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Board Review Week of July 27th - DOC


									Board Review Quiz – February 2010


1. Question 175
An 8-year-old boy presents with wheezing, coughing, and difficulty breathing of 6 months' duration.
Findings on his history and pulmonary function tests are suggestive of moderate persistent asthma.
In preparation for asthma management, you have reviewed the current asthma guidelines,
educated the patient on peak flow monitoring, and discussed possible therapeutic options. You
decide to start him on a daily inhaled corticosteroid.

Of the following, the MOST likely adverse event he may experience from inhaled corticosteroids is

    a)   acne
    b)   decreased adult height
    c)   mood swings
    d)   oral candidiasis
    e)   weight gain

2. Question 114
You admit a term newborn to the neonatal intensive care unit because of noisy breathing. Findings
on physical examination include mild micrognathia, an intact palate, and inspiratory stridor with
suprasternal retractions when the infant is in the supine position that diminish but do not disappear
when the infant is prone. Stridor becomes more audible when the infant cries. When the infant is
asleep and prone, the breath sounds are clear and equal bilaterally, with no stridor or wheezing.
There is no heart murmur. Pulse oximetry is 94% on room air.

Of the following, the MOST likely cause of this infant's stridor is

    a)   cleft lip
    b)   laryngomalacia
    c)   tracheal hemangioma
    d)   tracheomalacia
    e)   vocal cord polyp

3. Question 207
A 16-year-old girl who has moderate persistent asthma presents to the emergency department with
coughing, wheezing, and increasing dyspnea. She states that she was feeling fine until she was
exposed to cologne that one of her classmates was wearing. An ambulance was called after her
symptoms did not improve following administration of two puffs of her beta2 agonist inhaler. On
physical examination, the teenager has a respiratory rate of 30 breaths/min, heart rate of 90
beats/min, and pulse oximetry of 98% on room air. She has difficulty completing a sentence and
points to her neck, saying it is "hard to get air in." Her lungs are clear to auscultation, and
rhinolaryngoscopy demonstrates adduction of one of the vocal cords during inspiration. Pulmonary
function testing shows a blunted inspiratory loop (Item Q207).

Of the following, the MOST likely cause for this patient's symptoms is

    a)   allergic rhinitis
    b)   asthma exacerbation
    c)   habit cough
    d)   sinusitis
    e)   vocal cord dysfunction

4. Question 111
A 10-year-old boy presents with a 2-month history of chronic cough. His parents are unsure of a
specific preceding trigger. They are concerned because the school nurse has called on multiple
occasions requesting that the boy be taken home due to his persistent cough. The boy denies any
chest pain, dyspnea, or syncope. Use of a sedating antihistamine and over-the-counter cold and
cough liquid has not alleviated his symptoms. On physical examination, the boy has vital signs
within the normal range and appears healthy. A thorough examination reveals no abnormalities.
During the encounter, the boy repeatedly exhibits a harsh, "barky" cough that resolves when you
leave the examination room, only to recur when you return. You suspect he has a psychogenic

Of the following, the MOST accurate statement regarding psychogenic cough is that

    a)   most cases are associated with underlying psychological illness
    b)   most cases are preceded by an upper respiratory tract infection
    c)   resolution of the cough often is followed by recurrent wheezing
    d)   symptoms persist during the day and while the child is asleep
    e)   the cough noise often is dramatically different from the postnasal drip syndrome cough

5. Question 15
A 10-year-old boy presents to the clinic complaining of tongue and mouth itching within a few
minutes after eating apples. His mother states that he has not experienced these symptoms with
other foods, but they occur every time he eats a fresh apple. He denies systemic symptoms, and
the oral symptoms resolve within a few minutes. Other than allergic rhinitis in the spring months,
he is healthy.

Of the following, you are MOST likely to advise his mother that

    a)   allergy skin testing to fresh apples probably will have negative results
    b)   cooking the apple will not alter its allergenicity
    c)   her son should avoid eating all fruits
    d)   her son should avoid milk products
    e)   her son's symptoms are related to his allergic rhinitis

6. Question 31
The mother of a 14-year-old girl who has asthma is concerned that her daughter's recent severe
exacerbation is due to mold exposure. Their home sustained flood damage last year. The mother
provides you with a list of diagnostic tests she found on the Internet, which she believes will help
confirm her daughter's mold allergy.

