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2019 Bank of Goodness > Respirology - 2019 Updated! > Flashcards

Respirology - 2019 Updated! Flashcards

1
Q

What is the most sensitive PFT for small airways disease:

a) FEV1
b) FEV1/FVC
c) FEF 25-75
d) peak flow velocity

A

c) FEF 25-75
(Forced Expiratory Flow)
● FEF 25-75: mean expiratory flow in middle half of FVC maneuver
o Reflects flow through small airways (< 2mm diameter)

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2
Q

A 15 year old boy with recurrent pneumonia. RML x3, RLL, LLL in the past. Next test:

a) Quantitative immunoglobulins
b) Pulmonary function tests
c) Lung scan

A

a) Quantitative immunoglobulins
Recurrent Pneumonia= 2 or more episodes in single year or 3 or more episodes ever (with CXR clearing between occurrences) - think primary immune deficiency
*if recurrent in same lobe suspect structural abnormality

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3
Q

14 year old boy with Duchenne’s, who is in a wheelchair, has recently seen his FVC fall from 30% to 21% predicted. What symptom will he most likely complain of?

a) Headache early in morning
b) Headaches in the afternoon
c) Tingling of his fingers
d) Dyspnea with exertion

A

a) Headache early in morning

- Nocturnal hypoventilation (early sign of muscle weakness) - morning headache, daytime fatigue

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4
Q

A 12 year old presents to your office with a history of quickly fatiguing with exercise. Her physical exam is unremarkable in your office. You send her for PFTs. What would you expect the results to be if her trouble was related to deconditioning? What if it was related to asthma? What about restrictive lung disease?
a. Fill in a table with normal, increased or decreased for the following PFTs: FEV1/FVC, MMEF25-75 and RV/TLC (rows for asthma and deconditioning).

A 
Asthma: FEV1/FVC decreased
- MMEF25-75 decreased
- RV/TLC increased
Deconditioning: FEV1/FVC normal
- MMEF25-75 normal
- RV/TLC normal
Restrictive: FEV1/FVC normal/increased
- MMEF25-75 normal
- RV/TLC normal/increased
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5
Q

Newborn has significant respiratory distress and CXR that is consistent with pneumonia. She is ventilated with PIP 36, PEEP 5 rate 60 bpm, FiO2 1.0, she is not saturating very
well. What is the likely diagnosis? What intervention should you start now?

A
  1. PPHN
  2. iNO

Depending on age-
Could also consider RDS and give BLES (bovine lipid extract surfactant) 5ml/kg

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6
Q

You see a 6 year old girl with a history of a productive cough and persistent otitis media. On physical exam, you note cobblestoning of the oropharynx. What is the
most appropriate diagnostic test:

a. Immunoglobulins
b. CT chest
c. tracheal aspirate
d. bronchial biopsy
e. call a psychic hotline

A

d. Bronchial Biopsy

Chronic cough + recurrent AOM + rhino sinusitis MUST consider Primary Ciliary Dyskinesia

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7
Q 
8 year old girl with cough at night and with exertion for the past three months. PFTs are all normal. What would you do next:
A) CXR
B) Treat with b2 agonist
C) Methacoline challenge
D) PH probe
A

C) Methacoline challenge

- very specific for asthma

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8
Q

7 year old with sore throat in the mornings, bad breath, chronic cough with abdominal pain for 2 weeks. Her cough is worse with activity. What test will give you the diagnosis?

a) Throat swab
b) Pulmonary function tests with methacholine challenge
c) pH probe
d) Upper GI series

A

c) pH probe

NASPGHAN recommends a trial of acid suppression in patients with symptoms consistent with GERD prior to referral to GI or pH probe.

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9
Q

6y F with chronic cough x 8 mos. Occurs unrelated to illness. It is a harsh cough during the day that decreases at night. Previous unsuccessful treatment for croup x 4 What is the likely diagnosis?

a. Athma
b. Post-viral cough
c. Habit cough
d. Vascular ring

A

c. Habit cough

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10
Q

A 1 year old child has a cough, and mom wants to know if she can use an over-the- counter cough preparation for him/her. What do you tell her?

A

No safe cough medications for kids under 6

  • no studies show significant benefit, and there is risk of serious side effects with over the counter cold medications
  • best Tx is rest and fluids
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11
Q

A child is seen at 4 weeks of age in your office. They have had viral URTI symptoms for a week and now have cough and tachypnea. There is no increased work of breathing or wheezing. On CXR there is patchy atelectasis and interstitial infiltrates. What is the most likely etiology:

a. Ureaplasma urealyticum
b. Chlamydia pneumonia
c. RSV

A

b. Chlamydia pneumonia
- young infants, afebrile illness, insidious onset between 1-3m
- repetitive cough “staccato”, tachypnea, rales in afebrile 1 month old is characteristic
- absence of fever and wheezing helps distinguish from RSV
- peripheral eosinophilia
- CXR with hyperinflation and minimal infiltrates

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12
Q

A 2 year old child is transferred to your center after 12 hours in a peripheral centre being treated for croup. They have had an acute onset of stridor and a barking cough after 1-2 days of viral URTI symptoms. There has been minimal response to 2 doses of neb racemic epinephrine and 2 doses of corticosteroid. On arrival the child is anxious, stidorous and has increased work of breathing. What is the next step in your management process:

a. Orotracheal intubation
b. Heliox
c. IV ventolin

A

a. Orotracheal intubation
- think bacterial tracheitis in kid with croup who is not responding to croup treatment
- tx: vanco or cloned and cefotax or ceftriaxone

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13
Q

3 mo with recurrent URTI. Has had on + off stridor since birth. On exam looks well, afebrile, VSS, intermittent stridor on inspiration. Most likely diagnosis?

a. Laryngomalacia
b. Viral croup
c. Laryngeal web
d. Vascular ring

A

a. Laryngomalacia

o Sx at 1-2 weeks and increase up to 6m (vs vascular ring where symptoms present at about 3 months)

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14
Q

A 4-year-old child has a chest x-ray done for a different reason, but it shows an asymptomatic solid circular lesion in the anterior mediastinum:

a) ganglioneuroma
b) neuroblastoma
c) lymphoma
d) teratoma
e) metastasis from a Wilms’ tumor

A

d) teratoma (anterior only - should have solid/cystic components)

or

c) lymphoma (can be anterior or other areas of mediastinum); non-Hodgkin or Hodgkin’s; but typically older age peak incidence + B symptoms

a) ganglioneuroma (posterior)
b) neuroblastoma (posterior)
e) metastasis (not common site for mets)

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15
Q

Newborn with respiratory distress and cystic lesion in LUL with tracheal deviation. What is the most likely diagnosis:

  1. CCAM
  2. Pulmonary sequestration
  3. Pneumonia
A
  1. CCAM
    congenital pulmonary airway malformation (CPAM)
    o Sx- asymptomatic, resp distress, resp infections, pneumo, hydrops, hypoplasia of other lobes, chest pain, mediastinal shift away
    o Ix- CT scan (even if asymptomatic)
    o Rx- resection by 1 year (malignant potential)
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16
Q

In asthma, bronchiolar hyperresponsiveness:

a. Is present even if spirometry is normal
b. Decreases with a URI
c. Is not a sensitive test for the diagnosis of asthma
d. Is not inherited

A

a. Is present even if spirometry is normal

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17
Q

3-year-old with asthma exacerbation in moderate respiratory distress. Can speak in sentences. Tachypneic and wheezing.

