PULMONOLOGY Flashcards
Newborn with inspiratory stridor and noisy
breathing; stridor improves in the prone position with head elevated and worsens in the supine position
Laryngomalacia (usually benign, self-limiting
and improves as the child reaches age 1–2 years)
What is the treatment for laryngomalacia?
Reassurance (careful observation and growth
monitoring)
Newborn with a hoarse voice, weak cry, and
biphasic stridor that is louder when awake.
Improves when positioned to be lying down on one side
Unilateral vocal cord paralysis
An infant with bulging anterior fontanelle, highpitched biphasic stridor, respiratory distress, and recurrent pneumonia
Bilateral vocal cord paralysis
Adolescent male present with shortness of breath, choking sensation within a few minutes after starting track training; there is a voice change during exercise. He was treated for exercise-induced asthma with no improvement in his symptoms. What is the next best step?
Vocal cord evaluation. Most likely diagnosis is
paradoxical vocal cord dysfunction
Child with a history of chin hemangioma,
worsening inspiratory stridor
Subglottic hemangioma
Newborn with intermittent cyanosis that disappears when crying but prominent during feeding; nasogastric tube unable to pass through the nostrils
Choanal atresia
An infant with cyanosis, the mother is mixing the formula with well water; normal cardiac and
pulmonary examination, normal pulse oximetry.
Chocolate-colored blood noticed when collecting the blood for testing
Methemoglobinemia
Boy with unilateral persistent offensive smelling
nasal discharge
Nasal foreign body
Recurrent pneumonia and nasal polyps
Cystic fibrosis
Recurrent pneumonia and nasal polyps
Cystic fibrosis
Sinusitis, bronchiectasis, situs inversus, reduced
male fertility
Kartagener syndrome
A 4-year-old boy is suffering from recurrent
sinusitis, chronic otitis media; during the neonatal period he had respiratory distress, daily nasal congestion, and wet cough. What is the most likely diagnosis?
Primary ciliary dyskinesia
Child with no known health problem woke up
suddenly coughing blood. What is the most likely cause?
Epistaxis
Child with a 1-day history of low-grade fever,
malaise, congestion, and very thick, very green
nasal discharge
Viral upper respiratory tract infection
Child with 2 weeks of clear nasal discharge and a cough that is worse at night and while lying down supine. Not responding to nasal allergy
medications
Acute bacterial sinusitis
A 7-year-old with fever, runny nose, throat pain;
the pharynx is erythematous and shows white
exudate
Viral pharyngitis
A 7-year-old with abrupt onset of fever, headache, stomach pain, mild throat pain; the pharynx is erythematous, with petechiae, no white exudates
Strep throat (Streptococcus pyogenes)
A 15-month-old boy presents with poor feeding,
high fever, thick, purulent profuse nasal discharge, crust and irritation around the nostrils
Streptococcal fever or streptococcosis
When can a child with streptococcal infection go
back to school after taking an antibiotic (become noninfectious)?
Next day if improved (typically 24 h after the
antibiotic)
Toddler with a barking cough, fever, inspiratory
stridor, suprasternal retractions, and neck
radiograph is normal
Croup
What is the mainstay treatment of croup?
Dexamethasone and racemic epinephrine can be used in moderate/severe cases
A toddler presents with high fever, looks toxic,
brassy cough, and stridor. He was sent home on
oral antibiotics and ibuprofen, a few hours later he died
Bacterial tracheitis
A 5-year-old, unimmunized, presents with sudden onset of fever, stridor, drooling and throat pain, leaning forward and crying
Epiglottitis
Preschool child has been having recurrent attacks of barking cough and croup over the last few nights, and no symptoms of cough in-between the attacks
Spasmodic croup or due to GI reflux
A 3-month-old with fever, cough, runny nose,
tachypnea and retractions. O/E: wheezing, and
crackles in both lung fields; pulse oximetry is 92%
Acute bronchiolitis
What is the first-line treatment for bronchiolitis?
Nasal suctioning and supportive care
A preterm boy with chronic lung disease is
receiving palivizumab prophylaxis, recovered from RSV bronchiolitis a few days ago. Can he take his next due dose of palivizumab?
No (discontinue palivizumab for the season)
A 1-month-old infant who was born at 35 weeks
during winter has been having nasal congestion for the last 2 days; stopped breathing for a few
seconds and turned blue, positive RSV
Apnea secondary to RSV viral infection
A 3-week-old with pneumonia; chest radiograph
shows bilateral infiltrates
Chlamydia trachomatis
Adolescent with fever, cough, chest pain, shortness of breath, tachypnea, and pleural friction rub
Streptococcus pneumoniae
Adolescent had influenza A infection, now is
having a very high fever, looks toxic; tachypnea,
respiratory distress, and tachycardia; chest
radiograph is positive for infiltration, cavities, and pleural effusion
Staphylococcus aureus pneumonia
A 7-year-old boy has a cough, on and off fever,
and headache for 2 weeks, on the exam he has
diffuse expiratory wheezing and crackles in both
lung fields with no retractions or tachypnea. Pulse oximetry is normal. The wheezing is not fully responsive to nebulized albuterol treatment. What is the most likely cause?