Of the following, the MOST appropriate testing to evaluate the girl for possible mold allergy is

    a)   allergy skin testing
    b)   applied kinesiology
    c)   cytotoxic testing
    d)   provocation-neutralization
    e)   pulse test

7. Question 63
The parents of a 10-year-old boy who has a peanut and tree nut food allergy ask your advice on the
treatment of food allergy reactions at school. They describe a scenario that occurred last year when
their son started itching diffusely and having difficulty breathing during lunchtime after
inadvertently eating some of his friend's chocolate candy bar that contained peanuts. At his current
school, the child is allowed to carry his own self-injectable epinephrine. His current weight is 90 lb
(41 kg).

Of the following, the BEST advice for the child, if a similar situation occurs, is to

    a)   have the school call emergency services (911), who should evaluate and administer
         epinephrine if needed
    b)   have the school nurse observe the child for 10 to 15 minutes while calling his parents
    c)   immediately administer 0.15 mg of self-injectable epinephrine
    d)   immediately administer 0.30 mg of self-injectable epinephrine
    e)   take an oral antihistamine immediately

8. Question 143
A 16-year-old boy who runs on his high school cross-country team has been having trouble with
coughing and wheezing during exercise. He has a history of intermittent asthma that is well
controlled when he is not running. His coach is worried that he may have exercise-induced asthma
(EIA) and would like him to use an inhaler when he exercises.

Of the following, the MOST appropriate response regarding EIA is that

    a)   a decrease of 5% in forced expiratory volume in 1 second during an exercise challenge is
         consistent with EIA
    b)   a slow warm-up prior to exercise has not been shown to improve EIA
    c)   most children who have a diagnosis of asthma do not have EIA symptoms
    d)   sports that require short, quick bursts of activity are more likely to cause symptoms
         compared with continuous activities
    e)   symptoms can start within 5 minutes of exercise, but peak symptoms usually occur after
         the exercise is stopped

9. Question 175
A 14-year-old patient of yours who has exercise-induced asthma (EIA) will be attending a soccer
camp this summer. The camp involves an intensive regimen, with exercise starting as soon as he
wakes up and continuing through the day. The boy would like to know if there is something he can
take to decrease his EIA symptoms that not only works quickly but lasts for 8 to 12 hours.

Of the following, the BEST choice is

    a)   albuterol
    b)   formoterol
    c)   ipratropium
    d)   montelukast
    e)   salmeterol

10. Question 191
You are conducting teaching rounds with a group of medical students who are rotating in the
pediatric intensive care unit. Their last admission was a 10-year-old boy who experienced severe
anaphylaxis to a flying insect sting. The boy thought it was a wasp that stung him when he was
playing in his backyard. Minutes after being stung, he developed diffuse pruritus and flushing.
Subsequently, he experienced throat tightness, difficulty breathing, and loss of consciousness.
Emergency medical services arrived within 5 minutes. They administered three doses of epinephrine
and a fluid bolus and endotracheally intubated him. You suspect an immunoglobulin E-mediated
reaction and discuss the different aspects of allergy testing.

Of the following, a TRUE statement regarding allergy testing for Hymenoptera is that

    a)   hymenoptera skin or serum testing results rarely are positive in patients who experience
         only local, "normal" reactions

    b)   hymenoptera skin testing is not recommended for children younger than 12 years of age
    c)   if skin testing results are negative, then serum immunoglobulin E testing does not need to
         be performed
    d)   this patient should be tested to all flying hymenoptera (ie, wasps, hornets, bees, yellow
    e)   this patient should undergo skin testing prior to hospital discharge

11. Question 207
A 12-year-old girl presents with a 6-month history of increasing cough, dyspnea, and wheezing. She
has a history of "asthma" but reports only using a short-acting beta agonist (SABA). Despite using
her SABA three to four times per day, she reports nightly asthma symptoms, significant limitations
in physical activity, and frequent asthma symptoms throughout the day. Spirometry performed in
the clinic shows significant obstruction, with a forced expiratory volume in 1 second of 58%.