Which test would you do:

a) chest x-ray
b) arterial blood gas
c) spirometry (FVC, FEV 1 )
d) O 2 saturation by pulse oximetry
e) flow, end tidal CO 2

A

d) O 2 saturation by pulse oximetry

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18
Q 
5 year old with asthma. Treated with ventolin overnight and Q 30 this morning. Aminophyline added this morning to help improve oxygenation. Child complaining of nausea and weakness. You should check:
A) serum sodium
B) serum glucose
C) serum potassium
D) serum magnesium
A

C) serum potassium
hypokalemia
o Symptoms: nausea (GI decreased peristalsis), neuromuscular excitability (hyporeflexia, paralysis), arrhythmias

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19
Q

You are called about an asthmatic with a unilateral pneumothorax. In arranging medical air transport to your Intensive Care Unit, you suggest:

a) insert a chest tube on the affected side
b) insert a chest tube if the pneumothorax is greater than 10%
c) insert a chest tube only if the patient requires intubation
d) insert a needle into the 2nd intercostal space, midclavicular line
e) transfer without intervention

A

a) insert a chest tube on the affected side

Boyle’s Law

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20
Q

Which is true regarding asthma management:

a) beta-2 agonists act primarily on small airways
b) systemic beta-2 agonists work better than inhaled
c) steroids increase the responsiveness to beta-2 agonists
d) Cromolyn is useful in the acute phase of asthma

A

c) steroids increase the responsiveness to beta-2 agonists

Steroids not only seem to reduce bronchial inflammation and hyperreactivity, and thereby the distribution of inhaled drugs, but also attend to reverse beta 2-receptor subsensitivity.

(we answered a)

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21
Q

Patient on budesonide 200 mcg bid for five years for poorly controlled asthma. Best to monitor?

a. No investigations
b. Height velocity
c. Cortisol levels

A

b. Height velocity

Screen for adrenal suppression if on high dose for >6 mos (morning serum cortisol)

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22
Q

A 6-year-old asthmatic has been receiving 400 mcg of budesonide 4 times daily for the past 2 months with no improvement. His cough is worse at night. Physical examination is normal. His inhalation technique is adequate. What next:

a) increase budesonide to 600 mcg 4 times daily
b) add oral prednisone for 5 days
c) add sodium cromolyn
d) add theophyline
e) add a long-acting beta-2 adrenergic medication

A

e) add a long-acting beta-2 adrenergic medication (salmeterol)

● Add-On Therapy to ICS if symptomatic or experiencing significant AE despite optimal use of moderate dose inhaled steroids
o (1) consider increasing steroid dose
o (2) add long-acting beta two agonist (if min. 4 y.o.)
▪ combined meds= Advair (fluticasone + Salmeterol), symbicort (budesonide + formoterol), zenhale (mometasone + formoterol)

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23
Q

The following is true about MDI’s in adolescents with asthma

a. pinch nose when using MDI
b. dispense medication at beginning of exhalation
c. hold breath for 3 seconds after puff
d. take medication in slowly through the whole of inspiration
e. hold MDI in mouth

A

d. take medication in slowly through the whole of inspiration
- consider put in mouth depending on how question is phrased
- should hold breath for 10 seconds after inhalation
- with spacer: slow (5 sec) inhalation with 5-10sec breath-hold OR regular breathing for 30 seconds (5-10 breaths)

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24
Q

Indication that asthma is in poor control:

a. 2 ventolins per week pre-exercise
b. 2 ventolins per week for symptomatic wheeze
c. 2 ventolins per week for night-time cough
d. 2 ventolins per month with colds

A

c. 2 ventolins per week for night-time cough

Signs of poor symptom control or exacerbation:
· Symptoms occurring ≥2 days/week or ≥8 days/month
· ≥8 days/month with use of inhaled short-acting β2-agonists (SABA)
· ≥1 night awakening due to symptoms/month
· Any exercise limitation/month
· Any absence from usual activities to asthma symptoms;
· Episodes requiring rescue oral corticosteroids or hospital admission;

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25
Q

What is the best indicator for mortality in asthma

a) previous intubation
b) previous oral steroids
c) family history
d) history of atopy

A

a) previous intubation

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26
Q

Which of the following is correct with respect to the use of a spacer with an MDI:

  1. Decreases spray effect
  2. Increases oral deposition
  3. Decreases bronchial deposition
  4. Usually requires a normal tidal volume
  5. Does not require coordination
A
  1. Does not require coordination
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27
Q

Asthma Question
What is an indication of bad control?
What should be monitored in chronic asthma for control?

A 
1. bad control: 
any night time symptoms 
limitations of activity
4+ daytime symptoms/week
4+ Rescue inhaler / week
Need for oral corticosteroids
ED visits
  1. monitor PFTs, ventolin usage, ED visits and hospitalizations
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28
Q

A 6 year old boy has been on moderate dose inhaled corticosteroids continuously for his asthma. His mother is concerned about his final adult height. What do you tell her about the current literature in the area:

a. He will be slightly shorter than his expected adult height
b. There will be no effect on his adult height
c. He will be significantly shorter than his predicted height
d. There will now be a significant catch up period of growth

A

a. He will be slightly shorter than his expected adult height

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29
Q

8 yo with BMI 25, SOB with exertion. Dad with allergic rhinitis. Patient has mild eczema. PFTs show. FVC 80%, FEV1 84% → 87% with bronchodilator and FVC to 85%. What is the treatment?

a. BID fluticasone
b. Salbutamol prior to exercise
c. Montelukast
d. Physical training

A

d. Physical training
- BMI 25 super obese for an 8 year old
- normal PFTs and no bronchodilator response (significant response is 12% increase)

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30
Q

Which of the following is the most helpful measure to decrease risk of asthma?

a. dust mite covers
b. elimination of environmental smoke exposure
c. removing pets from the home
d. breastfeeding

A

d. breastfeeding
- all of them except removing pets will decrease risk of asthma (exposure to pets is protective against asthma)
- choosing BF over elimination of smoke because the therapeutic effect comes from long standing avoidance of cigarette smoke even prenatally

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31
Q

Teen with asthma. Still symptomatic on inhaled fluticasone 125 mcg BID and monteleukast. Uses ventolin QID. Best treatment to address acute and chronic symptoms.

a. Salmeterol and fluticasone
b. Formoterol and budesonide
c. Salmeterol and ciclesonide

A

b. Formoterol and budesonide
“in adult patients who are poorly controlled the use of budesonide/formoterol in a single inhaler as a rescue medication instead of a SABA in addition to its regular use as a controller therapy has been shown to be effective”

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32
Q

Teenager with history of asthma. She is currently on Fluticasone 125 mcg bid. She has been needing to use her Ventolin puffers, two to three times a week in the day time over the past while. What four suggestions could you make for her management?

