistent asthma. For a 17-year-old patient, normal FEV1/FVC is 85%; that figure reduced by 5% is consistent with moderate persistent asthma.
A 2-week-old infant presents with inspirational stridor. It is much worse when the child is upset.
What is the most likely diagnosis?
Laryngomalacia
Explanation
Laryngomalacia is the most common cause of stridor in the newborn period. The laryngeal cartilage is just not stiff enough, and inspiration causes significant luminal narrowing. The stridor can occur at birth, but it most commonly presents at 2 weeks of age. Most children outgrow the disorder by 12–24 months of age.
A 15-year-old boy with a current history of active influenza A presents with abrupt onset of:
Fever
Tachypnea
Tachycardia
Cyanosis
CXR shows distinct pneumatoceles.
What is the most likely bacterium causing this illness?
Answer
Staphylococcus aureus
Explanation
Classically, look for this organism to cause pneumonia in a patient with recent or current upper respiratory infection or influenza infection. They may be doing better and then suddenly develop abrupt new symptoms of fever, tachypnea, tachycardia, and cyanosis. Pneumatoceles are classic for S. aureus, but can also be seen in Streptococcus pyogenes pneumonia—the influenza history here helps you separate these two.
A 17-year-old boy from northwest Arkansas who hunts frequently presents with a 1-month history of:
Low-grade fever
Cough with occasional hemoptysis
Chest pain
10-lb weight loss
Several verrucous lesions with irregular borders and microabscess formation at the periphery on the left arm
CXR shows upper lobe infiltrates with a cavitary lesion.
What is the most likely diagnosis?
Blastomycosis
Explanation
This is a classic description of blastomycosis that causes chronic pneumonia with dissemination to the skin. Most cases occur in Arkansas, Mississippi, Illinois, Wisconsin, and the states bordering these areas
A 15-year-old boy with cerebral palsy and seizure disorder with recurrent choking presents with:
Fever
Tachypnea
Tachycardia
Cyanosis
CXR shows diffuse infiltrates.
What is the most likely diagnosis
Aspiration pneumonia
Explanation
When there is a predisposition to aspiration, such as a history of seizure, neurologic disease, or dysphagia, pneumonia may be caused by aspiration of anaerobic oral flora and gram-negative organisms.
A 17-year-old Black girl presents for evaluation after receiving a CXR in the emergency department for a “possible pneumonia” that turned out to be a viral infection. However, the CXR shows that she has significant bilateral hilar and mediastinal adenopathy. She is completely asymptomatic and denies fever, night sweats, or weight loss. CXR shows no infiltrates. Tuberculosis, fungal diseases, and malignancy have been ruled out.
What is the most likely diagnosis
Sarcoidosis
Explanation
This is a classic presentation for sarcoidosis. She has Stage I, with bilateral hilar adenopathy and no parenchymal infiltrates. Many patients with sarcoidosis are asymptomatic, in which case, there is nothing therapeutically to do. If she had eye or CNS involvement, heart conduction abnormalities, severe pulmonary or skin signs/symptoms, or persistent hypercalcemia, then you would intervene with systemic steroids. Without these findings, just follow her for symptoms, which are unlikely to occur in most patients. Remember that erythema nodosum is associated with this, and if found, is a good prognostic indicator.
A 13-year-old girl presents with an initial history of:
Sore throat that is negative for group A Streptococcus by culture
Hoarseness
Now, 2–3 weeks later, she develops pneumonia.
What is the most likely etiology of her biphasic disease?
Chlamydia pneumoniae
Explanation
Chlamydia pneumoniae (formerly Chlamydophila pneumoniae) causes epidemic pneumonia in older children and adolescents. It is the cause of up to 10% of community-acquired pneumonias. This biphasic course is classic for C. pneumoniae infection.
A kindergartner with asthma is admitted to the hospital because of an acute asthma exacerbation.
What is the most likely cause of the acute asthma exacerbation in this child?
Answer
Viral infection
Explanation
While there are multiple asthma triggers (e.g., cigarette smoke, allergic rhinitis, gastroesophageal reflux, exercise), the most common risk factor associated with asthma hospitalization in this age group is viral infection.
A 17-year-old boy has the following:
Sinusitis
Bronchiectasis
Situs inversus
What is the most likely diagnosis?
Primary ciliary dyskinesia (PCD), Kartagener syndrome
Explanation
PCD is a rare autosomal recessive disease that can be sporadic or familial. There are numerous mutations that can cause the disorder, but half of the patients with PCD have Kartagener syndrome. It is associated with the 3 listed findings, as well as reduced male fertility
An 8-year-old girl presents with:
Iron deficiency anemia that was initially diagnosed 1 year ago
Progressive dyspnea
Fatigue
Recurrent cough with new onset hemoptysis
Sputum that shows hemosiderin-laden alveolar macrophages
What is the most likely diagnosis?
Answer
Idiopathic pulmonary hemosiderosis (IPH)
Explanation
Even though this disease is very rare, it still appears in the content specifications of the ABP. Typically, IPH presents before 10 years of age and may be progressive or abrupt in presentation. The progressive form is like this vignette, with iron deficiency anemia being the first abnormality noted (followed by the cough and hemoptysis). The key to making this diagnosis is having sputum or bronchoalveolar lavage that shows hemosiderin-laden alveolar macrophages
A 3-year-old girl presents with:
Rectal prolapse
Nasal polyps
What is the most likely diagnosis?
Cystic fibrosis (CF)
Explanation
Nasal polyps occur in up to 50% of patients with CF, and finding them in a child < 12 years of age guides you toward CF as a possible diagnosis. About 20% of patients with CF have rectal prolapse during early childhood. Remember, at birth about 10–20% of CF patients present with bowel obstruction, which is manifested by meconium ileus.