Of the following, the MOST appropriate asthma medication to consider starting in this child is

    a)   a high-dose inhaled steroid and long-acting beta agonist
    b)   a medium-dose inhaled steroid and oral leukotriene antagonist
    c)   an oral leukotriene antagonist only
    d)   omalizumab
    e)   oral theophylline and daily SABA

12. Question 223
You are evaluating a 12-year-old boy for a routine assessment prior to starting school. He is
generally healthy, except for mild seasonal allergic rhinitis that is controlled with an as-needed
second-generation antihistamine. However, his mother has noted that over the past 6 months he
has awakened coughing 1 to 2 nights a month. In addition, once or twice a month she has noticed
that he "wheezes" during physical exertion, although he is still able to continue his activity. A
pulmonary function test in the office reveals age-appropriate lung function with a normal forced
expiratory volume in 1 second (FEV1) (>80%) and normal FEV1/forced vital capacity ratio. You
suspect asthma.

Of the following, the MOST appropriate classification for this boy's asthma is

    a)   exercise-induced
    b)   intermittent
    c)   mild persistent
    d)   moderate persistent
    e)   severe persistent

13. Question 254
You have been asked by a local school to provide recommendations about the use of self-injectable
epinephrine for anaphylaxis. The school supervisor is concerned about the increased incidence of
peanut and tree nut food allergy. School officials have requested that each child who has a
diagnosis of "food allergy" have two self-injectable epinephrine devices at the school nurse's office.

Of the following, the BEST response regarding anaphylaxis is that

    a)   a patient should not receive a second dose of epinephrine unless a clinician is present
    b)   epinephrine reaches higher peak plasma concentrations if injected into the thigh rather
         than the arm
    c)   families should keep one epinephrine autoinjector in the car in case a reaction occurs after
    d)   skin manifestations (eg, flushing, itching, urticaria) are rare in severe anaphylaxis
    e)   subcutaneous injection of epinephrine is preferable to intramuscular injection

14. Question 57
You are evaluating a 2-year-old girl in your office who suffered a near-drowning accident at 1 year
of age that left her ventilator-dependent. She receives feeding via a gastrostomy tube and has a
seizure disorder that is well-controlled by medications. Her mother reports that the child sometimes
seems to choke after her tube feeding and that she has developed a fever and an increased oxygen
requirement. On physical examination, the girl's tracheostomy tube site is clean and dry, her

temperature is 39.0°C, her heart rate is 140 beats/min, and her respiratory rate is 48 breaths/min.
You obtain a chest radiograph (Item Q57).

Of the following, the MOST likely diagnosis is

    a)   aspiration pneumonia
    b)   congenital lobar emphysema
    c)   pneumothorax
    d)   pulmonary hemorrhage
    e)   viral pneumonia

15. Question 89
You are called to the emergency department to evaluate a 1-year-old girl who was rescued from a
house fire by paramedics. She was found unconscious at the scene and had soot around her nares.
On arrival to the emergency department, she is able to open her eyes but still appears sleepy. Her
temperature is 37.0°C, heart rate is 150 beats/min, respiratory rate is 30 breaths/min, and blood
pressure is 90/60 mm Hg. Her oxygen saturation by pulse oximetry is 97% on 100% oxygen
administered at 8 L/min via a nonrebreathing facemask. The nurse asks if you would like to reduce
the oxygen because the girl's oxygen saturation is = 95%. You explain to the nurse that the pulse
oximetry findings are unlikely to be reliable in this patient.

Of the following, the MOST likely reason for inaccurate pulse oximetry results in this patient is

    a)   elevated concentration of carboxyhemoglobin
    b)   elevated concentration of fetal hemoglobin
    c)   elevated concentration of methemoglobin
    d)   the inability of pulse oximetry to discriminate values greater than 90%
    e)   the presence of hypotension and shock

16. Question 98
You are evaluating a 3-day-old 1,300-g infant who was born at 30 weeks' gestation. He did not
have early respiratory distress. He has been receiving intravenous nutrition and slowly started
enteral feedings yesterday. Today he has several episodes of apnea lasting 20 to 30 seconds that
are associated with cyanosis (pulse oximetry reading of 75%) and bradycardia (heart rate of 75
beats/min). He has responded to tactile stimulation and blow-by oxygen. Physical examination after
one such episode reveals good color, perfusion, tone, and reactivity. The lungs are clear, and the
chest wall is stable. There is no heart murmur. The abdomen is soft and nontender, with normal
bowel sounds.