A
  • review proper puffer technique including use of aerochamber and ensure patient compliance with medication
  • eliminate environmental exposures
  • no tobacco smoke (first or second hand)
  • allergens (pets, dust mites, mold)
  • pFT
  • Treat comorbid rhinitis, sinusitis, GERD
  • Impact of obesity
  • Education
  • Asthma action plan

If worsening -

  • could add LABA/ics
  • if significant allergic component could use omalizumab
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33
Q

4 year old with asthma on inhaled steroids. Name 2 mechanisms of delivery of asthma medication.

A
  • multiple dose inhaler
  • DPI (dry powder inhaler) device (diskus, flexhaler autohaler, twisthaler)
  • nebulized solution
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34
Q

Child in status asthmaticus who has been given inhaled beta agonists, ipratroprium bromide and iv steroids. Heʼs still in trouble.
What are FOUR other medications that can be tried?

A
  1. IV magnesium sulphate
  2. IV ventolin
  3. IV aminophylline
  4. heliox
  5. Ketamine
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35
Q

An 18-year-old male presents with left sided chest pain that radiates to his shoulder. There is a pneumothorax visible on chest x-ray. What is the most likely explanation:

a) idiopathic
b) cocaine abuse
c) status asthmaticus
d) emphysematous bleb
e) previously undiagnosed Marfan syndrome

A

a) idiopathic
Most common cause of spontaneous= Primary idiopathic: usually resulting from sub pleural blebs.

Primary spontaneous pneumothorax (PSP) typically occurs in tall, thin boys (teenage years). Smoking cigarettes increases the risk.

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36
Q

17 yr old male found to have pneumothorax on CXR. He
had been at a party that night. What is the number one cause of pneumothorax?
a) Spontaneous
b) Cocaine
c) Status asthmaticus
d) Undiagnosed Marfan syndrome

A

a) Spontaneous

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37
Q

Teen with tension pneumothorax, where do you put the needle?

a. needle over 3rd rib, in the second intercostal space at the midclavicular line
b. needle over 5th rib, in the fourth intercostal space midclavicular line
c. Needle in 2nd IC space, anterior axillary line

A

a. needle over 3rd rib, in the second intercostal space at the midclavicular line
- OR 4th ICS in anterior axillary line

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38
Q

Teen with ARDS. What is the most likely:

  1. increased pulmonary airway resistance
  2. decreased compliance
  3. decreased elastic recoil
  4. hyperinflation
A
  1. decreased compliance

The atelectasis, edema, and inflammation seen in ARDS define it as a restrictive lung disease. ARDS lungs have low compliance, and also have low functional residual capacity. (“baby lungs” Inactivation of surfactant)

Acute respiratory distress syndrome is a life-threatening lung condition involving non-cardiogenic pulmonary edema due to disruption of the alveolar-capillary barrier. This results in hypoxemia, loss of aerated lung tissue, decreased respiratory compliance, and usually requires PICU admission for mechanical ventilation

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39
Q

15 y/o status post therapeutic abortion. Sudden onset of respiratory distress. On exam, bilateral crackles. She is coughing blood. What is the best test:

  1. ECG
  2. Pulmonary angiography
  3. CXR
  4. Pulmonary V/Q scan
  5. Leg dopplers
  6. CT chest
A
  1. Pulmonary angiography - gold standard
  • spiral CT with contrast could also be an option, but not normal CT chest
  • has a PE (pregnancy is risk factor)
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40
Q

2-year-old with persistent wheezing localized to the RLL x 8 weeks. Unable to obtain inspiratory and expiratory films. Next test:

a) lateral decubitus chest x-ray
b) CT chest
c) MRI chest
d) nuclear lung scan
e) bronchoscopy

A

a) lateral decubitus chest x-ray
▪ Side with FB will not deflate when placed in dependent position (i.e. if right side has foreign body, put right side down and right side will not deflate as expected
o If high degree of suspicion, bronch should be performed despite (-) results.
▪ And if (+) Hx and convinced can go right to bronch.

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41
Q

Infant has problem of vomiting with feeds and chronically wheezy. Upper GI shows indentation of upper esophagus. What are two diagnoses you consider?

A
  • vascular ring
  • pulmonary artery sling
    (2 specifically say in Nelson’s that they are associated with esophageal indentation, wheeze and vomiting)
  • Esophageal web
  • Diverticulum
  • Tumor
  • Enlarged LN
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42
Q

Wheezing toddler with URTI symptoms. Which is a proven therapy?

a. O2
b. racemic epi
c. iv steroids
d. bronchodilators

A

a. O2

for bronchiolitis

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43
Q

Proven therapy in a kid with recurrent viral wheezing?

a. Ventolin
b. Fluticasone X 3 weeks

A

a. Ventolin

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44
Q

teenage elite female athlete is having episodes of shortness of breath, chest tightness and wheezing with exercise. She has had an oxygen sat during the episode of 100%, a negative bronchodilator challenge and a negative CXR. What is the most likely cause of her condition? What is the best management of this?

A

Paradoxical vocal cord dysfunction
- speech therapy and behaviour modification are therapeutic

  • symptoms include throat tightness, dyspnea, wheeze, chest tightness, cough
  • no response to bronchodilators
  • CXR is normal
  • PFTs are normal aside from the inspiratory flow loop
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45
Q

What is the management of exercise induced asthma?

A

Note re exercise induced asthma:

  • diagnosis of EIA can be confirmed by 15% decrease in FEV1 5-10 minutes after an exercise test (non asthmatic people increase their FEV1 in response to exercise)
  • SABA 15 minutes prior to exercise
  • warm up and cool down
  • avoid exercising in cool, dry environments
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46
Q

Kid with wheeze 5-6 yrs old. You have dx asthma. Unresponsive to therapy, steroid, laba, leukotriene inhibitor. Has dyspnea and wheeze. List 4 alternative diagnosis to asthma in your ddx.

A
  • allergic rhinitis/sinusitis
  • foreign body aspiration
  • laryngeal web, cyst or stenosis
  • vocal cord dysfunction/paralysis
  • TEF
  • vascular ring, sling or external mass compressing airway
  • viral bronchiolitis
  • GERD
  • bronchiectasis (CF)
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47
Q

A 3 month old child had a TEF repaired in the first few weeks of life. He now presents in your office with stridor. List 3 causes of his stridor.