Mycoplasma pneumoniae
What is the most helpful diagnostic test in cases of atypical pneumonia possibly due to Mycoplasma pneumoniae
Polymerase chain reaction (PCR) from nasal
washing for Mycoplasma antigen
What is the antibiotic of choice for older children with atypical pneumonia who are ill enough to require hospitalization?
Macrolide antibiotic to shorten the course of
illness
Mississippi and Ohio river valleys, chickens, caves, low-grade fever, cough, hilar lymphadenopathy
Histoplasmosis
Adolescent living in Arkansas presents with
flu-like symptoms; fever, chills, headache,
myalgia, and cough; 2 weeks later developed
hemoptysis, chest pain, shortness of breath, weight loss, extreme fatigue, and skin lesions. Chest radiograph shows a focal mass with well-defined margins about 6 cm in size in the right upper lobe and few other focal segmental opacities
Blastomycosis
Child visited California’s San Joaquin Valley
3 weeks ago, now has a fever, chills, cough, weight loss, chest pain, and erythema nodosum. Chest radiograph is normal
Coccidioidomycosis
What is the most sensitive serologic test in cases with suspected coccidioidomycosis?
Coccidioides immunoglobulin M (IgM)
History of asthma, recurrent attacks of fever,
fatigue, coughing mucus plugs, hemoptysis,
eosinophilia, high IgE
Allergic bronchopulmonary aspergillosis
A sore throat with hoarseness; 3 weeks later
develops pneumonia
Chlamydophila pneumoniae
Toddler with a history of choking 2 weeks ago; he has had a cough since then, wheezing, diminished breath sounds on the right; normal chest radiograph
Foreign body aspiration
Chest radiograph views that may help in the
diagnosis of cases with suspected foreign body
aspiration
Inspiratory and expiratory or bilateral decubitus
views to see asymmetric hyperinflation on the
side with foreign body due to ball-valve effect
Child with progressive dyspnea, fatigue, recurrent cough, new-onset hemoptysis; sputum shows hemosiderosis-laden alveolar macrophages, and CBC is consistent with iron deficiency anemia
Pulmonary hemosiderosis
African-American with shortness of breath,
blurring of vision, erythema nodosum,
hypercalcemia, elevated ACE level. Chest
radiograph shows bilateral hilar lymphadenopathy
Sarcoidosis
Child with recurrent episodes of left lower lobe
pneumonia; chest radiographs demonstrated focal consolidation in the same location in all events; between episodes the child is well, active, and playful
Pulmonary sequestration
Child with fever, chest pain, and productive cough; chest radiograph shows cyst-like lesion close to the mediastinum
Bronchogenic cyst
An infant has difficulty with feeding, stridor,
recurrent wheezing, history of recurrent
pneumonia. Barium esophagography showed
posterior compressions. What is the most likely
diagnosis?
Vascular ring
Asthma > 1 night/week, throughout the day,
extreme limitation of activity, FEV1: < 60%
Severe persistent
Asthma 3–4 nights/month, daily, some limitation
of activity, FEV1 60–80%
Moderate persistent
Asthma 1–2 nights/month, 3–6 days/week, minor limitation of activity, FEV1 > 80%
Mild persistent
Asthma ≤ 2 days/week, 0 nights/month, no
limitation of activity, FEV1 > 80%
Intermittent
Step 1 management of intermittent asthma
Short-acting beta agonists (SABA) as needed
Step 2 management of mild persistent asthma
Low-dose inhaled corticosteroids (ICS)
Step 3 management of moderate persistent asthma
Medium-dose ICS, and consider short course
oral corticosteroids (OCS)
Step 4 management of severe persistent asthma
Medium-dose ICS + LABA and consider a short
course of OCS
What is the most effective primary controller
treatment for asthma of any severity?
ICS
A 10-year-old boy has shortness of breath and
cough every time he runs or exercises; positive
family history of asthma; on physical exam the
lung is clear, the pulmonary function test is
normal. What is the next best step?A 10-year-old boy has shortness of breath and
cough every time he runs or exercises; positive
family history of asthma; on physical exam the
lung is clear, the pulmonary function test is
normal. What is the next best step?
Exercise-induced asthma—use albuterol
(bronchodilator) inhaler 15 min before exercise.
Warm up prior to strenuous activity
Child with nighttime snoring, enlarged tonsils, and difficulty concentrating in school
Obstructive sleep apnea