Of the following, the MOST likely cause of the apnea episodes in this infant is

    a)   anemia of prematurity
    b)   apnea of prematurity
    c)   hypoglycemia
    d)   necrotizing enterocolitis
    e)   sepsis

17. Question 116
An 18-month-old boy presents to the emergency department with a 2-day history of cough,
posttussive emesis, and diminished food intake, although he has been taking liquids. The coughing
began after eating some popcorn. His mother explains that he has had no fever or rhinorrhea. He
had an episode of bronchiolitis at 3 months of age but has no other history of respiratory illness,
chronic cough, or other health concerns. He is the youngest of four children cared for at home. On
physical examination, his vital signs are normal, his height and weight are at the 50th percentile for
age, and the boy is mouth-breathing with mild nasal flaring. Oxygen saturation is 94% on room air.
Auscultation of the chest reveals diffuse rhonchi and wheezes that are markedly louder on the left
side of the chest.

Of the following, the MOST likely diagnosis is

    a)   bronchiolitis
    b)   community-acquired bacterial pneumonia
    c)   cystic fibrosis
    d)   foreign body aspiration
    e)   reactive airway disease

18. Question 132
A nursing student is preparing a family for the discharge of a 4-week-old infant who was admitted
to the hospital for evaluation of an apparent life-threatening event (ALTE). During the 3-day
hospitalization, results of all studies were negative. The infant, who was born at 39 weeks'
gestation, has had stable vital signs and no apnea or cyanosis during this hospitalization. Therapy
for reflux has been initiated. The nurse asks you, in the presence of the parents, if a home apnea
and bradycardia monitor should be prescribed.

Of the following, the BEST evidence-based information regarding the use of home apnea monitoring
is that it

    a)   has been proven to decrease the risk of sudden infant death syndrome in infants who have
         had prior ALTEs
    b)   has been proven to prevent death in term newborns who have been diagnosed with ALTE of
         unknown cause
    c)   is highly effective in preventing recurrent ALTE attributed to gastroesophageal reflux
    d)   may be efficacious in monitoring preterm infants who have hypoxia due to apnea of
    e)   usually is prescribed for the first 9 months in high-risk preterm infants

19. Question 137
You are caring for an 8-month-old infant in the pediatric intensive care unit. She has been
hospitalized for 1 week with respiratory syncytial virus bronchiolitis. In discussions with the mother,
she reports that the child has very frequent, large, foul-smelling stools. Physical examination of the
child reveals a temperature of 37.0°C, heart rate of 140 beats/min, respiratory rate of 35
breaths/min on the ventilator, and blood pressure of 80/40 mm Hg. Her oxygen saturation is 90%,
and her most recent arterial blood gas shows a pH of 7.25, Paco2 of 70 mm Hg, and Pao2 of 70 mm
Hg. Her weight is 7 kg, and she appears malnourished, with decreased muscle development. No
obvious congenital abnormalities are apparent. Her chest appears hyperinflated, she has no heart
murmur, her pulses are equal and strong, and her abdomen is protuberant with normal bowel
sounds. Computed tomography scan of her chest was obtained earlier today to evaluate enlarging
cystic-appearing lesions on her chest radiograph (Item Q137).

Of the following, the MOST likely underlying diagnosis in addition to bronchiolitis is

    a)   Clostridium difficile infection
    b)   congenital lobar emphysema
    c)   cystic adenomatoid malformation
    d)   cystic fibrosis
    e)   pulmonary sequestration

20. Question 140
A previously healthy 3-year-old boy presents to the emergency department (ED) with a 5-day
history of a "barky" cough and low-grade fever (temperature no greater than 38.4°C. Yesterday his
temperature increased to 39.5°C, he developed increased hoarseness, and he refused to eat. In the
ED, his temperature is 39.4°C, he appears toxic, he exhibits stridor and intercostal retractions, and
his oxygen saturation is 91% on room air.