A
  • refistulization (recurrence of TEF)
  • stricture
  • GERD
  • Croup
  • Vocal cord paralysis
  • Subglottic stenosis
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48
Q

A child is noted to have nasal polyps. Next step:

a) referral for surgical excision
b) intranasal corticosteroids
c) oral antihistamines
d) oral decongestants
e) arrange a sweat chloride

A

e) arrange a sweat chloride

CF should be suspected in any child younger than 12 yr old with nasal polyps, even in the absence of typical respiratory and digestive symptoms.

Nasal polyposis is also associated with chronic sinusitis

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49
Q

14 year old with CF has sudden onset of severe left chest pain over for the past three hours. The pain is now involving the left shoulder. Some respiratory distress. Mother notes that he has been well, but did miss physio that week. Most likely diagnosis is:

a. RLL pneumonia
b. pneumothorax
c. pleural effusion

A

b. pneumothorax

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50
Q

Teen boy with CF has had 2 days of gradually increasing pleuritic chest pain.

What is the most likely cause?

a. Infective exacerbation
b. Pneumothorax
c. Pleurodynia

A

b. Pneumothorax
- asymptomatic but is often attended by chest and shoulder pain, shortness of breath, or hemoptysis.

Exacerbation - more likely to comment on:

  • increased RR
  • WOB, SOB, Decreased exercise tolerance
  • Decline PFTs
  • Fever
  • Increased cough, sputum change
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51
Q

In a child with cystic fibrosis, which of the following findings would have the worst prognostic implications:

a. liver disease
b. hemoptysis
c. malnutrition
d. pneumothorax
e. pancreatitis

A

ANSWER: c. malnutrition
*a. liver disease (third most common cause of death in CF after resp failure and transplant complications)
- other prognostic factors:
o Gender (F slightly worse)
o Type of infection (Burkholderia cepacia leads to early deterioration)
o FeV1
o CF related DM associated with poor prognosis

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3
4
5
Perfectly
52
Q

What clinical situation predisposes to the worst outcome for cystic fibrosis?

a) malnutrition
b) liver disease

A

a) malnutrition

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
53
Q

What can cause a false negative sweat chloride test?

  1. Low albumin
  2. Low magnesium
  3. Low phosphate
  4. Low chloride
A
  1. Low albumin
  • other false negatives: dilution, malnutrition, edema, insufficient sweat quantity,
    hyponatremia, hypoproteinemia
54
Q

Girl with rectal prolapse x 2 reduced easily in the ER. What do you do?

a. reassure mom
b. observe and follow in 3 months
c. sweat chloride
d. barium enema

A

c. sweat chloride

55
Q

3 month old boy comes in for routine newborn care. The mother describes symptoms of URTI and mentions that when he has coughed on two recent occasions, she has noticed a swelling protruding from his anus [picture of rectal prolapse]. List the most likely underlying etiology .

A
  • most cases are idiopathic
  • rule out underlying conditions including CF and sacral nerve root lesions
  • Pertussis
  • Diarrhea
  • Constipation
  • Malnutirition
  • Ehlers-Danlos
  • UC
  • Intestinal parasites
56
Q

16 yo female with CF and complaints of chest pain, cough that produces a rust colored sputum.

  1. What is the most likely diagnosis
  2. List 2 investigations to confirm diagnosis.
  3. What is your treatment?
A
  1. ABPA - allergic bronchopulmonary aspergillosis
  2. dx: sputum culture for aspergillus
    - skin test for A. fumigates
    - Specific IgE and IgG for A. fumigates
    - Eosinophils in sputum
    - elevated serum IgE
    - CXR
    - PFT
  3. oral corticosteroids first line
    - may need antifungals, but goal is to control the allergic reaction to the fungus, not treat the fungus
57
Q

List 3 organisms that colonize airway of patients with CF

A
  • staph aureus
  • hemophilus influenza
  • pseudomonas aeruginosa
  • MRSA
  • stenotrophomonas maltophilia
  • burkholderia cepaciae
  • aspergillus
  • nontuberculous mycobacertia
58
Q

You are unable to obtain a sweat sample in a neonate. List 3 other ways to confirm the diagnosis of CF.

A

Presence of typical features OR
Hx of CF in sibling OR
Positive newborn screen

PLUS

  • x2 elevated sweat chloride
  • Identifying x2 CFTR mutations
  • nasal potential difference
59
Q

Kid with CF. Reduced PFT by 30%. Maxed out on salbutamol. Give four interventions to improve his lung function

A
  • chest physiotherapy
  • human recombinant DNase (dornase)
  • nebulized hypertonic saline
  • routine aerobic exercise
  • ensure adequate nutrition
  • antibiotic therapy
  • inhaled corticosteroids
  • voluntary cough and forced expiratory maneuver (in-ex sufflator)
60
Q

A chest tube was inserted into a child with empyema and whiteout of the left lung field. 12 hours after the chest tube insertion, a repeat CXR shows persistent pleural air. The chest tube system is patent. List 3 causes of the persistent pleural air

A
  • bronchopleural fistula
  • necrotizing pneumonia
  • equipment failure
61
Q

A 16-month-old ex-prem with BPD presents with fever (39.4), cough, rhinorrhea, and dyspnea. On exam, febrile, RR 40, no wheeze, but decreased air entry over LLL. There have been several other infants in the community who have been recently admitted to hospital and found to have RSV. What would be your management of this infant:

a) outpatient Ventolin q4h
b) outpatient Pulmicort
c) outpatient antibiotics
d) admit for treatment with Ribavirin
e) admit for blood culture, IV antibiotics, and tests for RSV

A

e) admit for blood culture, IV antibiotics, and tests for RSV
- or maybe outpatient antibiotics depending on clinical picture, but err on side of caution given BPD

CPS- RSV High Risk

  • Premature
  • < 3 mos
  • Hemodynam sig cardiopulmonary disease
  • Immunodeficiency
62
Q

4-month-old ex-prem with RSV. pH 7.31, pCO 2 60, pO 2 94. Best management:

a) humidified oxygen and careful monitoring
b) intubate and ventilate
c) RSV immune globulin
d) steroids
e) antibiotics

A

Probably b) Intubate + Ventilate

but depends on the LOC, WOB - you might be okay to do HFNC trial

63
Q

A 2 month old child is seen with a 3-4 day history of viral URTI symptoms, now has progressively increasing work of breathing. RR is 65, O2sat is 91% on room air. On auscultation there is diffuse wheezing. Of the following treatment modalities, which has been proven effective in this disorder:

a. Neb ventolin
b. Neb racemic epinephrine
c. Corticosteroids
d. O2

A

d. O2

64
Q

Baby with severe bronchiolitis, wheezing, severe retractions, lethargy. HR 160, RR 12, Sats 82% what is the next step.

a. Give racemic epi
b. Give salbutamol
c. Give steroids
d. Bag-mask ventilation

A

d. Bag-mask ventilation

65
Q

B) How does palivizumab minimize risk and by what mechanism does it work?

A

decreases hospitalization risk but does not decrease severity of infection in those who get RSV despite prophylaxis; works by conveying passive immunity

66
Q

List a couple of babies who should get palivizumab

A
  1. Clinically significant CHD or CLD (on bronchodilator, steroids, diuretics or supplemental O2) and <12 months of age at start of RSV season
  2. prems without CLD born before 30+0 weeks who are less than 6 months old at start of RSV season (can offer it but it’s not essential)
  3. infants born before 36+0 weeks, less than 6 months old at start of RSV season who would need medevac for hospitalization
67
Q

A patient with recurrent pneumonia, sinusitis, bronchiectasis in RML. One should investigate for all of the following except:

  1. CF
  2. Alpha-1-antitrypsin deficiency
  3. Ciliary dyskinesia
  4. Hypogammaglobulinemia
  5. CGD
A
  1. Alpha-1-antitrypsin deficiency
    - CF, PCD and immunodeficiencies can all cause bronchiectasis
    - alpha-1 antitrypsin causes liver disease in kids, lung disease (COPD) not usually seen until 20s
68
Q

14 yo boy with recurrent wheezing. CXR shows bronchiectasis. Most likely diagnosis?

A

CF (most common cause of bronchiectasis in industrialized nations)

69
Q

Bronchiectasis and recurrent wheezing in a 14 year old boy. What are 3 causes

A
  1. CF
  2. primary ciliary dyskinesia
  3. humoral immune deficiency
  4. recurrent pulmonary infection/infection with pertussis, measles or TB
  5. Allergic bronchopulmonary aspergillosis
  6. Post infectious
  7. Foreign body
70
Q

A 3-year-old boy comes for a regular checkup. He attends day care and he always seems to get “colds”. He does not eat well and his weight gain has been poor. He snores, and usually wakes up several times during the night. You notice that he cannot breathe through his nose and that his tonsils are large. Most appropriate investigation:

a) chest x-ray
b) lateral view of the nasopharynx
c) overnight oxygen saturation recording
d) morning capillary blood gas analysis
e) electrocardiogram

A

c) overnight oxygen saturation recording

- poor man’s oximetry

71
Q

Parents are worried about their 9 year old daughter; she has been snoring a lot and having episodes overnight where she stops breathing. Polysomnography was done and shows episodes of significant, severe central apnea.

What to do?

a) consult ENT
b) MRI brain
c) brainstem evoked auditory potentials
d) pH probe
e) CPAP overnight

A

b) MRI brain

· CSA is rare in children >1 year of age. Underlying disorders are dominated by neurosurgical disorders.

72
Q

Which of the following is treatment for obstructive sleep apnea?

  1. CPAP
  2. T & A
  3. BiPAP
  4. Nasal O2
A
  1. T & A

TA hypertrophy the most common cause of obstructive sleep apnea

73
Q

You are seeing a 6 year old boy in your office. His mother is concerned that he snores, and occasionally seems to pause in his breathing while he is asleep.
a. What is the most common reason for obstructive sleep apnea in children?

A

a. adenotonsillar hypertrophy

74
Q

Name 2 severe complications of OSA

A
  • pulmonary hypertension, systemic hypertension, right sided heart failure
75
Q

List 4 daytime symptoms of obstructive sleep apnea.

A
  • mouth breathing
  • chronic nasal congestion
  • hyponasal speech
  • morning headache
  • poor appetite
  • secondary enuresis
  • decreased mood, behavioural difficulties (irritability, aggression, impulsivity), impaired learning and academic function
  • daytime sleepiness
76
Q

5 things you would tell a boy to improve his sleep hygiene

A
  • consistent bedtime
  • consistent waking time
  • age appropriate number of hours in bed per night
  • sleep in a quiet, dark place
  • avoid hunger and eating prior to bed
  • avoid caffeine, alcohol and nicotine
  • relaxation techniques before bed
  • no screens before bed
  • read a book before bed
  • exercise in the day but not within 2 hours of bedtime
77
Q

3 yo with CP with recurrent symptoms of aspiration. Admitted with pneumonia, abscess and pleural effusion. What would be your choice of antibiotics.

a) Vanco & Amp
b) Amp & gent
c) Clinda & Gent
d) Azithro
e) Cefuroxime

A

c) Clinda (staph, strep and anaerobic coverage) & Gent (if gram negative suspected)

OR pip/tazo or amox/clav

78
Q

3 year old with cerebral palsy chokes with feeds on past history. Currently presents with fever, increased respiratory rate and chest X-ray shows an air bubble on left chest, surrounded by consolidation with a pleural effusion. What is the diagnosis?

a) Lung Abscess
b) Pulmonary sequestration
c) Diaphragmatic hernia

A

a) Lung Abscess
- most commonly arise from aspiration, necrotising pneumonia or chronic pneumonia
- classical appearance of a pulmonary abscess is a round cavity containing a gas-fluid level

FYI
Pneumatocele - thin walled gas filled cysts that develop in lung parenchyma (often complication of acute pneumonia 2dary to staphylococcus aureus)
Features that favour a pneumatocele over an abscess are:
- smooth inner margins
- little if any fluid content
the wall, if visible, is thin and regular
- tend to persist despite an absence of symptoms

79
Q

Child with CP has recurrent choking episodes. Presents with LLL pneumonia and air fluid level and significant pleural effusion. What is the investigation to help with management.

a. Sputum cultures
b. Blood culture
c. Pleural fluid culture
d. Bronchoscopy and culture

A

c. Pleural fluid culture

CPS Statement: Complicated Pneumonia
· Pleural fluid should be sent for culture - often the yield is low because they have already received antibiotics, but pneumococcal PCR may be helpful
· Blood cultures are only positive in 10%
· Sputum is difficult to obtain

80
Q

A child presents to the emergency room with shortness of breath and wheezing. This occurred suddenly after playing with older sibling. What should be the next management step after a CXR?

a) Bronchoscopy
b) Ventolin via nebulizer
c) Racemic epinephrine

A

a) Bronchoscopy

- foreign body

81
Q

The reason that oxygen-helium mixtures are used in airway diseases:

a. reduces pulmonary airway resistance
b. reduces small airway inflammation
c. reduces peribronchial inflammation

A

a. reduces pulmonary airway resistance

- decreases turbulence of flow

82
Q

How does helium work in a ventilated patient?