Of the following, the MOST appropriate next step is to

    a)   administer dexamethasone intramuscularly
    b)   endotracheally intubate the child
    c)   obtain a lateral neck radiograph
    d)   perform an emergency tracheostomy
    e)   perform pulmonary function testing

21. Question 201
You are evaluating an 18-month-old boy in the emergency department who appears "toxic" and is
sitting uncomfortably and leaning forward in his mother's lap. His temperature is 40.0°C, heart rate
is 140 beats/min, respiratory rate is 35 breaths/min, blood pressure is 90/60 mm Hg, and oxygen
saturation on room air is 94% by pulse oximetry. He is drooling from the corners of his mouth, and
his cry appears muffled. The nurse shows you the lateral neck radiograph that was just obtained
(Item Q201).

Of the following, the MOST appropriate next step in the treatment of this patient is

    a)   administration of intramuscular penicillin
    b)   blood cultures and a complete blood count
    c)   emergent otolaryngology and anesthesia consultation
    d)   intramuscular administration of dexamethasone
    e)   throat culture

22. Question 227
You are working in the emergency department when a mother brings in her 8-month-old son. She is
concerned because he has had diarrhea for 2 months that has worsened over the last day. She
explains that the stool is greasy, but there is no blood. He has had two episodes of sinusitis but no
hospitalizations. They are new to town and he has not seen a physician since his 2-month health
supervision visit. On physical examination, the boy appears pale, cachectic, and mildly dehydrated
but alert. He has nasal congestion, his lungs are clear, and findings on his abdominal examination
are normal. His weight is below the 5th percentile, length is at the 10th percentile, and head
circumference is at the 25th percentile. He has a foul-smelling, greasy stool in his diaper.

Of the following, the test MOST likely to reveal the diagnosis is

    a)   enzyme-linked immunosorbent assay for Giardia
    b)   serology for antigliadin antibodies
    c)   stool evaluation for alpha-1-antitrypsin
    d)   stool evaluation for ova, cysts, and parasites
    e)   sweat test

23. Question 229
You are evaluating a 2-month-old infant who has stridor. His mother states that the stridor is worse
during and immediately after feeding. She has thickened his feedings, and he has been prescribed
antireflux medications. On physical examination, he appears comfortable and in no distress. His
respiratory and cardiac examination findings are benign. As you observe his feeding, he develops

Of the following, the MOST appropriate next step in this patient's evaluation is

    a)   barium swallow
    b)   computed tomography scan of the chest
    c)   electrocardiography
    d)   radiography of the neck
    e)   sweat test

24. Question 233
You have been treating a 5-year-old boy in the pediatric intensive care unit who has been receiving
mechanical ventilation for 10 days due to pneumonia caused by Staphylococcus aureus. He required
chest tube placement for an empyema. Over the past 3 days, he has developed a persistent air
leak, and you are concerned that he may have developed a bronchopleural fistula.

In discussions with his parents, a TRUE statement regarding bronchopleural fistulas is that

    a)   bronchopleural fistulas are not associated with increased mortality
    b)   bronchoscopy may be useful for both diagnosis and treatment
    c)   computed tomography scan is of little value in establishing the diagnosis
    d)   surgical therapy is rarely successful
    e)   they are likely to heal spontaneously within 12 to 24 hours

25. Question 249
You are evaluating a 15-month-old boy for cough and fever of 5 days' duration. His parents report
that he is producing blood-tinged sputum with coughing. His family is new to the area. Review of his
medical record demonstrates three previous episodes of right lower lobe pneumonia. In response to
your questions, his parents state that he tires easily. On physical examination, the boy's weight is
8.5 kg, temperature is 39.0°C, heart rate is 140 beats/min, respiratory rate is 40 breaths/min,
blood pressure is 88/55 mm Hg, and oxygen saturation is 92% by pulse oximetry on room air. He is
in mild respiratory distress, and you can hear crackles in the upper right lung and decreased
aeration of the right lower lung. Chest radiography demonstrates multiple large cysts in the right
lower lobe. Some of the cysts contain air-fluid levels (Item Q249).

Of the following, the MOST appropriate next step in the treatment in this patient is

    a)   administration of amoxicillin and follow-up in 2 weeks
    b)   aortography
    c)   computed tomography scan of the chest
    d)   referral for pH probe
    e)   thoracentesis


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