A

● 60-80% helium + 20-40% oxygen
● reaches lower airway more easily because lower resistance/turbulent flow
o lowered gas density= laminar flow overcomes airway obstruction

83
Q

What statement is not true regarding Intal (sodium chromoglycate/cromolyn):

a. no bronchodilator effect
b. mast cell stabilizer
c. not used in children less than 5 years old
d. good for exercise induced asthma
e. prevents late onset allergic effect

A

c. not used in children less than 5 years old (false- must be min. 2 y.o.)

  • can be used for prevention of exercise induced asthma or allergen induced bronchospasm (but is not a bronchodilator so do not use in acute exacerbation)
  • prevents mast cell release
84
Q

12 month old M with pneumonia and toxic. How to treat?

a) IV Ceftriaxone or Cefotaxime and macrolide
b) IV Ampicillin

A

a) IV Ceftriaxone or Cefotaxime and macrolide

CPS
Outpatients: PO Amoxil
Hospitalized, not unwell: IV Ampicillin
Hospitalized, unwell: IV Ceftriaxone/Cefotaxime
Complicated pneumonia: IV Ceftriaxone/Cefotaxime
Rapidly progressing multilobar disease or pneumatoceles: add vanco

Macrolide: treatment may be appropriate to hasten recovery in children who are more seriously ill or have persistent cough

85
Q

5½-year-old child with a recent upper respiratory tract infection, now has respiratory distress and BP 150/110. Most likely:

a) anxiety
b) pneumonia
c) myocarditis
d) Henoch-Schonlein purpura
e) post-streptococcal glomerulonephritis

A

e) post-streptococcal glomerulonephritis

if presented with full-blown acute nephritic syndrome, with brown/red urine, proteinuria (reaching nephrotic range), edema, hypertension, and elevated serum creatinine. Fluid overload from nephrotic range proteinuria can lead to resp distress due to pulmonary edema. Hypertension is present in 50-90% of pts and varies from mild to severe.

86
Q

Child with eczema and recurrent pneumonia. Hepatomegaly, petechiae, otitis media and low platelets. What do you expect?

a. elevated IgA and IgE
b. immune response to polysaccharide vaccine
c. oral Candida
d. abnormal mitogen proliferation

A

a. elevated IgA and IgE (low IgM and IgG)

Wiskott-Aldrich syndrome: atopic dermatitis,
thrombocytopenic purpura w/ normal-appearing megakaryocytes but small defective platelets, and undue susceptibility to infection
- have poor response to polysac vaccines

87
Q

Alpha-1 antitrypsin. Most likely presentation in children?

a) jaundice
b) emphysema
c) bronchiectasis
d) pneumonia

A 
a) jaundice
Typical presentation in kids:
- neonatal cholestasis
- later-onset childhood cirrhosis
Dx: - serum immunoassay shows low level of alpha-1 antitrypsin
88
Q

Child with recurrent OM, sinusitis, and dextrocardia.

a. ) Diagnosis?
b. ) Test to confirm diagnosis.

A

a) Primary ciliary dyskinesia (with Kartagener triad):
- Triad:
- Situs inversus totalis
- Chronic sinusitis and otitis (Clinical feature that distinguishes it from CF)
- Bronchiectasis
b) - curettage from nasal epithelium or endobronchial brushing to obtain suitable specimen for transmission electron microscopy

89
Q

Describe technique for MDI inhalation for teen

A
  1. Shake the MDI;
  2. Breath out to the end of a normal breath;
  3. Actuate through an open mouth, just after inhalation begins; 4. Breath in slowly over 4 s to 6 s, to full lung volume;
  4. Hold breath 5 s to 10 s; and
  5. Wait 30 s to 60 s, shake and repeat above steps.
90
Q

Which is true regarding reactive airways disease:

  1. B2 sympathomimetics are specific for small airways
  2. Intravenous B2 agonists have less side effects than inhaled ones
  3. corticosteroids increase the efficacy of B2 agonists
  4. you require a greater mg/kg dose in a 3 year old compared with an adult
A
  1. you require a greater mg/kg dose in a 3 year old compared with an adult
91
Q

A 7 year old with CP, severe GERD and frequent choking spells while eating is admitted to the hospital with fever and increased RR. On CXR there is an air bubble in the LLL with surrounding consolidation and pleural effusion. What is the most likely organism that is causative

a. Staphylococcus
b. Haemophilus
c. Anaerobes
d. Mycoplasma

A

Pneumatocele is AIR FILLED - most classically caused by staph a.

Lung Abscess - commonly arise from aspiration, necrotizing pneumonia, chronic pneumonia. In aspiration usually mixed with anaerobes. Appearance is a cavity with GAS-FLUID level

(they’re probably getting at c. anaerobes)

92
Q

Sweat Chloride False +ve

A 
Eczema
Malnutrition/FTT
Anorexia
Adrenal Insufficiency
Muchausen by proxy
Nephrogenic DI
Hypothyroidism
Autonomic dysfunction
Prostaglandin E infusion
93
Q

3yo boy with history of URTI presents with stridor. Vitals normal and stridor present when he is excited. What is the best management?

  1. Oral steroids alone
  2. Racemic epinephrine
  3. Nebulized steroids
  4. Humidified oxygen
A
  1. Oral steroids alone
94
Q

Best treatment for recurrent viral wheezer in a child under 3 years?

a) salbutamol PRN
b) fluticasone x3 weeks
c) PO prednisolone x3-5days
d) montelukast

A

a) salbutamol PRN

CPS Preschool Stmt:

Children one to five years of age with recurrent (≥2) episodes of asthma-like symptoms, no wheezing on presentation, frequent symptoms or any moderate or severe exacerbation warrant a three-month therapeutic trial with a medium daily dose of ICS (with as-needed SABA). Clear consistent improvement in the frequency and severity of symptoms and/or exacerbations confirms the diagnosis

Children one to five years of age with recurrent (≥2) episodes of asthma-like symptoms, no wheezing on presentation, infrequent symptoms, and mild exacerbations can be monitored and re-assessed by a health care practitioner when symptomatic. Alternatively, a therapeutic trial with as-needed SABA is suggested. Convincing parental report of a rapid and repeatedly observed response to SABA suggests the diagnosis

95
Q

Teen with poor control on 250 BID what do you add to help control

a) fluticasone plus salbuomol
b) budesonide plus formetrol
c) cycldesinide

A

b) budesonide plus formetrol

Teens >12 : Low dose ICS with SABA –> Add LABA –> Add LRTA

When adherence to a low dose of ICS in adults (250 mcg/day or less of HFA beclomethasone) or moderate dose of ICS in children six years of age and over (200 mcg/day to 400 mcg/day of HFA beclomethasone), together with trigger avoidance and education are insufficient to control asthma symptoms, then a combination inhaler containing both an ICS and a LABA (eg, fluticasone plus salmeterol or budesonide plus formoterol) is the preferred treatment option.

96
Q

Boy with resp distress, decreased breath sounds, CXR: L white-out. Next step?

a) decubitus xray
b) ultrasound
c) CT chest
d) thoracocentesis

A

b) ultrasound

From the CPS Statement on COmplicated Pneumonia - CXR, then Chest US… only CT if other Dx suspected

97
Q

6 week with RSV, started to have fever one day later. CXR shows small opacity on RML. What is dx?

a) RSV
b) GBS
c) strep pneumo
d) staph aureus

A

a) RSV

98
Q

You diagnose a child with CF based on an abnormal sweat chloride. The reason for doing DNA testing is:

a. confirm diagnosis
b. rule out whether the parents are carriers
c. to diagnose her cousin who is failing to thrive with CF
d. to give the parents some idea about prognosis
e. so that antenatal testing can be done on subsequent pregnancies

A

d. to give the parents some idea about prognosis

99
Q

Asthma Control Criteria

A 
Daytime Sx  < 4 / week
Nighttime Sx < 1 / week
Need for SABA   < 4 / week
Physical Activity   Normal
Exacerbations   Mild/Infrequent
Absences      None
PEV1 or PEF    >90% personal best
PEF diurnal variation   <10-15%
100
Q

An asthmatic comes to ER mod/severe, treated with ventolin.atrovent and steroids (oral dex) , on 1Litre of O2 and sats well, several hours later, still moderate work of breathing what is the next step

Magnesium sulfate
intubate and ventilate
aminophyliine

A

MgSO4

CPS:

IV magnesium sulphate may be considered in cases of moderate and severe asthma with incomplete response to conventional therapy during the first 1 to 2 h

101
Q

What is a long term side effect of inhaled corticosteroids?

Growth suppression
recurrent infections
moon facies
immunosuppression

A

Growth Suppression

102
Q

A known asthmatic is seen in clinic for an in-grown toenail. As the family is leaving, the child’s mother requests a blue puffer refill. You therefore take further history and discover that the Ventolin is used on average 4 times per week. You therefore:

a) Renew the Ventolin
b) Prescribe a long-acting beta 2 agonist
c) Prescribe a corticosteroid puffer and renew the Ventolin
d) Prescribe oral corticosteroids and renew the Ventolin

A

c) Prescribe a corticosteroid puffer and renew the Ventolin

103
Q

A young girl is known to have congenital central hypoventilation syndrome, for which she has a tracheostomy. Which of the following must be performed yearly?

a) Holter monitor
b) Audiology testing
c) Brain MRI
d) Laryngoscopy

A

a) Holter monitor

(autonomic dysfunction)

CCHS is a clinically complex neurocristopathy that includes a variable severity of respiratory and autonomic dysregulation, as well as Hirschsprung disease and neural crest tumors in a subset of patients.

104
Q

A boy with CF presents with increasing cough over several weeks. His FEV has dropped 18%. Which organism is most likely to be responsible?

a) Stenotrophomonas maltophilia
b) Mycoplasma pneumoniae –
c) Burkholderia cepacia
d) Pseudomonas aeruginosa

A

Could be any but

d) Pseudomonas aeruginosa is most classic organism

H. Flu and S. areus are most common in young kids.

Burkholderia cepacia - associated with rapid deterioration

105
Q

A child comes in with pneumonia and an effusion. What is the most likely organism?

a. haemophilis influenza
b. streptococcus pneumoniae
c. staphylococcus aureus
d. mycoplasma pneumonia

A

b. streptococcus pneumoniae

CPS statement: uncomplicated pneumonia - Strep pneumo most common organism
Uptodate: Epidemiology of parapneumonic effusions and empyema in children
- S. pneumoniae (pneumococcus) is the most common pathogen causing parapneumonic effusions and empyema.

106
Q

A teenage girl has vocal cord dysfunction. Her pulmonary function testing shows:

          	a) FEV1 < 80%
          	b) FVC < 80%
          	c) FEV1/FVC < 80%
          	d) truncated inspiratory and expiratory loops
A

Correct would be truncated inspiratory loops

The gold standard of diagnosis, though, is flexible fiberoptic laryngoscopy during an acute episode where paradoxical vocal cord adduction during inspiration is seen.
Since breathing is normal between episodes, both studies often are nondiagnostic, and history remains the mainstay of diagnosis.’

2019 AAP News

107
Q

How would you treat eosinophilic esophagitis?

A) oral fluticasone with MDI
B) oral steroids
C) Refer to allergist for skin prick testing
D) observe

A

A) oral fluticasone with MDI

First line.

108
Q

Patient with CF comes in with worsened respiratory status and green sputum. What do you treat with?
A) antifungal
B) septra
C) cipro

A

Totally depends…

Probably Cipro for it’s anti-pseudomonas coverage

TMP-SMX good for MRSA and burkholderia
Antifungal - aspergillis

109
Q

A child with a tracheostomy has a block trach with respiratory distress and does not respond to suctioning.

a) epinephrine neb
b) intubate
c) replace trach tube
A

either b) intubate from above if has normal upper airway

or

c) replace trach

110
Q 
What is the most likely vitamin deficiency in a child with CF?
A. 	A
B.     D 
C. 	E 
D. 	K
A

Vitamin D

Because pancreatic insufficiency results in malabsorption of fat-soluble vitamins (A, D, E, K), vitamin supplementation is recommended. Several vitamin preparations containing all 4 vitamins for patients with CF are available. They should be taken daily. Despite this supplementation, vitamin D deficiency is common and should be treated with doses of cholecalciferol (vitamin D3) rather than ergocalciferol (vitamin D2) in the range of 1,000 units/kg/wk.

(Nelsons)

111
Q

Match the clinical information with the right blood gas

  1. 7.50 / 20 / 18 BE -5
  2. 7.30 / 33/ 17 BE – 4
  3. 7.46 / 45 / 35 BE + 7
  4. 7.32 / 52 / 21 BE + 3

OSA
Urea Cycle Defect
Resucitation with 80ml/kg RL in OR
Lasix overdose in CHF kid

A

A neonate with a urea cycle defect = 1 (respiratory alkalosis – blowing off C02 because of hyperammonemia)

Teen resuscitated with 80cc/kg of RL in the OR = 2 (hyperchloremic metabolic acidosis- worsened lactic acidosis?)

Lasix overdose because he was a kid with CHF = 3 (Lasix causes a volume contracted metabolic alkalosis)

A kid with OSA = 4 (respiratory acidosis C02 retaining)

112
Q

What will give you a false negative Sweat Chloride test?

a) Hypothyroid
b) Edema
c) Eczema
d) Hypogammaglobulinemia

A

b) Edema

Hypothyroid and Eczema can give you false positives

113
Q

12 year-old girl with previously well-controlled asthma on low-dose inhaled corticosteroid. Over the past month, she has had increased symptoms with ventolin use 4-5 times per week.

What is the next appropriate step in management.

  1. Montelukast
  2. Continue low-dose CSI and add LABA
  3. Switch to a medium-dose CSI
  4. Prescribe a 3 day course of oral prednisone
A
  1. Continue low-dose CSI and add LABA

because she is 12+

114
Q

3 Year old on 50mcg fluticasone, BID. Has 2x nightly exacerbation per week, missed few days of daycare. On exam - no wheeze but has prolonged expiratory phase.

a) . Add a LABA
b) Add a Leukotriene inhibitor
c) Start oral prednisone
d) Increase dose of fluticasone to 100ucg BID

A

d) Increase dose of fluticasone to 100ucg BID

CPS statement on preschool asthma starts fluticasone at 100-125ug BID (low dose)

115
Q

31 week GA baby, now 3 mos old. It is October. Parents are non-smokers. Mother planning to stay at home with babe.

A) What one intervention can you do to minimize risk of severe RSV bronchiolitis?
B) How does this intervention minimize risk and by what mechanism does it work?

A

a) Palivizumab
b) Monoclonal antibody against RSV, needs monthly injection during season

*** But if this kid doesn’t have significant CLD or CHD or from Inuit community, he doesn’t qualify

116
Q

Patient presents with symptoms of a URTI and has a past history of AOM’s. Ig’s are done and show N IgG, IgM and low IgA. Besides an increased risk of infections what else do you counsel the mother about?

A

Risk of anaphylaxis to blood products

Isolated IgA Deficiency
Most common immune abnormality - but it is not an immunodeficiency

5 As:
Asymptomatic in most
Atopy/Autoimmunity
Anaphylaxis to blood products
Ascend to CVID
Ataxia-Telangiectasia must be ruled out
117
Q

Few months with stridor & brassy cough. CXR shows right aortic arch. You suspect vascular ring. 3 investigations.

A

CT Angio / MRA
Echocardiogram (look for other lesions)
Bronchoscopy (visualize area and degree of compression)

118
Q

Teacher thought 9yr boy hyperactive / inattentive. Not this way last year.

Mom notices he breathes through his mouth. 3 further questions on history.

A
  • Nasal congestion
  • Snoring
  • Morning somnolence
  • Apneas
  • Sweating while sleeping
  • Mouth breathing
  • Moodiness
  • Hyperactivity
  • Cognitive problems
  • GERD
119
Q

4 things on history for an asthmatic that put them at increased anesthetic risk

A
  • Wheeze with exercise
  • URTI in past 2 weeks
  • Poor control
  • Previous intubation
  • Previous ICU admission
  • > 2 ED visits in past 6 mos
  • Systemic corticosteroid use
  • Passive or active smoking
  • Frequent use of reliever
120
Q

What would PFT show in Asthma

FEV1/FVC
FEF 25-75
RV/TLC

A

FEV1/FVC - Decreased

FEF 25-75 - Decreased

RV/TLC - Increased (high RV due to air trapping + hyperinflation)

121
Q

You are seeing a 6 year old boy in your office. His mother is concerned that he snores, and occasionally seems to pause in his breathing while he is asleep.

a. What is the most common reason for obstructive sleep apnea in children?
b. Name 2 severe complications of OSA.

A

a. Adenotonsillar hypertrophy

(others - chronic rhinitis/nasal obstruction, craniofacial abn, GERD with pharyngeal edema)

b. Pulmonary hypertension
Cor pulmonale
HTN
FTT
Arrhythmia
Cognitive and behavioural difficulties
122
Q
  1. 11yo boy with new onset intermittent cough for past 6 months. Normal exam. Give 3 things on your differential
A 
Habit
Postnasal drip 
GERD 
Asthma
Sinusitis/Rhinitis
123
Q

In newborn with meconium aspiration, what are 4 mechanisms of interference with the child’s respiratory ability?

A 
Surfactant def
V/Q mismatch
Air trapping 
Pneumothorax
Inflammatory and Chemical Pneumonitis
Persistent Pulmonary Hypertension
Acidosis, Hypoxemia, Hypercapnea
124
Q

Mom presents with 2 month infant with concerns of stridor and tracheal tug when babe is upset or crying .
What is the most likely diagnosis (1)?
How would you confirm this on examination (1)?

A

Laryngomalacia

Changes with position of child - increases w/ feeding and sleeping supine… better when prone
but really, most definitive is flex laryngoscopy

125
Q

A 13 year old girl with cystic fibrosis has had a 5kg weight loss as well as a decline in her FEV1 by 10%. She states that she has been compliant with her chest physiotherapy as well as her nutritional supplements. Name 5 reasons for the decline in her clinical condition

A 
Pulmonary exacerbation
Allergic bronchopulmonary aspergillosis
Invasive non-tb infection
Non-compliance
Obstruction from nasal polyps
Poor nutrition
Pancreatic insufficiency
Progressive obstruction (bronchiectasis)
CF Related Diabetes
126
Q

Complication after repair of vascular ring?

A

Tracheomalacia

127
Q

A young child who grew up in a refugee camp comes to Canada and his TB skin test is 8mm of induration.

a. What are three reasons for a positive skin test.
b. What two other investigations will you do now to determine if he has latent TB?

A
  • TB infection
  • prior BCG vaccine
  • infection with nontuberculosis mycobacteria
  • incorrect method of TST administration
  • incorrect interpretation of reaction

b. IGRA
Acid fast bacilli smear and culture (sputum or gastric aspirate)

128
Q

Differentiate asthma from severe scoliosis according to PFTs

FEV1
FEV1/FVC
FEF 25-75
TLC
RV/TLC
FVC
VC
A

Asthma. Scoliosis

FEV1 Low N

FEV1/. <0.8 N
FVC

FEF Low N
25-75.

TLC High. Low

RV/ High N
TLC

FVC N Low

VC Low Low

129
Q

14 year old boy with symptoms of wheeze and cough that begin 15 minutes after starting to run cross country. No previous asthma and no symptoms when not exercising. You suspect exercise induced asthma (they tell you this).

a) What one respiratory function test will prove your diagnosis
b) What one pharmacologic treatment do you recommend

A

a) Exercise challenge spirometry

b) Short Acting Beta Agonist pre exercise

130
Q

List 3 criteria used to make the diagnosis of asthma in a preschooler.

A

CPS Statement

1) Documentation of airflow obstruction
(preferred by HCP, alternative by convincing parent report)

2) Documentation of reversibility of airflow obstruction
(Preferred improvement to SABA ± steroid by HCP, alternative by convincing parent report of response to 3 month trial medium ICS + PRN SABA)

  1. No clinical evidence of alternative Dx

2019 Bank of Goodness (22 decks)

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